Fish for the best variety of CCG

Talk to newly emerging clinical commissioning group leaders and one thing quickly becomes obvious: there is no single way in which CCGs will operate. Adaptation and evolution to match the unique local health ‘eco-systems’ is already happening and is amazing to watch.

These are going to be truly local organisations, with an approach specific to local needs and thus also to engaging their GPs and stakeholders. To use a fishing analogy, it will be more like a tropical reef with a huge variety of fish rather than a salmon farm.

This adaptation is being shown in a number of ways, but is beginning with the variation emerging around the country in how two main roles of chair and accountable officer will operate.

One CCG may have a GP chair and a GP in the accountable officer role. A neighbouring CCG may have a GP chair and an ex-primary care trust or other manager as the accountable officer. Another a few miles down the road may have a lay chair and GP accountable officer. Some or all of them may share an accountable officer, across two or three CCGs (often also alongside sharing a chief financial officer). Better still a small number may embed their accountable officer role within the senior team of the local council - following on from successful previous arrangements with PCT chiefs.

It doesn’t stop there. Nearly all will have part time chairs who either continue to practise as a clinician or do other roles. Many of those with a GP accountable officer are describing themselves as a “clinical AO” with an intention to do the role in some part-time format in order, quite rightly, to also continue some clinical practice.

This is a good idea, but what is considered to constitute an acceptable level of “part time” to do the role effectively will vary with the strengths of the people, the level of challenge of the local circumstances and what the commissioning board expects the accountable officer to deliver.

Early test

Some are already putting in place quite strong chief operating officer roles that they expect to carry the majority of the “management” functions or tasks for the CCG - especially perhaps where there are clinicians in post as the accountable officer backed by a clinical chair. The challenge here is that the accountable officer role carries formal statutory accountabilities which at the end of the day are something that you cannot truly delegate to a COO or elsewhere. 

Different localities will probably, very soon (post authorisation), adapt and adopt an even greater variety of approaches to commissioning to suit their specific local needs. That could be argued in many ways is the entire point of these reforms so must be a good thing. How the commissioning board manages this variety from a performance management point of view will be a challenge - and an early test of the genuine intention to create a new paradigm of relationships and culture from the centre in how it handles local relationships.

The beauty of the local variation is that it means that there is also no single “right” model of leadership for these roles. It’s not about being the biggest, strongest or prettiest. What matters is what is needed for success in your particular area. What’s required then, instead of a single approach, is leadership breadth. The ability of leaders in these different models, and differing definitions of role, to move between varied leadership approaches, styles, techniques and skills in order to navigate through a complex and often uniquely local set of circumstances.

CCGs are statutory organisations but will work more like a membership organisation and are unlike anything the NHS has seen before. The nature of leadership required will not be “heroic” but genuinely more diffuse. The idea that the two or three senior roles in the organisation are the “be-all-and-end-all” of decision making, strategy setting and even holding to account, will be a premise born of old PCT or SHA dynamics and no longer true. Leaders’ ability to understand this fundamental shift will be key to their success, the engagement of their GPs and stakeholders and ultimately the survival of the new system itself.

Creating effective processes for engaging all the local stakeholders, discussing strategy and making decisions will all be more complex than before - and rely less on one or two people leading, and more on a range of “members”.

Facing the financial challenges - and the de-commissioning agenda required to free up commissioning from operating at the margins - will require rigorous and collective engagement of the CCG members in the whole agenda. This is of course a great challenge, but one which the new CCG leaders genuinely seem aware of and energised by - motivated by the very opportunity to be local that is at the heart of these changes.

In many ways the nature of CCGs is also going to create a potential dichotomy: internally - a membership model requiring diffuse, federate leadership behaviour; externally - a potential continued expectation of “heroic” leadership and accountability as in hierarchical structures.

For those managers from PCT or SHA backgrounds this adjustment could be a radical - and uneasy - one to their self-image and the leadership approach which they need to present to others. The challenges are extreme. The risks might be high. But the benefits for local populations and the service could be enormous. l

Phil Kenmore is director of the UK public sector practice for Hay Group.