Why CCGs should be encouraged to innovate in the new NHS

Innovation can be difficult in any organisation; those working in the NHS experience first hand the tension around delivery, which emerges when the desire to get things done quickly and efficiently (and often how they have been done before) comes up against the chance to experiment.

It’s this kind of tension that can lead to NHS staff from all professions facing the charge of being risk averse or unimaginative. As a broad generalisation this is unfair but we do know that the service does not make things easy for people who want to push the boundaries. Despite the challenges, however, examples of great innovation continue to emerge at a local level. Where people are allowed, encouraged and supported to improve and change things, they do so well.

Clinical commissioning groups are the fundamental building blocks of the reform programme. Crucially, this is different from local innovation – it is a high profile national programme of reform, which has been the subject of varying degrees of scrutiny.

It is party political and concerns the most sensitive of all public services. It is for all these reasons that the innovation and difference the reforms seek are at risk of being sidelined.

From a very early stage of the debate, CCGs have been associated with innovation and doing things in the most appropriate way for their patients. The implicit intention is one of variation where appropriate, doing things in a way that is relevant for local need and meaningful for both patients and clinicians.

If the reforms are to deliver the innovation and difference promised, policy makers and the NHS Commissioning Board will almost certainly face that same “delivery tension”. The question is: will any migration from central advice be tolerated?

The authorisation process for CCGs is reaching a critical phase. This is a window of opportunity – and a test – for the board. It is here the fundamental principle of difference will be really trialled. Sir David Nicholson has acknowledged that the board may need to experiment a little in this process – the delivery tension here will be explicit and emerge from the potential conflict between the drive to get through the authorisation timetable, and the time required to make some adjustments and create the conditions for other models to be tried.

As the authorisation process guidance for CCGs is complex and, at least on the surface, exhaustive, it is likely there will be varying operating models. This should not be a problem in itself – CCGs are new organisations and will have significant statutory responsibilities to fulfil.

If this is the “spine” of the organisation, like a set of minimum standards, it need not be a problem for innovation and local relevance built around it. The test is likely to be with the development agreement and rectification plan process that all CCGs must sign up to, prior to full authorisation.

Notwithstanding that a rectification plan implies correction is necessary, the test here will be how insistent the authorising body will be that CCGs comply with specific items in particular ways. Where this process is agreed positively, there remains scope for latitude and innovation; where it is administered in a way that is punitive, any chance of innovation or difference will be, by definition, eliminated.

Challenge the system

But what of the people who step forward and are appointed to the critical roles – most publicly, the chair, accountable officer and chief finance officer?  The diversity of those leading commissioning organisations has dramatically reduced in recent years. How many women will take up the most senior roles in CCGs? How many black leaders will successfully emerge through the process? And how many people who are appointed will have had diverse career experiences that can bring alternative perspectives and challenge the system?

Each time the NHS clusters or adjusts reporting relationships, the diversity of the leadership population seems to decrease. This is hardly the fault of those who remain but the reasons why should be scrutinised – the opportunity that presents itself to the NHS Commissioning Board to create a cadre of over 600 CCG leaders is a rare one.

The whole process of developing new organisations is one based on a certain amount of guess work. The authorisation journey is based on the idea that we know what a good CCG looks like – and what good CCG leaders looks like. But of course we don’t know. The risk of relying too much on previous experience is that the NHS will simply recreate what it has had before. Sir David Nicholson has talked about the need to experiment – and this should be encouraged.

This is an unusual opportunity for the NHS – and should not be seen as another task to be delivered. If the CCGs all look the same next year, it may be tidy but difference, diversity and innovation will have been consigned to the “too difficult” list – something the NHS cannot afford to happen.

Three steps allow innovation and difference to flourish:

• Where people are allowed, encouraged and supported to improve and change things, they do so well; create an environment where this is possible.
• Innovation can be built around minimum standards, or the “spine” of the organisation; don’t let tick box standards put innovation in a sealed box.
• Think about diversity and career experiences that can bring alternative perspectives and challenge the system. The reforms are a real chance to be new and different; put the gear box in first, not in reverse.