Archive for the ‘CCG Governance’ Category


Clinical leadership sits at the heart of the thinking behind the introduction of CCGs.  But as a result great expectation and great responsibility has been placed on the GPs who have taken on leadership roles in CCGs.

These are not easy jobs.  There are a number of complex elements to them that we have explored in previous posts on this site:

In ‘the importance of localities’ we established the need for those GPs leading localities to build the relationship with member practices,

‘The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.’ 

In ‘8 top tips to drive GP engagement’ we identified that beyond developing the engagement of member practices a key role of GP leaders is to influence individual GPs, and that achieving this is no mean feat. 

Beyond that we determined in ‘CCGs are redefining out of hospital care’ that GP directors in CCGs have a key responsibility in the transformation of these localities around a redesigned general practice.

In ‘Is your CCG really clinically led?’ we established that GP directors have a corporate responsibility for the overall performance of the organisation and how it discharges its responsibilities,

‘An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.’

So in summary: build a relationship with practices, create an emotional connection between every member GP and the CCG, lead the transformation of general practice and community services, and take responsibility for the CCG hitting all of its statutory duties.

Can we expect our GP Directors to achieve all of this in 3 or 4 sessions a week?  Have we created undoable jobs?  Are we setting our GP leaders up for failure?  The public debate about GP directors has focussed on the potential for conflict of interests and how these are managed.  But it is missing the real question which is how realistic are the expectations we have placed upon these new GP Directors, many of whom have only been in these roles since April, and how are we supporting them to be successful?

And of course these GPs are primarily elected rather than appointed.  We give them the title of GP director, and then wait for the magic dust to descend and the great leader to emerge.  By and large it is sink or swim.  We are expecting leadership talent to emerge simply because they are GPs, without any structured development programme beyond that provided locally. 

There are examples of fantastic, courageous and highly talented GP leaders who are doing an amazing job and who provide inspirational examples of what is possible.  But how are we helping those for those learning the trade, who have taken on responsibility for leadership in the most testing time the NHS has ever known?  Doesn’t there need to be more: more structured leadership development, more visible support, more investment?  Isn’t this where we need those who are offering to support CCGs to focus their efforts?

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As only 22% of CCGs have a GP as accountable officer, there are those who believe that CCGs are simply management run organisations supported by a few enthusiastic GPs – PCTs in all but name.

Many of those working in CCGs would refute the suggestion, pointing to the fact that they are a membership organisation, and that the GPs are not supporters but the real engine of the CCG.

According to Wikipedia, ‘CCGs are clinically led groups that include all the GPs in their geographical area.  The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients’. But are CCGs really clinically led?

The number of management directors varies according to the size of the CCG.  Most (over three quarters) have a manager as Accountable Officer, and all have a Chief Financial Officer.  Larger CCGs may also have a management director for quality, for strategy or commissioning, even for contracting.  Where there is a director there is generally a management team, and so the risk is that much of the organisation can start to operate outside of the GPs’ control.

Some CCGs have tackled this by having a ‘Clinical Executive’ or some such group that is responsible for all of the day to day operational decisions of the CCG.  This group is ‘advised by’ the accountable officer and CFO.  Whether in reality this group is able to take all of the required decisions probably depends on the size of the CCG – this model may work in a small CCG but would be hard to manage in a larger organisation.

Other CCGs have clinical directors who are responsible for specific clinical areas, such as planned care, frail elderly, or mental health.  This is an obvious route initially to go down, but in practice it does not answer the question of how the corporate areas of quality, contracting and finance are clinically led.

While you can argue that it is not in a GP’s skill set or knowledge base to be an expert on safeguarding or finance, if a CCG is to be genuinely clinically led then it is important that safeguarding or finance decisions are not taken in isolation of the GPs.

An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.  They are not there as elected representatives making sure there interests are reflected.

To some this may seem like semantics, but in order for CCGs to be truly clinically led this is what is required of the GP leaders.  It is not just clinicians making sure that the changes to urgent care are clinically led, it is making sure the organisation as a whole is clinically led

All of this of course sits within the reality of the limits on the time of the GP leaders.  Often they are carrying out these roles in two or three sessions a week.  To really lead an organisation in that time can feel almost impossible.

Some CCGs are recognising this as an issue, and are pairing management directors with clinical directors.  The pairing is then responsible to the rest of the organisation for that area, so for example contracting is both the management director for contracting and a specific GP director’s responsibility.   It is a version of what hospitals have done with directorates for many years (although not at board level), and is something that may well be effective for CCGs.

There are no simple solutions to ensuring that CCGs are genuinely clinically led. It is, however, critical that they are.  What is important is that CCGs continually reflect on how they are developing, how the clinical voice provides leadership, and make changes where they are required.


What is the role of the GP Chair?  While it seems a straightforward question, it is becoming clear that it is one that is fraught with complexity.

