Archive for the ‘CCG Performance’ Category


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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Accountable care organisations are in danger of becoming yet another passing trend in the NHS, without them really being properly understood.  They have been talked about by some, but I suspect most aren’t really clear what an accountable care organisation really is.  Until recently, this was certainly true for me.  However, having looked into it, I think they have much to offer current thinking in the NHS.

In the US the starting point for Accountable Care Organisations is what they term the ‘triple aim’.  The triple aim is the requirement for each healthcare organisation (commissioner and provider) to deliver three things simultaneously: quality patient experience, population health and cost effectiveness.

Previously the US has only focused on quality of individual patient experience.  As you will be aware, this has led to it spending 18% of GDP on healthcare with a large proportion of the country uninsured.  Out of necessity those leading US healthcare have understood that embedding the triple aim within all healthcare organisations is critical to the development of an effective healthcare system.

Accountable care organisations start with the premise that to meet the triple aim, the primary focus must shift to keeping people healthy.  The highest quality health experience is not getting sick in the first place.  It is avoiding diabetes, not receiving the best treatment for diabetes once I have it.

Accountable care organisations in the US are providers not commissioners.  The contracts they receive are not activity based.  Payment by results encourages more treatment of the sick, not prevention of sickness.  The payments are capitation based.  Providers have a cost envelope to deliver care within for a population.  What they don’t spend they can keep.

Healthcare providers are, understandably, resisting the move to accountable care organisations.  In their eyes it shifts the risk from the payer to the provider.  It does.  That does not, however, mean that it is wrong.  A prevention mentality amongst providers is critical to changing the healthcare system.  The more progressive US providers understand this and are, somewhat reluctantly, taking this on.

Another key difference between the US system and the NHS is that they do not have this clear distinction between primary and secondary care.  In the NHS providers deliver either primary or specialist care.  In the US it is not uncommon for a healthcare provider to own specialist and primary care facilities. And what they are doing is strengthening primary care.  They are building something called the Primary Care Medical Home (PCMH), which is like QOF but focused on impact, rather than collection of the extra income.  They are taking case management seriously and starting to show really powerful results.

We should question why in the NHS we cling so tightly to this separation between primary and secondary care.  Integration between the two needs to happen. We cannot continue with secondary care throwing bricks at primary care for failing to control demand, and primary care accusing secondary care of fraudulent up-coding.  Either primary care harnesses clinical commissioning and forms a new relationship with secondary care, or hospitals start buying GP practices.  With no new money, something has to change.

As clinical commissioners we should learn from the US that the notion that payment by results allows activity to be shifted from secondary to primary care is flawed.  It simply encourages more treatment activity, leaving less money for prevention.   We must change our payment models to ones based on capitation payments.  Providers must innovate to make a profit on this basis. This will change how general practice operates as well as how hospitals operate.

Accountable Care Organisations are a development in the US we must watch closely.  As the Affordable Care Act (or Obama-care) spreads across the US we will see this grow.  We are better placed to apply these principles in the NHS, if only we can get outside of our organisational boundaries.

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As we move into winter and hospitals move more regularly into red and even black alerts, local escalation is critical.  It is important that the system is managed effectively, and strong multi-agency responses are co-ordinated.  So whose responsibility is this?  While it is clear that the NHS Commissioning Board (NHSCB) is responsible for leading the response to any category 1 train-crash type incident, it is less clear who is responsible for the more common ‘system in crisis’ issues.

The guidance, however, is relatively straightforward.  Clinical Commissioning Groups are category 2 responders.  Really this means that in the event of a major incident we have a responsibility to co-operate and share relevant information with other category 1 and 2 responders.  However, the Health and Social Care Act says that, ‘The Board and each clinical commissioning group must take appropriate steps for securing that it is properly prepared for dealing with a relevant emergency’.

‘Relevant emergency’ is defined in the Act as any emergency which might affect the CCG (whether by increasing the need for the services that it may arrange or in any other way).  The NHSCB must take steps to secure that each CCG is properly prepared for dealing with a relevant emergency.

On this basis it is clear that each CCG is responsible for dealing with the ‘system in crisis’ issues, and the NHSCB is responsible for ensuring the CCG is set up correctly for this purpose.  But to date the implementation has not really followed the guidance.  Around the country (although it varies) the Local Area Teams are starting to assume a responsibility for traditional Silver and Gold calls when the local system overloads.

