The big question nervously whispered in the shadows of the corridors of power is: “what will be different about clinically led commissioning?”. Many have sought the answer - few have found it. Paul Zollinger-Read sheds some light on the direction clinically led commissioning might take.

Perhaps the first area that stands out from organisations that are already clinically led is that of distributed clinical leadership. Here we could do far worse than look at some of our high performing foundation trusts. They are clinically focused, put the patient first yet also united by a corporate vision.

Sixty per cent of change efforts will fail – a sad but well-known fact. But we know success is more likely when there is a common vision.

The flicker of the vision is starting to glow in many developing clinical commissioning groups and the leaders now need to focus intensively on developing depth and breadth to an agreed shared purpose. Investing time and effort in developing local ownership is a necessity or the journey will be short. This is perhaps one of the most pressing priorities. How deep does ownership go in your clinical commissioning group?

Some areas have also begun to recognise the sense in extending the “common purpose” across organisational boundaries to develop integrated care. This has largely been clinically led and to some extent frustrated by the fog of policy uncertainty. This desire to push the boundaries is something we must support.

The next important difference we see emerging is the notion of value. “Managing in challenging times” is a mantra for many CCGs. Most clinicians fully grasp the need to live within our means; but some will shuffle uneasily as the tentacles of budget management reach down to the individual level.

Yet over the past year many have reframed this in a discussion on value, where value is a function of quality and cost effectiveness. This is crucially important, and not just a conceptual trick, for it holds quality right where it needs to be out in front in the decision making process. It reframes the quality, innovation, productivity and prevention debate and enables clinicians to focus on what matters. QIPP has become synonymous with saving money. Somewhere along the journey we have forgotten the underlying principles: it is about doing the right thing once and once only.

Some CCGs are fixated on the financial challenge; but the notion of value is helping many focus on the right things, recognising that financial management cannot be addressed in isolation.

The benefit of clinically led commissioning most often trailed is local service transformation. This is not a game for one player and we are starting to see a recognition that transformation requires economy-wide solutions and that often the answers reside outside of healthcare.

We have people who are leading this refreshing approach and there are clear links between this and the desire for system integration. This area is a murky mix of commissioning and provision. The mixture is not an environment the purists like, yet if we do not recognise it for what it is, we will suffocate the solutions we need.

One final point on innovation. We are starting to see significant clinical innovation yet this on its own will not be enough.

Our thinking on how we innovate the supply chain of commissioning support requires a step change. Some are showing innovation but many are not and if it looks like something you have seen before it probably is. We risk mediocrity; we can only afford excellence.

Hippocrates said: “Healing is a matter of time, but it is sometimes also a matter of opportunity.” Clinically led commissioning provides an opportunity to innovate.

It is certainly starting to show the difference it can make. We must build on a good start. The need to develop common purpose within and across local economies; the need to allow the freedom to innovate, experiment and learn from failure, and finally the recognition that organisational and support service innovation is as important and fundamental as clinical innovation.

How we respond to these three challenges will shape the development of clinically led commissioning.