Archive

Posts Tagged ‘Clinical Commissioning Group’

Feb
02

It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (http://ccginformation.com/a-3-step-guide-for-developing-general-practice/).  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.

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Dec
08

The Health Service Journal (HSJ) has this week declared that the ‘Oxfordshire battle will determine the impact of CCGs’ (here).  This is because, as the HSJ puts it, ‘One of the largest and most advanced attempts to bring about integrated, outcomes based commissioning has been delayed following objections from two powerful provider trusts.’

So is the HSJ right? The conclusion seems to have been drawn from what the events in Oxfordshire say about relative ‘power’ of purchasers and providers.  In the private sector different industries have different relative levels of buyer or supplier power.  In some sectors buyers (like supermarkets) wield great power and can drive price down.  In others (like the oil industry) suppliers wield the power and determine the price that buyers must pay.

So the HSJ argument is constructed on the basis that the formation of CCGs was to increase buyer power over providers, and that the amount of power exerted (in this instance the imposition of a specific contract) is the marker of CCG impact.

But there is very little about CCGs that is different from predecessor commissioning organisations that would increase their ‘buyer power’.  Maybe knowledge of services by the GPs and clinicians involved in CCGs, but at best there are only changes at the margins and certainly not enough to effect a significant switch in power.

I would argue that the whole notion of relative power is unhelpful for where we are in the NHS today.  The win/lose mentality between providers and commissioners has not served the NHS well in the past, and is extremely unlikely to help in the future.  It doesn’t help supermarket suppliers or those who buy oil.  And in the highly politically charged environment of the NHS, adversarial relationships inside the NHS will always damage the consistency of public message required to enable change to happen.

CCGs are most likely to be successful not because of an increase in relative power, but because of the ability of their clinicians to create partnerships with other clinicians and drive whole system change to improve outcomes. 

It is effective partnerships that are required, not power games.  According to Wikipedia, a partnership is, ‘an arrangement in which parties agree to cooperate to advance their mutual interests’.  And while it is tough to develop strong commissioner provider partnerships in the current environment, this is what is required. 

It is tough in part because the tight financial state of the NHS means there is limited funding to smooth the transition to any new model.  It is tough in part because each organisation has its own regulator putting pressure on it to take action that may be at the expense of partners.  And it is tough in part because people are not perfect, and in a pressurized environment any misplaced comment or action can quickly undo progress that has taken months to build.

The HSJ is being deliberately provocative in stating the ‘battle of Oxfordshire will determine the impact of CCGs’, but it raises an important challenge as to how we choose to monitor their impact.  Measuring whether or not contracts are imposed is not a good marker.  Any perpetuation of the win/lose mentality of provider commissioner relationships is unhelpful.  A much better marker is the ability of CCGs to form relationships that enable new ways of working that in turn drive improvements in outcomes.  Neither CCGs nor providers can make the changes they need for a sustainable future in isolation; it has to be done in partnership.

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Dec
01

I recently watched a TV debate about smoking and the NHS.  One man was arguing forcefully that it was his right to choose whether he smoked, how much he smoked and what he smoked, and that it was the job of the NHS to provide care for him when he needed it.  In his mind the two were in no way linked and he was irritated by the notion that the NHS might have a role in influencing his behaviour in relation to smoking.

In this country we love the NHS.  In the celebration of Britain at the Olympic opening ceremony the NHS took centre stage.  We are proud of our system because it is available to all, is free at the point of delivery, and is based on clinical need, not ability to pay.  It is our hero, because when we need it, it will do everything it can to save us.

As we consider our future vision for the NHS, the key is not so much understanding what the NHS is, but understanding our relationship with the NHS.  The man in the smoking debate was clear: the NHS for him is something akin to a ‘safety net’, there for him when he needs it.  And this is not an uncommon view.  The current furore over A&E and winter is driven largely by the symbolic importance of A&E as the front line of the safety net that the NHS provides.

