How to ensure member engagement in CCGs

As the 211 clinical commissioning groups get up to full steam, two of them in particular have begun to address the issue of how to ensure a vibrant and engaged membership that is so vital in ensuring delivery on their clinical commissioning responsibilities.

‘Early discussions also helped to frame a local “contract” between the membership and the CCG, on the basis of “offers” and “wants”’

The notion of the CCG as a membership organisation is unusual. Practices are members, not the individuals who work in them. Membership is compulsory but there is no active decision to join and no fee is paid in exchange for services gained. The group exists primarily for the benefit of the community and not for the members, but it is the members who will secure success or otherwise for the CCG.

Calderdale and Greater Huddersfield clinical commissioning groups have been working with Ashridge Business School to examine the notion of membership and research good working practices within and outside of the NHS. The product is a process and a toolkit that can be used by other groups to inspire dialogue internally on the issue and plan for development.

The process of engagement includes online surveys, large group discussions, small project based deliberation, benchmarked research and, finally, the production of the toolkit. The toolkit comprises a definition of membership competencies and a summary of research.

The process of the work is as important as the product in helping to frame clearer notions of membership and commitments required of members and the CCG to get the most from the arrangement.

A definition of membership

The early stages of the project engaged the two CCG boards and about 150 practice leads in reflection on the definition of the membership, today and tomorrow, and the rights and responsibilities assumed. The discussion was not without contention.

'There was no single organisation that could demonstrate the same characteristics as the CCG.'

Matt Walsh, chief officer at NHS Calderdale, led discussions for his group. He says: “For some, membership meant those GPs on the local performers list who have the right to vote representatives to the board. For others, membership was much broader and included those within the practices and for the CCG. Some colleagues felt that in future community representatives should be part of our membership.” 

Positions taken by the leadership on the definition were key to targeting engagement over the next period.

Membership manifesto

The early discussions also helped to frame a local “contract” between the membership and the CCG as a corporate organisation, on the basis of “offers” and “wants” from both perspectives. This formed the basis for a higher level commitment between the practices and the commissioning group as a corporate body.

Steve Ollerton led the discussions for Greater Huddersfield. He says: “Our manifesto not only calls for practices to shape commissioning policies, but also to make them real for patients in the way daily decisions about referral and treatment are taken. But in return, practices gain the right to be fully informed and engaged in decision making and to receive feedback on performance and to develop new skills.”

These broad principles were to then provide a framework for more detailed commitments.

A focus for development

The discussions established seven domains for successful operation as a membership organisation:

• Having a clear membership contract.
• Promoting the organisation to the membership.
• Involving members creatively in policy and decision making.
• Encouraging and promoting best practice.
• Providing information and advice to members.
• Engagement and the wider public.
• The development of member skills.

Each of the domains has their own success criteria that can be used to assess the current state of CCG development and then to form the basis for a prioritised development plan:

• Having clear and accessible strategies and plans that members can understand, and which they can readily associate their roles.
• The provision of clear and accessible information and guidance on pathways and referrals.
• Clear and timely information on what the CCGs and practices are achieving.
• Clearly articulating the basis for decisions made.
• Having an effective mix of communication process to suit members' working lifestyles.
• Helping practice leads disseminate information.
• Responding promptly to member queries and issues raised.

The domains were then used to research good practice nationally and internationally from a broad and at times eclectic mix of organisations, including the British Medical Association, the Ethical Trading Initiative, the US based Commercial Brokers Association and the UN.

Where research had been subject to peer review, we concluded that the examples warranted the term good practice ideas. In addition, we conducted more specific investigations of four membership organisations to obtain examples of application that had not been subject to academic study but nonetheless warranted some reference. These were then applied to each of the domains.

What the research indicated

There was no single organisation that could demonstrate the same characteristics as the CCG. The successful engagement of CCG members is critical to effective healthcare provision.

Clinical commissioning groups have a number of distinct characteristics: the practices are members not the individuals; no membership fee is paid; the CCG does not provide members with services per se; the practices must be part of the organisation; the practices provide services that are commissioned in part by the CCG but mainly from NHS England; the practices shape and determine local policy.

So the concept and dynamics of this relationship are shared in part by other benchmarked organisations but never in total. There really is no equivalent organisation with this set of internal dynamics.

‘For organisations that pride themselves on being more bottom-up, the notion of an active and vibrant membership needs more attention and action.’

The domains, however, provided a structure for enquiring on the approaches taken to each of the key areas. “Good practice" is practice that has been reviewed and viewed to be a positive source of insight.

A literature search on the practice of organisations demonstrated how to meet the characteristics contained within the toolkit. Articles from academic journals highlight peer reviewed practice and media articles identified pertinent points of view. Of those that were peer reviewed, some were based on applicable theoretical models, others experimental research methodology and others on organisational or political research.

The research does not provide a fixed solution, rather a set of possibilities for each CCG to consider and then take themselves forward.

Next steps

For Calderdale and Greater Huddersfield the project provided a process for engaging practices in shaping the CCG’s internal activities, helping to make the organisation more home grown than imposed.

The project provided a structure and form for the discussion with the provocation of external benchmarked references to stretch thinking and to embrace more creative solutions. The two organisations will be using the resulting model and toolkit to plan their development, linking well with other organisation development and community engagement strategies.

While the CCG authorisation process emphasised the key issues of clinical and public engagement, it said little about the notion of membership as a driving force for change in clinical commissioning.

For organisations that pride themselves on being more bottom-up, this notion of an active and vibrant membership needs more attention and action. Without it, leadership succession will be limited, ownership of policy will be partial and members of the public will be left with the impression that the determination of local healthcare lies behind closed doors.

Dr Steve Ollerton is clinical lead and Carol McKenna is chief officer at Greater Huddersfield CCG; Dr Alan Brook is chair and Dr Matt Walsh is chief officer at Calderdale CCG; Kathryn Winterburn is senior leadership and organisation development consultant at Health Education Yorkshire and the Humber; Simon Standish, Helen Eyre and Ayiesha Russell are consultants at Ashridge Business School.