A major challenge for commissioners is how to foster clinicians with the potential to become entrepreneurs. Kingsley Manning has some advice.

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As the NHS faces an increasingly challenging future, we need a new generation of leaders. And nowhere is this need more pressing than in primary care.

For most people the GP practice and the local acute hospital have been the two central pillars of the NHS. But while the acute hospital is going through a period of sustained and unrelenting change, the typical GP practice remains much as it was a generation or two ago. Or so it would seem to many of their patients, sitting in a crowded reception, waiting to be ushered in for a brief consultation.

Ever-rising GP hospital referrals reflect a high-expectation but risk-averse culture and an increasing concentration of expensive technology and expertise. GPs no longer have a monopoly in their gatekeeper role, with more and more patients taking matters into their own hands by turning up in accident and emergency and walk-in clinics, or simply ringing for an ambulance.

Static or declining cost productivity, coupled with the anachronism of the partnership business model, provide two key conditions for a revolution in primary care. To these can be added three further crucial catalysts for change.

First, a generational shift in expectations, not least among those of us with our newly acquired bus passes. Second, the increasingly widespread availability of cheap, substitutional technology; from the internet, to texts, to dispersed diagnostics to distant patient monitoring. And finally a fundamental swing in demand, driven by the approaching tsunami of long term conditions.

Bottom-up revolution

The coming revolution will not only change primary care for ever but also reshape the whole panoply of clinical and social care outside the hospital. But to be successful all revolutions ultimately need leaders.

However, leadership in the NHS has traditionally focused on the skills and characteristics needed to manage large, complex organisations; emphasising collaboration and consensus, evolution rather than revolution.

NHS leadership is primarily about managerial leadership, an approach that will be reinforced by the demand for the professionalisation of management that will inevitably follow the Francis inquiry into Mid Staffordshire Foundation Trust. The current emphasis on clinical leadership is an attempt to bring clinicians into that managerial process; the development of clinical commissioning groups is the prime example.

The leadership needed to transform primary and out-of-hospital care is, however, of a very different character. The nature of these services demands diversity, experimentation and localism; this has to be a bottom-up revolution. This needs entrepreneurial leadership; but the NHS has been profoundly suspicious of the entrepreneur.

Within the NHS community, entrepreneurs can be tolerated as eccentrics or as interesting peripheral players, but they are seldom to be trusted to drive real and important change. They aren’t team players, they are more interested in winning then collaborating and they rarely make good managers. And if they succeed there are the difficult issues of personal success and reward.

While there are good examples of new businesses developed by GPs in diagnostic scanning, by community nurses in wound care, and in lower-back treatment by physiotherapists, they remain very much the exception.

Faced with constrained resources and the potential for multiple failures across the system, the push towards controlled corporatism is understandable. At the same time, however, a fundamental shift in the nature of primary care represents one of our best hopes of keeping the NHS solvent.

The challenge for the NHS Commissioning Board and CCGs is therefore how to foster a generation of entrepreneurs, clinical entrepreneurs drawn not just from the ranks of the GPs but from right across the clinical professional spectrum. As service designers and commissioners and as the de facto overseers of primary care services, CCGs are uniquely well placed to respond to this challenge. That response should have four components.

First, invest in local clinicians acquiring some of the basic business skills, largely common sense, needed not only to start but also to grow a new enterprise. With a little bit of mentoring, coaching and formal training, many clinicians can find their inner entrepreneurial being.

Using freedoms

Second, explicitly encourage the development of new service models and new business models, with priority given to services models that integrate primary care into managing long term conditions.

In doing this the trickier challenge both for the CCGs and the local entrepreneurs will be to come up with the new business models. For these new businesses will have to attract investment from outside the NHS as well as facilitate transfers of cash within the local health economy. Most of the investment required will therefore be needed to fund the initial transfer of performance risk to the new business.

Third, use the freedoms given to CCGs to limit local competition, and foster and nurture new local businesses, rather than simply throw up further defences for existing services and organisations. Changes to the bill and reassurances from the secretary of state will enable CCGs to create protected opportunities for new local businesses, underpinning start-ups with contracts, without the need, initially at least, for them to be exposed to the cold blast of wholesale competition.

In this way CCGs can play a positive role in local economic development and in doing so create a new and positive culture for clinical entrepreneurs.

Finally, learn to celebrate rather than resent entrepreneurial success. If appropriate risks have been transferred, if the new business has delivered on quality and costs, and if the patients have become loyal customers, then professional and material success will have been duly earned. And more importantly, that entrepreneurial success will be making an important contribution to delivering higher quality, better value local health services.

The NHS needs a new generation of leaders, but they can’t be all clones. Some of those leaders need to be disruptive entrepreneurs if the level of transformational change we need is to be achieved.