Our attachment to the NHS is driven by stories of how the NHS (our hero) saved me/my grandmother/my father/my niece.  These are powerful stories from key moments in our lives.  Regardless of what happens to me or my family I know the NHS will be there for me when I need it, and that is why I will do whatever I can to protect it.  My attachment is built on this metaphor of the safety net, reinforced by powerful, personal stories.

Conversely, prevention does not create the same stories or drive the same level of attachment.  In the same way that a safety engineer that spots an irregularity in an aircraft maintenance check and prevents an accident ever occurring will never be a hero in the same way as the pilot who safely lands a misfiring plane on the Hudson river, so the flu jab will never be a hero in the same way as the hospital that nursed my grandfather back from the brink of death from flu.

And herein lies the problem.  Because our vision for the future of the NHS is one that has prevention as its hero, and that has citizens as active partners with the NHS in improving their own health.

Paul Pholeros has given a great TED talk on ‘Housing for Health’.  You can find the transcript here.  He describes how in 1985 a man called Yami Lester saw that for the aboriginal population of Central Australia 80% of the illnesses walking into clinics were infectious diseases caused by a poor living environment.  They examined the housing conditions of 50,000 Indigenous Australians and found that only 35% had a working shower, only 10% were electrically safe, and only 58% had a working toilet, all primarily due to a lack of routine maintenance.

The Housing for Health project works on toilets, showers and electrical safety, and as a result over 10 years has delivered a 40% reduction in environment related hospital admissions.  I am not doing this story justice here and I would encourage you to read it for yourselves, but the point is that providing great treatment for the infectious diseases was not the answer; rather it was preventing the diseases from occurring.

We are fortunate not to be dealing with the same developing world poverty of the Indigenous Australians in Central Australia.  But if we believe that the role of the NHS is also to improve health in partnership with the population, and not to simply provide a safety net for all, then our work on a 5 year vision for the NHS must start with this as the conversation.

Delivering 5 year plans to improve health will be impossible if we end up fighting a public whose primary goal for the NHS is to defend the safety net and the hero of curative medicine.  We need to create a new hero for the NHS, to build a belief in the power of prevention and partnership, and we need to do this by developing powerful, engaging stories like that given by Paul Pholeros as an antidote to the stories that are shaping our current thinking.

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Apr
14

The biggest criticism GPs level at their CCG faces is that it has ‘become the PCT’.  GP practices have engaged with CCGs on the basis that things will be different, and that the unilateral decision making of the past will not be a feature of the future.

This presents a real challenge for CCGs.  The pressure for action and for quick decisions from the Commissioning Board and from acute trusts and other organisations make it difficult for CCG leaders to be constantly saying that they will check with their practices and get back to you.

The challenge is to get the right balance between the leadership making decisions quickly, and taking time to engage with practices when decisions need to be made.  If a CCG leadership team get this balance wrong, they will quickly find out about it.  Either the member practices will accuse them of acting like the PCT, or partner organisations will claim they are slow and unresponsive.

The larger the CCG the harder this challenge becomes, because it is harder to get the views of so many practices in a short space of time.  This risks practices becoming disenfranchised and the engagement that is so critical to CCG success dissipating.

So what steps can CCGs take to meet this challenge?  The first is to ensure there is high visibility of the leadership team by the practices, in particular the Accountable Officer (and Clinical Chair if the Accountable Officer is a manager).  If practices are confident that the leadership understand where they are coming from they are much happier for decisions to be made on their behalf.  Dissatisfaction arises when decisions are made that are not explained and seem to take no account of what these decisions mean for practices and their patients.

The second step is to ensure that there is an explicit understanding of which decisions need direct practice involvement.  The reality is that it is not possible (or desirable) to involve every practice in every decision.  But this does not mean that they should not be involved in any.  CCGs must have mechanisms for identifying which decisions require all practices to be involved, and then for acting on this.

This is particularly important for the most contentious decisions, which will often be the decisions that directly impact upon primary care.  CCGs need an extremely transparent and fair process that engages practices, but does not just involve GPs, when making decisions that impact upon primary care income.  These include decisions on local enhanced services, on how the quality premium will be used, on any practice incentive scheme, and to a lesser extent on any support linked to delivery of the QOF commissioning indicators.