While this is understandable if CCGs do not yet have the necessary capacity or infrastructure, it is important that CCGs grasp the nettle that and take this responsibility on as quickly as possible.  The opportunity of clinical commissioning is to drive the response to these crises in new, innovative and more effective ways.  Responses that are built on relationships between clinicians across all sectors can ensure that not only is today managed effectively, but that changes to systems are put in place that mean the crisis is less likely to happen in future.

At the heart of the strategy of many CCGs is the shift of activity out of acute setting into the community.  In the past acute trusts have used these crises as a mechanism to demonstrate that PCT demand management strategies are failing.  In the new world this needs to change.  CCGs can use these crises to understand where the capacity in the community is lacking, and use the urgency of today to fill this gap.  Each crisis is not a demonstration of failure, but an opportunity to put another building block in place to create tomorrow.

Many health and social care organisations have become cynical and often critical about the silver and gold responses.  They are often seen as bureaucratic and adding little real value. In some places they are reduced to pure status-reporting with no real action coming out of them.  As CCGs take over responsibility for these responses it is critical that they embark on honest conversations with their health and social care partners as to how this could change.  A partnership approached to the redesign of the response to these crises is likely to be well received.

This issue is critical to CCGs at this early stage of their development.  Many acute trusts and Local Area Teams do not believe CCGs are capable of system leadership.  Ensuring that the response to crises is timely and effective is a highly visible route to building confidence in CCGs.  It is vital that CCGs grasp this with both hands.  It is no good CCGs having grand plans for tomorrow if they cannot manage today, and the reality is that clinically led CCGs are set up to manage today much more effectively than any commissioning organisation in the past.  Leaving it to others now may seem easy in the short term, but will store up trouble for the future.



Most CCGs are working on some form of system of case management of those at high risk of admission.  Debates in this area are now tending to focus on the appropriate use of risk stratification technology.  It has become almost an IT software debate as to which is the most effective, the implication being those with the best IT software will have the best results.

I have been involved in a number of case management systems.  They have struggled to be successful as programmes largely because the total outlay in the infrastructure to put them in place has not been offset by a greater (or even similar!) reduction in acute activity.  The cost of the additional nurses in the community, social services input, and GP and practice time has been more than any reduction in acute activity.

We can demonstrate that the cohort being case managed cost less than they used to, or even less than a control group.  Finance colleagues struggle with this because there is no actual money for them to put their hands on.  We then get into technical arguments about ‘regression to the mean’ (that those at high risk of admission were on the road to recovery and so would have cost less anyway).  Hence the conclusion that the identification of the right client group, and so the use of the right IT software, is the ultimate key to success.

There is an article on case management that I think should be mandatory reading for every CCG Accountable Officer.  It was published in the New Yorker magazine (!) in January 2011, and is entitled ‘The Hot Spotters’ by Atul Gawande.  It is easy to find on the internet, or you can access it here

This article talks about the work of Jeff Brenner in Camden, New Jersey, and how he developed case management.  Its roots are not in saving money but in treating people as people.  It does save money because individuals from health partner and build relationships with individuals in the community.  They do what they can to give them what they need and to help them take responsibility for their own lives.  Saving money is the bi-product, because it prevents the development of ever increasing need for episodes of care.

In the NHS we have been distracted by risk stratification tools and are wandering down a blind alley.  At the heart of case management of those at the highest risk of admission lies a fundamental shift.  It is a shift away from delivering care on an episode basis, and towards the delivery of care on a human being basis.  The health service may interact with individuals through a series of episodes of care, but ultimately we are treating human beings.  The move to case management should be encapsulating this shift.

The evidence is clear that a very small number of patients are extremely costly, whether it is the 5/50 rule (that 5% of the patients generate 50% of the cost), or Jeff Brenner’s finding that 1% of the patients accounted for 30% of the costs.  The failure to demonstrate the financial return in this country points not to the failure of case management, but to a failure of the way we do case management.

Case management systems in the NHS are funded largely on an episode by episode basis.  Primary care tend to be paid for the number of meetings they have, community organisations are paid for the number of extra visits they do, social workers for the extra packages of care, and voluntary organisations for the additional activity they undertake.  This mindset that we are paid for the actions we take, and not the results of the action, stifles the innovation that is so critical to case management.

