The NHS Commissioning Board local leadership challenge
The Commissioning Board’s local medical leads should be “shape shifters”, says David Black – flexibly commissioning a variety of services while keeping a clear strategic overview.
Sci-fi fans will know of shape shifters, they are often the “good guys” able to take on many different forms. The new NHS Commissioning Board local area team medical leads need similar skills, particularly during transition.
Medical/clinical leadership at the commissioning board’s local offices must be high on flexibility and avoid being territorial. The medical lead will be responsible for practitioner performance and dental, optometry and community pharmacy commissioning.
However essential these functions are, they must not prevent medical leads having a clear strategic overview of the challenges and priorities for action in their local health and social care systems. These will include immediate performance problems, but also medium- and longer-term strategic service rationalisation and reconfiguration needs.
Clinical colleagues including public health directors and clinical commissioning group leaders are immersed in organisational development, while provider trust colleagues are facing the challenges of cost control, patient safety and a medical workforce engaged in appraisal and revalidation.
The commissioning board medical lead is in a unique position to meet with colleagues in clinical leadership roles individually, and bring clinical leaders, including public health, together, to facilitate outward-looking, cooperative working to meet the system-wide challenges we all face.
Clinical leaders working introspectively and isolated from each other will fail, but together they will develop a shared vision based on the “triple aim”; to improve the health of the population, enhance patient experience of care and control the cost of care.
This collective clinical voice is vital to make the case for service rationalisation and removal of duplication to improve outcomes while reducing cost. As a result, the commissioning board local medical lead may need to provide systems leadership. In addition to regularly meeting individual clinical leaders, they may need to host local clinical summits to provide a senior clinical overview of progress on the key local strategic priorities. They must ensure the clinical voice is heard – aligning support across a virtual clinical leadership team will be powerful in making the case for change with the public and other stakeholders.
However, this need will vary greatly and calls for flexibility and a willingness to be federal, sharing clinical leadership with others. The prize in “liberating the NHS” is to achieve clinical and particularly primary care accountability and responsibility for outcomes and use of resources. The commissioning board must ensure this happens.
A good area for shared leadership and shape shifting is in the commissioning of general practice. The objective is to achieve consistently delivered, high quality, efficient services that proactively plan care and effectively steward resources. Many CCGs are grasping the challenge and leading this work. As membership organisations, CCGs should be well placed to deliver this task.
The local medical lead role must be flexible, supporting leadership by CCGs and stepping in to lead when CCGs are not ready or able to do so. However, the medical lead must ensure and be assured that the system effectively links individual practitioner performance, practice performance and practice development to keep patients safe and promote excellent general practice. Therefore processes must be in place now to bring together CCG and primary care trust work on general practice quality, safety, development and resource utilisation.
In practical terms, a group with PCT and CCG membership is needed and should report to the PCT and CCGs. A federal leadership approach is needed to both optimise delivery and assurance. An approach that shares responsibility for general practice is likely to continue under the commissioning board.
However, potential difficulties may arise if either PCT or CCGs feel their responsibilities are being usurped. A medical lead with strong professional relationships with CCG leaders and able to use an open and inclusive leadership style is most likely to succeed.
A key role for the medical lead will be to oversee the delivery of the NHS outcomes framework (with the nurse lead) and other aspects of the NHS mandate. PCT medical director colleagues have expressed concern about the delivery of this responsibility, which has been led in PCTs with analytical support.
The commissioning board local office may not have these resources in-house; however, the medical lead role should be to ensure that CCG plans relate to the health and wellbeing strategy boards and are informed by public health advice.
Plans must also be clear in their intent to deliver the outcomes framework and the mandate and show synergy with the public health and social care outcomes frameworks. The medical lead will be able to access expertise through commissioning support organisations and public health and other bodies including observatories, clinical senates and professional committees.
However, keeping a strategic perspective is most important; do plans address the main challenges locally? The medical lead will need to ensure that they are known to their health and wellbeing boards by taking opportunities to attend or representing the commissioning board.
There remains uncertainty about exactly how the new system will work. However, it is clear that the commissioning board will have the central role in ensuring commissioning is coordinated to deliver the outcomes framework and mandate. It will hold CCGs to account and support their development and it will directly commission primary care and specialised services with CCGs commissioning most of the rest.
The need for coordination is obvious. Improving general practice is also essential as primary care has the NHS’s greatest impact on reducing mortality and improving chronic disease outcomes, as well as optimising resource use. Integration across primary, secondary, community, tertiary and social care is needed to deliver an effective system that satisfies patients. The medical lead will be responsible for elements of performance management in addition to working collaboratively across the system.
The commissioning board local area team will need to foster mature relationships to ensure that CCGs, trusts and other organisations are not defensive and are open and honest. The medical lead will often need to take an “honest broker” approach to be successful.
New commissioning board responsibilities for resilience and emergency response should also provide opportunities for the collaborative working that is critical for success. The medical lead should take a role in this.
The commissioning board local office medical lead will add maximum value if they are able to forge strong professional relationships with clinical leaders in CCGs and providers, maintain a clear strategic view of priorities and bring clinical leaders together to promote a shared vision.
They must be willing to lead where gaps arise, and equally, willing to allow other clinical leaders to lead. They must recognise their core function but must not be precious in working across the unclear demarcation with CCGs, especially regarding general practice. Some will have a very significant role in directly commissioning services, including specialised services. They must recognise their own capacity and expertise and be active in bringing in help and expertise from a range of sources, including senates.
The current environment is particularly fluid, and it now seems likely that the number of NHS local area management teams will be significantly less than the current number of PCT clusters.
PCT medical directors must now focus even more effort on supporting their teams to maintain morale and keep skilled staff. Some commissioning board medical leads are therefore likely to lead larger teams covering populations of more than two million and with significant direct commissioning responsibilities. Personal development should be a top priority.
PCT medical directors now and commissioning board medical leads in the future need to be shape shifters, changing what they do and how they do it as circumstances change. They must develop themselves and their teams.
They must not be afraid to try new approaches and equally willing to recognise when to engage or stop, with strategic priorities and the “triple aim” always in mind.