It is also worth CCGs considering having something akin to a ‘management allowance committee’ that oversees how the £25 per head is used, that creates a transparency with the member practices.  When practices feel that the CCG is using the management allowance in ways they do not understand a divide can quickly develop between the practices and the CCG.

The third step is to ensure that when a decision has been identified that requires input from all practices, that there is a mechanism for making this happen.  This cannot always be that the discussion goes to a set of once a month locality meetings and then be brought back to a further joint meeting.  Whilst sometimes this will be appropriate, taking 6 weeks or more to make a decision is simply too long.  Virtual mechanisms need to be put in place that are effective, that can operate alongside face to face meetings.

The final step is to continually review the processes that the CCG has in place.  Getting the balance right is almost impossible to achieve, so working out whether it is speed of decision making or practice engagement that is suffering will be a quick guide to how things need to change.  For CCGs to be different, and to be clinically led organisations that have genuine practice engagement, they must strive to rise to this challenge.

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Mar
16

The history of Clinical Commissioning Groups (CCGs), short as it is, has conspired to set CCGs up in competition with each other.  At a time when many are already predicting the demise of CCGs, it is critical that CCGs work together to be successful.

So how has this situation come about?  The primary reason is the authorisation process.  This created a competition between CCGs (‘What wave were you in?’, ‘How many conditions do you have?’ etc etc), that is neither helpful now, nor conducive to future success.

This competitiveness stems from the origins of CCGs as self-selected groupings of GP practices.  These groupings often set up around historic alliances and rivalries.  Once practices made a choice as to where their allegiances should lie, they naturally wanted to validate this decision making by demonstrating that ‘their’ CCG was better than the CCG they had chosen not to join.  This has meant that the biggest barriers to joint working exist between neighbouring CCGs with whom the strongest alliances are most important.

Some CCGs have already had to deal with some of these turf wars as different groups have had to come together to form a larger whole.  Making this work internally has taken such effort that building relationships with other CCGs has understandably taken a back seat.

The limited management allowance, and the fact that many GPs are carrying out the commissioning role in 1, 2 0r 3 days per week, mean that the capacity for collaborative working between CCGs has not existed, even when the desire to do so does.  Completing the collaborative agreement template that exists for CCGs remains on the to do list of most CCGs, rather than the tasks completed list.

The time has now come to draw a line under the past and put an end to any competition.  It is incomprehensible that at this stage any one CCG has all the answers.  It is critical that CCGs learn from each other, because ultimately we will succeed or fail as a collective.

CCGs are totally new organisations.  There are sets of issues that CCGs are dealing with that predecessor organisations such as PCTs never had to, such as creating effective governance as a membership organisation of GP practices, developing meaningful and sustainable practice engagement, managing the NHS Commissioning Board, and making commissioning support effective.

So what can we do to learn from each other?  How can we recognise the constraints that we all operate under, and yet create the capacity to learn from and support each other?

The starting point is for CCGs, individually and collectively, to commit to doing this.  It is critical we are active in this, and do not leave it to others (in particular the NHS Commissioning Board) to arrange on our behalf.  We must decide for ourselves what good is, and find ways of sharing and learning that are effective for us.

This website is one opportunity for sharing between CCGs.  One of the most common requests we receive is for case studies on how individual CCGs have successfully met some of the challenges they face.  So here are three things that you personally can do to help the development of collaboration between CCGs:

  1. Request information and advice from other CCGs.  Use this site to pose questions that you want the answers to.
  2. If you or your CCG has a case study of success in any of the categories in the sidebar of this site, send them to us and we will gladly publish them to make them accessible to others.  We have had specific requests for examples of how CCGs have created strong practice engagement, and of where CCGs have developed effective primary care strategies, so if you have examples particularly in either of these areas we would be more than happy to publish them.
  3. Finally, tell other people who work in CCGs about this site.  The more we share and learn together, the stronger we will be!

