A study of clinical leadership in and around CCGs has revealed a very mixed picture of the viability and contribution of clinical commissioning groups. John Storey and Martin Marshall explain the results
Clinical commissioning groups were central to the health reforms. Charged with service redesign, GPs were handed a substantial part of the total NHS budget, with a remit to leverage expenditure more effectively and with a view to reallocate with new service offerings.
Current centre led initiatives such as the better care fund and the new models of care outlined in the NHS Five Year Forward View have been firmly embedded in the CCGs – so are the CCGs living up to expectations?
‘There were expectations of system transformation but so far the delivery of such change has been patchy’
The Open University Business School’s study of clinical leadership in and around CCGs, funded by the National Institute for Health Research’s Health Services and Delivery Research Programme, reveals a very mixed picture.
There are reasons to be both optimistic and pessimistic about the viability and contribution of CCGs.
There are numerous impressive examples of dedicated and effective clinical and managerial leadership, and yet grassroots GP engagement and identification remains problematic. There were expectations of system transformation led by these bodies but, so far, the delivery of such change has been patchy.
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A question of power
How much power and influence do CCGs actually have?
Our national survey found that half of governing body members judged the centre, in the shape of NHS England, to exercise “quite a lot to very extensive” influence. One could view this as a significant advance for localism or as a sign of a significant legacy of central power and influence – and one that is possibly growing.
Despite a limited clinical leadership pipeline and unfilled seats on governing boards, there are promising instances of active and talented clinicians involved in locality leadership and special projects.
These distributed forms create leadership “in little chunks”. The emergence of the GP federation is promoting some new clinical leadership but, given that the provider stance is perceived as more “natural” for GPs, this presents some risk to staffing on the commissioning side. If a key measure is clinician influence, a possible negative might be the uncertainty about the relative power and influence of managers and clinicians in steering the CCG.
‘There are promising instances of active clinicians involved in locality leadership’
The business school’s evidence suggested a significant number of GP governing board members felt their management teams were still the primary drivers. On balance, there were as many responders suggesting that managers held the main influence as there were saying that GPs held sway.
One of the more eye catching initiatives of a seemingly radical kind is the number of outcome based, prime contractor deals, and it continues to grow. On the surface they appear to tackle problems of integration but beneath, there is uncertainty about how they will work out in practice. There are indications that relationship issues are obscured rather than truly resolved.
Clinical leaders seem to be more willing to challenge or ignore diktats and messages from above, and to encourage their managerial colleagues to do the same.
The clinician/manager relationship is changing to one of greater mutual understanding, interdependency and an acknowledgement of complementary skills. Clinical leaders also tend to dislike bureaucratic processes and are more likely to focus on outcomes. As an extension of this, they are interested in driving a different set of priorities – for example, a multimorbidity rather than single disease focus.
Perhaps most crucially, there are signs that clinical leaders are starting discussions with their colleagues about a new conceptualisation of what it means to be a doctor, emphasising a professional responsibility for making the system work for population health, as well as individual patients.
Clinicians are more able and willing to challenge unacceptable performance by their colleagues and are doing so with the expert help of managers - for example, by using more sophisticated incentive schemes that reward collective behaviours.
Activities directed at integration have been much discussed in and around CCGs, but mainly these remain only as plans. Health and wellbeing boards have been even more tentative in their work.
‘Clinicians are more able and willing to challenge unacceptable performance by their colleagues’
Some of the more notable interventions have occurred in those areas with pioneer status that have worked with local authorities to provide new services for people with long term conditions or people with complex needs. These often include social needs including housing, alcohol or drug dependency and other needs that require more than a GP or medical input.
CCGs are only one part of a larger system. Despite some of the rhetoric, such as “GPs in charge”, there is a complex web of other forces and players. The health secretary still sets challenges (expected standards and priorities) and NHS England seeks to make sure these are addressed.
There are still nationally set standards - for example, relating to emergency care; as such CCGs are not entirely free agents. But, working within this institutional field, a significant number of GP leaders have shown how the obstacles and the limitations can be overcome.
John Storey is professor of management at the Open University and chief investigator of National Institute for Health Research; and Martin Marshall is professor of healthcare improvement at UCLPartners and a co-investigator