Wednesday, 7 December 2011

Power (What's in a word?)

One word has stood out to me over the past few weeks. It was said at the excellent NHS Alliance Conference, on stage, and struck me as an interesting concept.

The word was 'power'. A small word but significant, and one which, in the context of NHS reform, has usually been used with reference to GPs recently. I think it's unhelpful.

The word 'power' may apply in some ways. GPs and other clinicians do have some power to influence commissioning decisions, to determine strategy and to spend real budgets. However this may have caused some dissatisfaction as 2013 approaches and the reality of commissioning complexities become apparent. GPs and other CCG clinicians have had power given to them, but now (before 2013) we need to accept and learn how to share power, let go of some roles and ensure that the system works in the best way for the patients.

What does letting go mean? As an example, it is clear the NHSCB will have a significant role in commissioning, including specialised services and primary care. Health and Wellbeing Boards will have a role in overseeing strategy and commissioning intentions for communities. Commissioning Support Organisations will provide intelligence, manpower and support. Local Authorities will increasingly expect an input into decisions which would be better taken jointly and affect social care. Secondary care services will hope for integrated working and planning of services. Managers are vital and key if we are to succeed.

What then, is the role of the CCG in this? Are we, as some suggest, really commissioning nothing? I'd argue we have a key role in ensuring this system works, in representing our patients and striving for improvements. We are used to working with consultants and other agencies when we care for patients, are often strong patient advocates, and coordinate complex care pathways for individual patients daily.

So are there better words than power? I prefer 'responsibility' and 'influence'. We have a real responsibility to commission effectively for our patients, to ensure they get the best services and in the right location. We have a responsibility to ensure we use resources appropriately, so that we protect patient care and have the ability to be flexible and improve services in the future.

The key is 'influence'. We must allow patients and the public to influence the way we commission and define our responsibilities. The contract planning underway is a current challenge for us - can we meaningfully engage to ensure we contract for outcomes that matter to patients? Can we plan for next year and include priorities that affect our populations? Can we deliver the better outcomes, working jointly with providers to plan better services? This will be the test for CCGs in the future.

So let's try to move away from 'power', and towards responsibility and shared influence. Build relationships that deliver, let go where appropriate and ensure the system works for patients.

To quote Thomas Jefferson:

I hope our wisdom will grow with our power, and teach us, that the less we use our power the greater it will be.

Friday, 11 November 2011


Mick Jagger may have felt that time was on his side, but many of us don't.  April 2013 looms large, with only 507 sleeps (it is nearly Christmas...) until CCGs must be authorised in full or partial form.   There remains significant variability in CCG progress and, whatever one feels about the reforms, this variability is unlikely to benefit patients.  So what are the main issues facing CCGs at the moment?  After a lengthy brainstorming session (alone) these are my thoughts, focusing on authorisation:  No doubt there are many more and they will vary - please let me know what I've missed.

Having a clear vision
The need for clarity increases, and having a clear vision to drive progress is vital.  Whilst we can't always wait for detail there is an increasing need as authorisation approaches, as the focus needs to be on patient care and services rather than structures.

Developing real and meaningful patient engagement
There is a definite desire to improve this, and many ideas re: doing so.  Avoiding token representation on committees, enabling genuine challenge from patients, ensuring a cross section of views - this will be a key test for clinical commissioning in the future and one we should be judged by.

Working together with clear roles
We must ensure we work together constructively and have clear roles.  CCGs should be clinically led, but with support and challenge from managers.  Relationships are vital, and the culture and behaviour of CCGs will determine success or failure.

Governance structures
CCGs have significant responsibility, and with that a duty to have strong Governance systems and support.  It's there to challenge and protect.  Separating governance and management is difficult, and will need much input from lay members.  Setting up audit committees, establishing clear lines of delegation - all important but time-consuming and must not detract us from the vision we set and the need to focus on patients.  Work with others to agree structures, taking advice from existing non executive directors and Chairs.  We have many of the responsibilities of PCTs but need to have a different feel and culture.

