The addition of clinical and lay members to CCG boards makes them more representative and transparent, says Dinesh Sinha
One of the key insights of the Francis report was the intransigence of the trust board at the heart of poor decision making, rebuffing efforts and information that deviated from its position. This could be thought of as an organisational “thick skin” that is at risk of developing in response to information from outside the board that challenges its internal understanding.
‘The ability to interrogate and challenge decisions and ways of operating are key to the value lay and independent clinical members bring to the board’
Many lay and independent clinical members bring past experience in boards and other senior managerial settings, which can be of benefit for developing board dynamics in clinical commissioning groups. The decisions required of CCGs are broad and cover all aspects of the local health economy. Hence many of the debates and papers presented to the board are necessarily high level and the sums of money involved are large.
A fresh perspective
The strength of lay and independent clinical members can be in their capacity to maintain the sensitivity of the board to the magnitude and impact of their decision and guard against any tendency to develop a “thick skin” such as in Mid Staffordshire. They can help preserve a fresh perspective and the ability to think outside the box to avoid familiar potholes.
Good medicine and business sense can be a potent but complicated combination. The ability to interrogate and challenge decisions and ways of operating are key to the value lay and independent clinical members bring to the board. They are able to do this given their independence from the immediate operational realities of the CCG, while keeping an ear close to the ground for emerging problems and difficulties.
‘The new organisations need to achieve their remit while also convincing stakeholders they are different from their predecessors’
They occupy significant roles in committees, such as for audit and remuneration, while also having relatively good access to confidential and crucial decisions, via invitation and representation on operational leadership. They can also assist the CCG in developing a culture of transparency, by using their presence to increase awareness of potential conflicts of interest, particularly when there are concerns that primary care clinicians may be having difficulties with these issues in their operational roles.
The importance of the secondary care specialists and lay members is in their ability to represent the diverse stakeholder groups, including patients in various settings and the community, as a whole on the governing body.
For example, while the CCG rightly considers possibilities to move more of patient care into primary care in an effort to improve quality, the secondary care specialists and lay members can help the board understand the possible impact and needs of secondary care patients. In the absence of such checks and safeguards, there is a possible scenario of the primary care “winning all”, to the detriment of patients needing care in other settings.
Meeting of minds
The paradox between a politically led government emphasising localism, while keeping a relatively tight rein on central contracts, continues to be a commissioning reality. This can lead to scepticism about involvement in the next big revolution in the healthcare landscape by clinicians and lay members, with concerns about the possible long term role of resilient, clinically led organisations.
The new organisations need to achieve their remit while also convincing stakeholders they are different from their predecessors. CCG governing bodies often hold meetings in a local government setting such as a town hall, which can confuse and cause misapprehensions about “political public meetings”, rather than meetings of a statutory health public body being held “in public”.
In such a context of ambivalence and significant change, the retention, training and ongoing support of lay and independent members is crucial to CCGs developing an external public profile and establishing functioning channels of communication with the public they seek to serve.
Dr Dinesh Sinha is secondary care specialist and consultant psychiatrist at Brighton and Hove CCG, Ashford CCG and East London Foundation Trust