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Feb
02

Last week I met up with a friend whom I hadn’t seen for a long time.  He asked me what I did for a living, and I replied that I worked for a CCG.  He asked me what a CCG was.  Good question.  I said it stood for Clinical Commissioning Group.  He was none the wiser.

It is an odd thing that ever since the purchaser provider split was introduced the idea of a ‘purchaser’ of healthcare has not really been understood by the public, or pervaded into the public consciousness.  PCTs were never really able to establish any form of identity, other than maybe as the organisation that wouldn’t fund treatments for specific heartbreaking cases.

The mistake I think is starting with a description of what a CCG is, or worse, a description of some of the legalities that sit around it.  It is a fast track to someone glazing over when you start to talk about being a statutory body that is being authorised by the NHS Commissioning Board with an individual constitution agreed by member practices!

The starting point is to understand why CCGs exist.  Ok, so why do CCGs exist?  Most CCGs have a vision/mission statement that goes along the lines of, ’to improve health outcomes and the quality of health care provision for the local population’.  The job of a CCG is to keep you healthy and make sure you get good care if you get sick.

Whilst this is a noble goal, it remains slightly nebulous.  Isn’t that the role of the local hospital?  Hospitals are easy concepts to understand.  They are where you go when you get sick and it is too complicated for your GP (or if you can’t get through to your GP!).  So what is the difference between a CCG and a hospital?

On the one hand they feel so different that it seems like a ridiculous question, but on the other it is true that hospitals and CCGs are both trying to improve health outcomes and the quality of care that is provided to those who need it.  So what really is different?

At this point there is a route we can choose to go down.  The difference is essentially that CCGs decide how NHS money is spent to keep you healthy and make sure you get good care if you need it, while the hospital’s job is to turn the money they receive from the CCG into great quality care.

Whilst this is true at its core, it is not attractive as a primary descriptor of CCGs.  It turns the CCG into an organisation that is then a middle layer of bureaucracy.  The government give the money to the CCG, who in turn give the money to the hospital.  What is the point?  Why doesn’t the government just give the money directly to the hospital, and save the millions of pounds it spends on CCGs?

We need to clearly articulate the value-add to that middle step that CCGs bring.  This is the key.  CCGs are made up GPs and GP practices.  They are membership organisations, with GP practices as their members.  So for a start this means that it is clinicians who are deciding how the NHS money is spent.  Not only is it clinicians, it is GPs.  90% of all healthcare contacts in the NHS are with GPs.  No-one understands the healthcare needs of a population served by a GP practice better than the GPs working in that practice.

Second, GPs in CCGs don’t simply decide how NHS money should be spent.  They work with doctors and nurses and other clinicians to design and implement new ways of working that will improve outcomes and the quality of care that is received.  So for example most GPs that I know are using the CCG to change the provision of services for people who want to die at home.  GPs know that most if their patients want to die at home with those closest to them around them, in an environment they feel safe and secure in.  GPs in CCGs are working with clinicians from hospices, hospitals, district nursing services and the voluntary sector to put the services in place to ensure that this is possible.

So what is our elevator pitch?  I think it goes along these lines.  CCG’s (Clinical Commissioning Groups) are groups of GP practices that decide how the NHS money is used in a way that means their local population is as healthy as possible and receives high quality care when they need it.  They use their understanding of their own patients, and their relationships with doctors, nurses and other healthcare professionals, to buy (‘commission’) the services that best meet their patients’ needs.  Because clinicians rather than managers are in charge, the NHS is safe in their hands.

I tried this with my friend.  He could understand what a CCG was.  His problem was that he had never heard of a CCG.  As a group it is critical that CCGs are not anonymous in the way that PCTs were.  We must use the trusted voice of the GP so that CCGs find their way into the public consciousness.  And we must collectively find a way of describing ourselves that is both easy to understand and that is consistent.

If you have a better alternative we would love to hear it – leave a comment, or send it to us at mail@ccginformation.com.