Many CCGs have set themselves up with a GP as Chair, and a manager as Accountable Officer.  Some reports indicate that this arrangement is in place in up to 80% of CCGs.  Detractors of CCGs regard this as evidence of lack of GP engagement in commissioning, but in reality it is simply an acknowledgement of where the relevant skills lie.

But it is not a straightforward arrangment.  Is the role of GP Chair an executive role or a non-executive role?  The guidance is ambiguous.  It starts with all the expected attributes of a non-executive chair (e.g. ‘ensure that the CCG has proper constituional and governance arrangments in place’, ‘ensure that the Governing Body is able to account to local patients, stakeholders and the NHS Commissioning Board’).  However it goes on to state, ‘All CCGs will need to identify their senior clinical voice for interactions with stakeholders, especially the NHS Commissioning Board.  This senior clinician will have a place on the CCG assembly.  In many cases, this will be the Chair of the Governing Body.’

So the role of the GP Chair is primarily non-executive, yet is also expected to be the ‘clinical voice’ of the CCG.  The reforms expect to hear a clinical voice not a non-clinical voice (regardless of who is accountable), and this pushes the GP Chair into taking on the role traditionally undertaken in NHS organisations by the Medical Director.

So is the GP Chair part of the executive management team?  Does he/she attend management team meetings?  If so who chairs these meetings, the Accountable Officer or GP Chair?

A common scenario is that the GP Chair chairs the Governing Body, and the Accountable Officer chairs the management team meetings, but with the GP Chair in attendance.  Naturally, the GP Chair takes on responsibility for those issues a Medical Director (conspicuous by their absence on CCG Governing Bodies) would normally take, such as CCG-wide clinical issues.

But this in itself is problematic.  How can the GP Chair hold the Accountable officer and management team to account at the Governing Body is he himself is part of the management team?

If the GP Chair is getting sucked into the operational detail of the day to day functioning of the CCG, where do they find the time to develop the Governing Body as a unit, and to manage outwards as the ‘clinical face’ of the CCG?  The reality is, they cannot do both.

We have identified 5 potential pitfalls for GP Chairs already (here). The role is complex, and for the majority of new GPs requires a totally new skillset to the one they thought they needed for the job.

The job is not to be the Accountable Officer by proxy.  It is not to have an individual right of veto on all decisions made by the management team. It is not to be the Medical Director.

The job is however to ensure that the organisation is and remains clinically led, and to hold the management team to account for that.  It is to manage external stakeholders as the clinical voice of the CCG.  And it is to ensure that the Governing Body is effective.

The reality is that to fulfil the requirements of the role effectively, GP Chairs should not be part of the management team.  Yes there needs to be a close and effective relationship and strong communication with the Accountable Officer, but there also needs to be distance.  It is hard for GPs to ‘let go’ and take the strategic view, but this is what is required.  The role is non-executive.

At present no-one is writing about this, but CCGs need to be sharing their experiences and learning journeys with each other about tough internal issues such as this in order to be effective.  If you want to share your experience contact us at


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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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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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.



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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According to the Health Services Journal, 60% of CCGs are planning to have a manager as Accountable Officer, with a GP as Chair.  While the logic of this appears sound (managers have the expertise to take on the responsibilities of Accountable Officer, and having a GP as Chair can ensure the organisation remains clinically led), it creates a whole set of potential pitfalls for those taking on the GP Chair role.  Below are listed the top 5 to watch out for:

1. The GP Chair becomes distant from the member GPs/practices.  Front line GPs view the GP Chair as one of ‘them’ rather than one of ‘us’.  The key role of the GP Chair is to be the representative of the members and their wishes, ensuring these are driving the organisation.  GP Chairs need not only to be doing this, but to be seen to be doing this.  A significant amount of time needs to be invested by the GP Chair in being visible and listening to member practices.

2. The GP Chair and Accountable Officer roles are not clearly defined.  Without this clarity there are two ways this can go wrong.  The GP Chair may let the Accountable Officer make all the decisions about the operation of the organisation, and it will end up functioning no differently from a PCT.  Alternatively the GP Chair acts as the CEO and consistently undermines the Accountable Officer.  Kakabadse et al, in their article, ‘Chairman and CEO: that sacred and secret relationship’ (Journal of Management Developmnet vol. 25, no. 2, 2006 pp 134-150), where they interviewed a whole range of Chairs and CEOs, conclude that, ‘effective governance application is dependent on the Chair and CEO nurturing a supportive and transparent relationship and manner of interaction’ p148.

3. The GP Chair gets sucked into the operational detail.  It can be easy for GP Chairs who have been given two, three or even four days a week for the role to default to using this time to support the development of new clinical pathways, or the operational detail of the organisation.  This is not the job of the GP Chair.  They must spend this time ensuring there is a clear vision and strategy for the organisation, and that this is consistently and effectively communicated both to the members and to partners across the health economy.

