Posts Tagged ‘GP leaders’


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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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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When I talk to managers and staff across the NHS, the question that I am most surprised to be asked is why I am so passionate about clinical leadership, and exactly why I think it is important for GPs to be commissioners.  I am surprised because the literature is unequivocal about the pivotal importance of clinical leadership.  But the reality is that many working in the NHS believe clinical leaders create more problems than they solve.

Taiichi Ohno (1912-1990) is widely regarded to be the father of the Toyota Production System, popularised as Lean Manufacturing.  He believed that managers could not manage if they did not understand the work place.  He was famous for drawing circles in the middle of the shop floor, and instructing managers to stand in them for days on end to observe what was going on and to understand the impact their instructions were having.

The complexity of healthcare makes it difficult for a single ‘workplace’ to be identified where managers can view the impact of their decisions, because patients have their own journeys that cannot be reduced to individual interventions.  Clinicians working within the system can however experience the impact of the decisions they are making.  NHS managers will never be able to truly appreciate the impact of their actions in the way that clinicians can.

Don Berwick, paediatrician and former President of the Institute for Healthcare Improvement and advisor to Barack Obama on health, asserted that the central premise of the health change debate was that only those who provide care (referring to clinical staff) can change it.  In the current financial climate it is even more important that those who understand the system make decisions about it.  The NHS Leadership website states, ‘Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart’.  McKinsey have written an article, ‘When Clinicians Lead’, and state that, ‘Leadership must substantially come from doctors and other clinicians.  Clinicians not only make the front line decisions that determine the quality and efficiency of care but also have the technical knowledge to help make sound strategic choices about longer-term patterns of service delivery.’.

GPs were largely uninvolved in PCT led commissioning.  Practice based commissioning did not give GPs real budgets or real accountability.  That all sat with managers at the PCT.  Commissioning decisions are critical.  They determine where precious, limited NHS funding is allocated.  They set the strategy.  They determine which redesign projects are worth investing in and which are not.  GPs are uniquely placed to make these decisions.  They understand the needs of the patients they see on a daily basis.  They are often leaders within their local communities.  They experience through their patients the impact of changes to the health system.  There is no one better placed to lead commissioning.  There is no one more able to put patient needs at the heart of commissioning decisions.  It is not just important that GPs lead commissioning, it is essential.

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