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Jun
16

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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Jun
10

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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Apr
15

As the number of Clinical Commissioning Groups (CCGs) shrinks and the average size gets higher, more and more smaller groups are ‘federating’ together into a larger organisation.  Here we explore what lessons CCGs can learn from one of the most successful examples of a federation being formed (the six colonies coming together to form a single Australia), and from one of the least successful examples (the brief establishment of a West Indies federation).

So why did Australia succeed where the West Indies failed?  A key reason was that the six colonies of Australia (Western Australia, South Australia, New South Wales, Victoria, Queensland and Tasmania) identified with the overall continent of Australia, and understood that there was a logic to them forming a federation.  The need to work together to protect the vast empty area of Australia was clear.  It is interesting that New Zealand chose not to join, for the very reason that they saw themselves as a different country, with a different climate and separated by the sea.  They did not naturally identify with the proposed federation. It is also worth noting that while the federation is considered to be of substantial importance to many Australians today, in 1901 when the federation was formed many of the general public were apathetic to it, and more concerned with dealing with the effects of the depression of the 1890s.

The West Indies federation was created in 1958 by Great Britain to enable it to become a fully independent state.  It was set up between 24 inhabited islands in the Caribbean, but there was no popular support for it.  Lack of identification with the federation by both the people and their leaders was one of the key problems that the West Indies faced.  People identified with the island they lived on, not the wider federation, and by 1962 the federation had been dissolved.

So the first lesson for CCGs is that the federation must make sense to the members.  There must be a logic to it and some natural sense of community amongst those who are involved.  Artificial constructs are much more likely to fail.  CCGs that widen across county boundaries where no historic links have existed could well be storing up problems for the future.

The Australians identified some clear benefits to federation.  Both Australia and the West Indies were seeking independence from England (there may be some parallels between colonial Britain and the NHS Commissioning Board!).  The Australians were keen to keep out unwanted foreigners, and needed a collective approach to dealing with the unions that were operating across the colonies.  There were also tariffs on the transport of goods across borders and the federation provided the opportunity to improve trade across colony boundaries.

What Australia succeeded in doing that the West Indies did not was driving the delivery of the potential benefits.  The West Indies never achieved a single customs union or freedom of movement.  The Australian colonies felt that if they fell on hard times that the others would come to their aid.  The West Indian island states did not share such a belief.  In the end the Jamaicans felt that achieving independence from England would be faster on their own than as part of the federation, and the federation collapsed.

There are some clear benefits to smaller groups federating together into a larger CCG.  There is buying power with commissioning support services, or the ability to deliver all support services directly.  The management allowance goes much further with statutory overheads only needing to be provided once.  A larger group can have much larger and more powerful voice with external stakeholders, including the NHS Commissioning Board, the Health and Wellbeing Board, and acute trusts. And potentially most importantly the financial position is much less volatile and can be kept much more within the CCGs control for a larger federated group.

But these are only potential benefits. They do not come simply because the group is larger.  The CCG has to work hard to deliver and maximise the benefits.  At the same time it needs to communicate these benefits to the member practices, because as in the case of both Australia and the West Indies they are likely to be apathetic at best to the federation.  Failure to do this will lead to individual groups within the federation thinking they can do better on their own, and the likelihood of the federation breaking up becomes much more real.

Australia had some strong leaders such as Alfred Deakin driving the federation.  They influenced the press where they could to provide a strong, consistent, reinforcing message.  The West Indies were plagued by political feuds between the influential leaders.  The office of the prime minister was weak, so strong central leadership never prevailed.

Strong leadership is needed in all CCGs, but particularly in large CCGs.  The Chair, Accountable Officer and whole Governing Body need to provide strong collective leadership, drive the federation, articulate the benefits of federation consistently and continually, and work together to resolve issues and disputes as they arise in a clear and transparent way.  Federations are fragile, particularly in the early days, and need to be respected and treated with care.  The key message from Australia in 1901 and the West Indies in 1958 is understanding that forming the federation is the point at which the real work begins.

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Mar
25

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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