4. The GP Chair develops poor or adversarial relationships with other Board members.  The Chair has to have a strong personal relationship with all of the Board members, in order to be able to discharge their role of creating Board cohesion and achieving consensus on issues under consideration that keeps all Board members intact.  If there are locality chairs on the Board, each with their own set of vested interests, this is going to be a significant challenge that GP Chairs need to be actively managing from day one.

5. Health economy CEOs do not know who to contact.  Clarity as to who is ‘in charge’ of the organisation from a stakeholder perspective is critical.  The GP Chair and the Accountable Officer need to work together to give clear messages to health and social care economy partners as to who should be contacted when.

The role of GP Chair in a member organisation that is a statutory body is a new one, and its complexity should not be underestimated.  The literature on Chair/CEO relationships, while relatively light, is helpful, but there is a unique quality to the GP Chair/Accountable Officer relationship in a CCG that requires the two individuals to work together both as leaders of the organisation, and in clarifying, developing and providing support for their respective roles.

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Many GPs have natural antibodies towards non-executive directors, often largely driven by a desire for control and a lack of understanding of the potential value they can add.  However, for CCGs to be effective getting the non-executive component of the Governing Body right is going to be critical.  In an earlier post ( ) we highlighted the need for effective challenge on these boards.

CCGs have been given a relatively free hand (so far) in the set up of their Governing Bodies, but this freedom is creating as much confusion as it is opportunity.  The draft guidance on clinical commissioning group governing body members: role outlines, attributes and skills (which can be found via the NHS Networks website ) is important because it outlines the competencies that will be required of all CCG Governing Body members.  Below are 5 ‘top tips’ for appointing to CCG Governing Body non-executive roles.

1.       Treat the secondary care specialist and registered nurse clinical members of the Governing Body as non-executive roles

There is a strong temptation to fill an executive director post with a nurse to satisfy the requirement for a registered nurse.  There is also a temptation to treat the secondary care specialist post as one that can augment the GP knowledge and improve redesign ideas.  An effective Board needs effective challenge.  The number of GPs on the Board make the potential for GP ‘group think’ high.  A key role of these clinicians needs to be challenging any signs of this group think from a clinical perspective.  If you are the person setting up the Board you need to make sure that the Board will ensure the organisation meets its statutory obligations.  Two non executives will not be enough to provide the support for the Accountable Officer in bringing robust challenge where it is required to the GPs, particularly on clinical and primary care issues. 

2.       Treat the 4 non-executive posts (the two lay members, secondary care specialist and nurse) as a collective

The governance requirements of CCGs will need these 4 non-executives working together to support the sub-committees and ensuring that there is strong internal governance within the organisation.  Audit committees, finance committees, remuneration committees, quality committees (and there will be more) need to be led and supported by strong non-executive directors.  The individuals should be able to work well together and respect each other’s views.  Sometimes they will need to speak with one voice.  The CCG organisational development plan needs to include how these 4 will be developed together.

3.       Ensure those in post meet the requirements of authorisation

Many CCGs have moved quickly to putting individuals into these 4 positions.  One of the tests at authorisation will be on both the skills and competencies of all of the Governing Body members, and on the mechanism by which they were appointed.  If you have people that it is now apparent are not fit for purpose better to have that conversation now rather than leave it until later.  In particular, some of the patient representatives currently on CCG Boards do not meet the minimum requirements laid out in the guidance.  Some CCGs have also moved straight to the appointment of a practice nurse for the registered nurse post.  While there may be circumstances where this is appropriate, it is far more likely that an experienced nurse leader with acute experience is going to be needed if they are going to be able to provide a different perspective and challenge GPs effectively.

4.       Be creative in how you appoint to these posts

There is an obvious pool for the two lay member positions in the existing non-executive directors of commissioning organisations that will no longer exist post March 2013.  However, recruiting secondary care specialists and registered nurses with no conflicts of interest is much less straightforward.  The complaint of many CCG leaders is why clinicians with no conflict of interest will have any interest at all in these posts.  There is significant merit in this point.  Recruiting cold through adverts is unlikely to return the calibre of person needed for CCG boards.  Some of the more forward thinking CCGs are working together to identify potential board members from their own clinical community, and creating reciprocal agreements to find these clinicians for each other.

5.       Take your time

Finally, with all the uncertainty around the bill and the likelihood of changes (tightening) to CCG governance, the rules are likely to change from the guidance as it exists today.  If you have gaps in these positions, unless you have very strong, available candidates for them, it would be wise to wait for a few months to see how the dust settles before appointing.  Whilst you do need to be developing your Governing Body so that it can effective as a unit in time for authorisation, there is definitely room for a couple of months purposeful waiting to see what changes emerge before progressing.

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