Ricardo Semler is a well-known businessman in Brazil. Back in the 1990s, when the Brazilian economy took a nosedive, he had to think about how his company, Semco, could survive.
Having done all the things he could, like cutting salaries and even having union representatives monitor all expenditure by co-signing cheques with the bosses, he decided on a radical plan.
He offered his employees the option of starting up their own satellite companies and leasing his premises and machines. Some took up this offer, some did not and remained salaried.
Many thought he was a bit bonkers, letting his staff use his assets.
I think Semler could teach the NHS a lot - particularly regarding the sometimes dysfunctional relationship between PCTs and clinical commissioners. Even more interesting are the parallels with PCTs and their own small satellites – primary care contractors.
Semler began by awarding certain contracts to his former employees rather than doing the work in house. They knew about his business so the interactions were already good; he gave them some start up training and, by allowing the use of his assets, their overheads were lower.
He looked for particular skills when awarding work. Some people he described as ‘mammoth finders’ - they had keen eyesight and could spot the opportunities (or prey) at a distance. Others were ‘mammoth killers’ – people who could secure the business. Last were the ‘mammoth cooks’ - the ones that could make something of the kill.
This made me reflect on the primary care clinicians I have met over the years. Some are excellent at telling me what the opportunities are, but when it comes to making a difference, they don’t know where to start. Others are excellent at making initiatives work and turning a profit, having seen how it could be done differently.
The person with the idea gets the job. They tell a good story, they are passionate. Great, get on with it then. But they may not know how to and we end up going round in circles, discussing the same things over and over until we are all totally fed up.
Why don’t we get to know our clinical commissioners’ skills better – are they mammoth finders, hunters or cooks? Which role are they happiest in and most skilled? (Have we given them any training, like Semler did his former staff?) Or should it be managers with the sharpened spears of project management or change management that take the clinical commissioning idea and make it work?
And why don’t we think of incentivising clinical commissioners differently? Semler incentivised his satellite companies in a wide number of ways.
To my mind, PCTs are too timid in using varied approaches. After all, GPs are business people. Why not pay them a small amount for the idea, run with it (with them in a consultancy role, doing the bits we can’t do) and if it works, reward them some more, or if it doesn’t, kill the idea before it costs the PCT too much. That’s what a commercial business would do. Or just pay them for the idea if it works and not if it doesn’t.
Semler also talked of three values that I think we should adapt for clinical commissioning: employee participation, profit sharing and information sharing. Why? As Semler put it: “Participation gives people control over their work, profit sharing gives them a reason to do it better, information tells them what’s working and what isn’t.”
How well does a PCT explain the data on activity, cost, financial position and so on to GPs? I think PCTs do provide this information but in many cases GPs tell me that they don’t have time, they think the information is too complicated and anyway, this is the PCT’s problem, not theirs.
But if we get the financial incentives right, help GPs prioritise and access the massive amount of complex data - acting as partners and guides in the ‘hunt’ - and match the right clinician to the right job with the right tools, could things improve? I think so.
Heather Henry is head of market and commissioning development at NHS Warrington.