Understanding and developing partnerships
Identify what the potential benefits are for collaborative work, and accept the need to 'let go' of some roles which may be better done jointly with a Commissioning Support Organisation or Local Authority.  Getting these arrangements right will be vital if we are to encourage wider views, better integration and efficiency with commissioning resources.  There are many competing interests but none should override what is best for the services or patients.  Provider partnerships are essential if we are to achieve integration and enable transparent governance mechanisms.

Establishing an effective Health and Wellbeing Board
These have tremendous potential, but will be judged on outcomes not words.  We have reviewed key issues in Nottinghamshire such as dementia, alcohol and substance misuse and childhood interventions.  We need to ensure the time given and potential for change is not wasted, and that there is a clear strategy and benefit from these boards.

Running Costs
There is still significant debate regarding size and running costs.  April 2013 is a deadline which does not allow for a lot of further reconfigurations. 

Setting Priorities
There seems to be an endless stream of improvement opportunities.  Establish which are most important to patients and for large scale benefit.  Some issues may be quality related, and having a firm understanding of these issues will be crucial.  QIPP is important if we are to have resources to improve services, but if we achieve financial balance at the expense of patient care we will have failed.

Transition arrangements
Establishing CCGs, PCT capacity reduction, newly clustered PCTs and SHAs and a new NHSCB represent significant challenges to the system.  We need to ensure quality and safety are the main focus during this period, and that we ensure there are robust systems to manage this.  Clusters will, rightly, want to have confidence in the arrangements set up and they will undoubtedly evolve over time.  We might resemble PCTs during the transition, but for a reason.

Valuing Clinical time
Balancing the roles of clinician and commissioner is difficult both in terms of time and duty.  Good governance and challenge will protect against this, but the interests of patients must be paramount.  Many GPs will be working harder to maintain patient continuity and fulfil their CCG role.  Organisational and personal development needs will be significant.  Working together with managers and as a GP community is vital if we are to succeed.

(For those of you who are curious, it's 43 sleeps until Christmas.)

Tuesday, 25 October 2011


It's been quite a few weeks for reflection as Chair of a Clinical Commissioning Group.  We have, as a team, been through a thorough and well conducted review of our capabilities, been shortlisted for an award and I've attended some excellent events for a broader view of the world.

We continue to develop as a CCG, and the diagnostic tool provided an excellent opportunity to review progress and future needs.  While the tool itself is open to some differences in translation (one person's 4/5 is another's 2/5) it did allow us to sit as a team and openly discuss where we felt we were strong and where we could improve.  We then used this tool as a basis for a Confirm and Challenge with our Cluster - a genuine challenge to our Governance arrangements, performance and engagement.  A useful insight for authorisation.  Fortunately we seemed to reassure those present, and we await formal delegation of roles and accountability.  Nationally, some have complained that the process is bureaucratic and we will replicate PCTs - true in some respects but we are responsible for health, patient safety and a large sum of public money, and with that comes a duty to fulfill duties and provide good Governance.  Personally, it helps me sleep at night.

After all this, it was refreshing to leave base briefly and head to the HSJ Summit.  The debates were excellent, the company good and it was a chance to reflect rather than leap from one meeting into another.  The passion for the NHS was palpable, and there was a definite sense of transition to clinical commissioning and increasing partnership. Can we succeed and continue the excellent work managers have done?  Can we finally work towards the seemingly impossible goal of true integration?  I hope so, but there was a huge sense of responsibility as I drove away from the meeting.  I believe we can, but only if we work with the managers who have delivered an NHS we can (mostly) be proud of.

Yesterday, my practice team reviewed cases of some patients diagnosed with significant illnesses in the last year.  It was noticeable that for these patients the system worked, that patients had appointments and treatment rapidly, and that clinicians had worked together.  To discuss patients with colleagues was a welcome break from establishing an organisation, and something we must  continue to do regularly.  We need to build on the system, improve where we can and reduce the inefficiencies in care that we see all around us (including Primary Care).  Quality and patients first, with faster more appropriate care are what matter to managers, clinicians and patients.  We have to deliver.