David Colin-Thomé reflects on a roundtable discussion asking whether clinical commissioning groups should exercise sovereignty or diplomacy to realise their ambitions
I recently convened a roundtable discussion for clinical commissioning group leaders to reflect on the first 100 days of GP-led commissioning. The meeting coincided with a fresh row about Gibraltar, which raised questions that should resonate with anyone involved in leading a fledgling CCG: namely, are desired results best achieved by asserting sovereignty or exercising diplomacy?
‘Winning hearts and minds at home has always been an essential precursor to difficult negotiations with third parties’
Clinical commissioning is an ambitious undertaking. Reconciling quality and efficiency is a longstanding challenge, now compounded by a fierce financial imperative and an immense level of public scrutiny.
I was concerned that these and other everyday realities may have disheartened some of our pioneers. However, I am pleased to say their feedback highlighted no shortage of will, though people did report highly variable levels of success, as well as some common frustrations.
If anything, there also seems to be an increasing focus on the fundamentals of service redesign, with two aspects regarded as being of paramount importance: a willingness to invest in primary care and the need for high quality commissioning support.
Some general themes emerged on what CCGs can do to help themselves: developing ownership; looking beyond commissioning support units; harnessing the power of data; and enlisting new talent.
Developing ownership
This cuts two ways: first, in terms of creating organisations that genuinely value and serve their constituents (be they clinicians or members of the public); and second, by encouraging everyone to accept responsibility and accountability for even the most “wicked” problems, including inherited deficits and private finance initiative schemes that could become millstones for certain local health economies.
‘All CCGs need do is assert their sovereignty when making decisions on where to look for help. After all, they are the customers and should not be told where to shop’
There was a general recognition that these were both areas where real diplomacy would be required. Winning hearts and minds at home has always been an essential precursor to difficult negotiations with third parties and everyone’s expectations should be grounded in what is − and what is not − possible.
Looking beyond CSUs
The CCGs represented in our sample expressed general disappointment with the performance of their local CSU. This reflected both a shortfall in terms of their capacity to support transformational change and irritation at the cost of some services provided.
Fortunately, NHS England is now emphasising that the necessary support may also be sourced from the third sector or commercial providers − and a multiplicity of support should help ensure best value. All CCGs need do is assert their sovereignty when making decisions on where to look for help. After all, they are the customers and should not be told where to shop.
Harnessing the power of data
All CCGs at our meeting recognised that data and intelligence can make a huge difference to clinical commissioners.
They were therefore inclined to use their independence to challenge the unintended consequences of the second Caldicott review, which threatens to deny CCGs access to patient identifiable data. Given GPs see such data all the time in their “day job”, they cannot understand why it should be different when they act as commissioners.
Techniques such as risk stratification and invoice validation are generally considered essential tools by those who have seen them used to good effect. So, any imposed block is perceived to be halting progress and considered a disservice to the NHS and patients alike. Sadly, diplomatic exchanges may not be enough to avoid a prolonged and unnecessary dispute in this area.
Enlisting new talent
The extent to which young doctors are aware of and involved in commissioning appears to differ wildly from place to place.
There have been some excellent schemes − like the Darzi fellowships in London − that have succeeded in motivating and skilling up a new generation of champions. But participants at our roundtable, including a GP who had just completed her vocational training, expressed disquiet about the lack of attention paid to commissioning in medical school curricula and via postgraduate education for GP registrars.
‘Part of the charm offensive should be supporting GPs in demonstrating that clinically led commissioning will replace the overly bureaucratic and adversarial approaches of the past’
Once again, therefore, it seems there is a role for diplomacy here − perhaps a charm offensive aimed at persuading upcoming professionals that their energy and skill can help improve the wellbeing of whole populations, not just individual patients.
Without proactive encouragement of this kind, the pressures of surgery life are likely to become all consuming and any spark of interest in or aptitude for commissioning could be extinguished before it takes hold.
Farewell adversarial transactions
Of course, part of the charm offensive should be supporting GP commissioning pioneers in demonstrating that clinically led commissioning will replace the transactional, often overly bureaucratic and adversarial approaches of the past. Commissioning has to be seen as real and relevant to providers, educators and, most of all, patients and the public. To transform care, commissioning has to be transformed.
So this straw poll of CCG leaders highlighted broad lessons and challenges, not just local war stories.
I remain convinced that, overall, CCGs will deliver beneficial changes and can fulfil some lofty ambitions. But to do so they will need to play to their own strengths and focus on their priorities. Otherwise, like the people of Gibraltar, they could find themselves between a rock and a hard place.
Professor David Colin-Thomé is an independent healthcare consultant
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