We need to find mechanisms to enable staff to care for these individuals however they need to be cared for.  They need to be free to make whatever intervention is necessary.  They need to have the time to try and build the relationships that Jeff Brenner is clear are key to success, ‘High-utiliser work is about building relationships with people who are in crisis’.  As CCGs we are now responsible for the system.  It is the system that is stopping case management being successful, and it is our job to change it.

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In any Clinical Commissioning Group (CCG) that has a locality structure, there will be variation in performance between the localities.  The challenge for CCGs, who have committed to a devolved model of delivery through localities, is how to tackle this variation, particularly how to tackle those localities that are not delivering to the same extent as the others.

The bigger the CCG, the more important the locality structure is.  It is the system that allows the CCG to operate as a true membership organisation, and that builds upon engagement in each individual practice.  Determining how to tackle poor performance at locality level starts with an understanding of what drives strong performance.

High performing localities have characteristics that are way beyond QIPP performance.  They have a way of engaging each of the constituent practices so that they become active members.  The representation from each practice is appropriate, senior and acts as a genuine conduit between the practice and the locality.  Trust and a sense of shared purpose between the practices is in place.  Locality meetings feel more like a team meeting than a battleground. 

The practices have a high level of confidence and trust in the GP Chair of the locality.  The locality has a shared picture of what it is trying to achieve.  The locality turns the ideas that the practices have into actions, generally by having a capable management resource.  It has a plan for what it is going to do across the year, which it monitors and reports on both to each practice and to the CCG.

The locality feels like it is part of the CCG, not at war with it.  It feels like its voice is heard and understands the role it plays within the CCG as a whole.  The locality believes in the CCG leadership and the CCG leadership believes in the locality, mainly because there is regular communication between the two.

For those who work with localities, while this picture does not sound wrong, it does feel some distance from the reality!  Localities are often characterised by inaction, divisions between practices or individuals, no clear direction, and an underlying dissatisfaction with the wider CCG.  In this situation there are potentially three levels of intervention a CCG should take:

1. Improve the support the locality receives.  As with anything, the first place to start when looking at any problem is yourself, in this case the CCG.  Localities can only be successful if they are given the right support.  In particular it needs a proper programme of support for the GP Chair.  These are new and difficult roles and adopting a sink or swim approach to success is unlikely to prove the most profitable.  The management resource needs to have the capacity and capability to corral the practices and turn the ideas into actions.  Localities cannot function effectively without clear and consistent information at locality and at individual practice level.  Clear systems of autonomy need to be in place: the CCG needs to have absolute clarity as to what decisions the locality can take and which need to be approved.   CCG leaders (GP Chair, Accountable Officer etc) need to take responsibility for connecting the locality with the wider CCG and ensure really strong two-way communication is in place. They should not leave this all to the GP Chair, particularly when difficult messages need to be given.

2. Change the leadership of the locality.  Most locality issues can and should be resolved by improving the support the locality, including the leadership of the locality, receives.  But there are localities where those leading the locality are not capable of creating the sense of cohesion and ‘team’ that the locality needs.  Rifts between practices can be deep and long standing and leadership skills beyond those that exist within the ‘willing volunteer’ currently chairing the locality are required.  Or the CCG may need to change the management leadership working alongside the GP Chair, if no real viable alternatives to the GP Chair exist, to ensure the skills that are needed are brought into the locality.

3. Reshape the Locality Structure.  Localities can be designed in a way to prevent them ever being successful, regardless of the leadership.  They can be too large, so that many of the constituent practices do not know each other and have no sense of affinity with each other.  Here the locality construct feels entirely artificial.  There are too many practice representatives for there to be any chance of creating a cohesive team.  Individual practices find it difficult to get their voice heard, and lack of attendance by individual practices goes largely unnoticed.  Localities can also be too small, particularly where one dominant voice creates resentment and disengagement with the other practices.  In these instances CCGs need to recognise they are still at an early stage of their development and be brave enough to change the locality structure.

Many from a performance background in PCTs or SHAs are sceptical about the ability of CCGs to deliver through a locality structure.  As the alternative is to revert to a centralised model, it is critical that CCGs take robust measures to tackle under-performance to build confidence in the model, as this sits at the very heart of long term CCG success.



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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