Sustainable GP leadership for commissioning

As clinical commissioning groups prepare for authorisation, GP leaders will be heading large, complex organisations with a challenging to-do list alongside their clinical responsibilities.

From September 2011 to January 2012, NHS Midlands and East commissioned a review of sustainable GP leadership in emerging CCGs across the East of England. The study included a review of the literature, a survey of all 27 emerging CCGs and seven PCT clusters, including a CCG self-assessment. Fifteen telephone interviews were undertaken with national and local leaders, including eight GPs. 

The literature on sustainability indicates that leaders will need to adopt more sustainable practices in order for their organisation to adapt, succeed and become “future proof” in response to environmental, social and financial complexities.

‘Those interviewed identified inherent risks such as dropping clinical sessions, losing income, taking unpopular decisions, and taking on significant new statutory responsibilities’

Leaders will need to exercise a duty of care for their own and their organisations’ sustainability, as well as for the wider business and society of which they are part. Although a snapshot at a time of rapid development, the work suggests that GP leadership in its current form may need to be strengthened to make it sustainable.  

Defining sustainable GP leadership

Concepts of sustainable leadership taken from other sectors were refined during the interviews to create a definition for GPs. Sustainable GP leadership for commissioning requires sufficient leadership capacity and competence. It is diverse, practised at different levels, shared or “distributed”, and in place for enough time to realise a positive impact for patients and the surrounding health system. If CCGs are to maintain performance over time, sustainable GP leadership consists of five interlinking criteria:

• Leadership capacity
• Leadership competence
• Working at different levels
• Succession planning
• Creating a positive impact.

The study used these five criteria to look at elements that both impede and enable sustainable GP leadership.

Clinical commitments

The availability of GPs to lead commissioning is dependent on a complex set of factors related to their dual role as both providers of care and commissioners. These include practice workload; individual choice and motivation; availability of skilled GP cover; relationships with partners; and breadth of CCG requirements.

The length, complexity and range of activities within consultations in general practice have increased. For example, a 40 per cent increase in the number of consultations was recorded between 2005 and 2008, and the average length of consultations increased from 8.4 minutes to 11.7 minutes between 1992-93 and 2006-07. The increase in workload, and hence availability, affects practices disproportionately as the distribution of GPs by PCTs ranges from fewer than 50 to more than 80 per 100,000 population.

Solutions include increased numbers of GPs and new models of primary care as recommended by the Royal College of GPs.

GPs adopt leadership roles to improve the care of their patients and gain satisfaction in doing so. However, those interviewed identified inherent risks such as dropping clinical sessions, losing income, taking unpopular decisions, and taking on significant new statutory responsibilities.

Other studies have similarly identified poorer job security, lack of a well-defined career path and opportunity costs – professional and financial – as hurdles in doctors adopting a managerial career. A culture where management and leadership are highly valued by doctors, and the role formalised as part of the day job, would provide an additional incentive.

A highly skilled and flexible GP workforce able to provide backfill was a key issue, potentially addressed by coordinated groups of sessional GPs with educational support, for example GP locum chambers.

GP chairs were remunerated on average for five sessions, and other GPs 1.5 sessions per week for their CCG roles. Self-assessment suggested CCGs underestimate the time and investment needed for GP leadership, given the size of the commissioning and development agenda.

‘GPs themselves should focus on delivering objectives that only they can do – and delegate the rest’

This can be observed among physician groups in the US, where significantly more time is recommended for medical leadership compared to CCGs, 20 versus six sessions per 100,000 population. The benefits of depth versus breadth of GP leadership need consideration. GPs themselves should focus on delivering objectives that only they can do – and delegate the rest.

Female demographic

The demography of the GP workforce is changing. In the East of England 47 per cent of all GPs were female, and 39 per cent were sessional, locum and salaried. This is similar to the national profile, with sessional and female GPs together making up two thirds of the GP workforce.

CCG governing bodies are required to include at least one registered nurse, one secondary care specialist and at least two lay people. As well as establishing wider clinical input, evidence from the private sector suggests gender diverse top-teams benefit from improved decision making, innovation and creativity, better governance and less “group-think”.  

The diversity among those participating from member practices was not recorded. However, at the time of the study, emerging CCG governing bodies typically comprised 11 members, including seven GPs, with 80 per cent male GP partners. Monitoring of diversity and establishing ways to enable sessional and female GPs and other clinicians to participate will support the creation of more diverse CCG leadership teams that reflect the wider GP and clinical community.

Leadership competence

The benefits of doctors taking management decisions to influence quality and spend are well recognised, as is the shift GP leaders need to make to adopt new leadership skills. While the numerous development opportunities to help with this steep learning curve were welcomed, it was suggested that a more sustained and strategic approach is now required and for development programmes to include “real time” on the job learning through observation, feedback and debrief.

Key to the concept of sustainability is the ability for leaders to sustain themselves and others to deliver their vision and avoid burnout. Even the most enthusiastic GP leaders said they were “at saturation point”. It will be important for GP leaders to develop insight on how they generate and derive energy, and equally encourage others to do so.

Working at different levels

A sustainable GP leader was described as one who was flexible, adaptable, resilient and could nurture others. They were able to work at different levels including with patients, in the practice, with peers, on the CCG governing body and across the system. The importance of maintaining clinical commitments was stressed to ensure credibility and inform clinical commissioning decisions.

‘A sustainable GP leader was described as one who was flexible, adaptable, resilient and could nurture others’

Organisational leadership and authority distributed between the governing body and member practices uses the intelligence of everyone – not just the heroic few – to help the organisation respond to complex demands and is a requirement for authorisation.

A flexible approach and collective responsibility to leadership reduces risk, increases organisational stability, improves decision making, reduces the need for bureaucracy, increases the likelihood of “followership” and enables the organisation to adapt over time. 

It was broadly acknowledged that GP leadership in principle needs to occur at different levels within the group, building on support from constituent practices and talent within the CCG. The engagement of the GP constituent body was seen as a top priority.

To create organisations different from more hierarchical PCTs, new skills in influencing, emotional intelligence, relationship building, team working, communication, collective decision making and a coaching style would be required to make distributed leadership a reality.

Succession planning

Talent management and succession planning to secure a pipeline of skilled leaders – so that success outlives particular individuals – are priorities for many organisations. CCGs primarily used localities to spot colleagues able to contribute. Formal professional processes for identifying talent and succession were welcomed, especially with many GPs nearing retirement: 36 per cent are aged over 50 and 10 per cent are over 60. There is also currently lower than anticipated levels of recruitment.

Creating a positive impact

Sustainable leadership cares for and avoids damage to patient outcomes and the surrounding health system. As GP leadership capacity is finite, all identified opportunity costs to practices in releasing often the most senior GP to commissioning. These included the creation of a vacuum for decision making; compromised relationships with partners; financial impact; continuity of patient care; and potential conflicts of interest. There had to be tangible benefits for practices.

Delivering a vision of a sustainable local system required organisational stability and robust long term relationships with stakeholders. Successful medical groups in the US have had continuity of medical leadership for a decade or more. Despite the well-recognised challenges faced, CCGs will have progressed substantially in the last year to embed GP commissioning leadership.

To further strengthen these roles requires sufficient time, space, development, stability and high levels of senior managerial support. In the longer term, a more structured and systematic approach to medical leadership is needed as recommended in other studies to ensure a sustainable local system.

Dr Penny Newman is primary care adviser for commissioning development at NHS Midlands and East

For more on this topic head over to the HSJ LinkedIn group on Tuesday 27th November, from 12pm for a discussion with Dr Newman