Clinical commissioning groups need the backing of their membership practices if they are to succeed, requiring a leadership style with pizazz
Clinical Commissioning Groups (CCGs) are membership organisations with a twist as it is compulsory for every GP practice to belong to a CCG. GP practices on the border of a CCG can, theoretically, change membership to another bordering CCG but the greater threat to every CCG will be having one or more grumpy, unwilling or negative GP practices in its midst.
Creating a successful membership organisation will be challenging to those used to line management or clear demarcation of roles in corporate organisations. The real strength of current arrangements, however, is it allows GPs and practices the independence to straddle that fine line between being an individual patient and community advocate while being responsible, as commissioner, for the greatest good of the greatest number.
Success will require many of the skills learnt in the days of locality commissioning groups and primary care groups (PCGs), who needed to garnish the support of their constituent practices and GPs if they were to succeed. We all learnt during those years that this required a leadership style that was supportive, enabling – even seductive – rather than one, which saw GP practices as being simply the foot soldiers at the frontline.
My five suggestions of how CCGs can create themselves as effective membership organisations of their constituent practices are not exhaustive or evidence based. They simply reflect my own lessons in building various emergent membership organisations in the past. They are:
1. Before telling them what you want, ask your members what they want. Having done so, make sure that you visibly respond to their concerns, motivators and dreams. Find out what their expectations of your CCG are and enable them to achieve, wherever possible, their own ambitions for patients within it. In PCG days, for instance, several had a “yellow card” system, which enabled every frontline clinician to fill in a yellow card, whenever a patient encountered a particular problem in the system or when clinician or patient could see a better way of doing things. These yellow cards gathered on the desk of an identified manager, who would champion issues/changes that accumulating yellow cards showed to be common themes. So the first question that CCGs need to answer must be less “How can we make frontline GPs useful to us?” and more “How can we show that we are useful to frontline GP practices?”
2. Having identified the “low hanging fruit” of issues/problems/possible areas of service redesign that most concern frontline clinicians and GP practices, the CCG must then be seen to actively champion the most important issues or areas raised. It is crucial to be seen to fly the flag of frontline concerns rather than adopt a “teacher knows best” approach. In PCG years this often started with the Health Authority accepting frontline GP requests to provide in house counselling for mental health patients in GP practices. This was possibly not a priority for the commissioners or public health but it was an action that got GPs and practices on side and then helped motivate to help the PCG succeed in its mission. First motivate and inspire your frontline GP practices because only then can you begin to effectively encourage them to step up to the awesome agenda of helping CCGs to redesign and make financial ends meet. In any emergent organisation (like CCGs) this may on occasion, at the beginning, require a strong challenge to outside forces which appear to threaten or squash the passion and motivation of frontline clinicians. You will be forgiven the occasional strident act on behalf of your constituent GP practices and sometimes against other, possibly national, bodies if that leads to a more cohesive and effective CCG. It is advisable to warn those, who may be offended, beforehand.
3. Personal contact, visible leadership and relationships are crucial. Forget emails with large enclosures. Few working GPs will read them. It all has to be done in person. Make sure that there is some person in your CCG, who relates to each and every practice (it doesn’t need to be the same person or even the CCG chair) but personal contacts with practices so that the CCG can understand their thinking and also relay its thinking are terribly important. Watch the language as you visit your GP practices – are they talking about “our” CCG or “the” CCG. This may mean arranging face-to-face events such as occasional practice closure days, when all local GPs can meet and discuss clinical issues but also CCG issues as well. In locality commissioning/PCG days this would involve evening meetings with wine and pizzas. There is nothing so deep in our culture as a meeting of minds over a meal and this helps to develop a feeling on the part of every frontline clinician that they are in full contact with their CCG leadership. Think of ways that you are going to do this because if the frontline clinician is alienated from CCG leadership then your battle is already lost.
4. The CCG leaders themselves and their mode of leadership are equally crucial in developing a membership organisation. CCG leaders need to be inclusive, humble and visibly open to ideas from constituent GP practices. They must forsake “ego” becoming the enabler, implementer and voice of their frontline GP practices. Forget the politically correct messages of traditional NHS management leadership course that would have leaders be simply corporate/listening men/women, who can convene and direct but whose main characteristic is as team players. In the real world, members of your organisation will demand far more. They want charisma, inspiration and integrity. They want to know that you are in the mire up to your armpits every bit as they are. They want to know that you are still thinking about how to get things straight at 3am and that you are working every bit as hard as they are. They want pizazz. They want you to be colourful, go ahead and optimistic. They want to follow you because they believe in you, your mission and the organisation that is going to achieve it. These are the essentials that are systematically omitted from traditional NHS leadership courses with the result that traditional NHS leadership has too often lacked these qualities and singularly failed to lead because of this – apart from simply following orders from above. Membership organisations want leaders, who are human beings not clones of currently accepted NHS management dogma.
5. Finally, every member of an organisation wants to be on the winning side. Show that they are. Celebrate achievements as visibly as possible and especially to patients and local communities. Show the added value of your mutual work in terms of improving local services and health. Grasp the national stage to showcase this if you have time and inclination. Victories, real victories rather than cants, are as important to CCGs as they are to armies. Be sure that you make those victories of not only the CCG but also its membership practices and frontline clinicians.
On an individual and emotional level this will require considerable change among our clinical and managerial leaders. Clinical leaders will need to keep contact with their frontline clinicians, which will be helped by them maintaining an element of clinical practice. For clinician leaders and frontline clinicians, the challenge will be to end an era, where clinical leadership was peripheral to the way that the NHS ran and to take the helm with a healthy dose of optimism, commitment, passion and disinterest. For managers, it will be time to break out of the “receiving orders from above”, “emperor’s new clothes” school of NHS thinking that crushed the ambitions of well-motivated clinicians and allowed bad care and bullies to flourish. Strong visible trusting relationships between clinically intelligent managers and managerially intelligent clinicians will engender the trust of the member GP practices that they support.
If CCGs simply assume a right to lead, regard their frontline GP practices as fodder for demand management and homogenising care then a giant opportunity will have been lost. If, alternatively, they can inspire, motivate and thoroughly connect with their frontline clinicians then they will have created a force quite unparalleled in the history of the NHS. Clinical commissioning is predicate on clinical leaders and clinicians at the frontline joining forces to put patients and their communities first. It is a formidable challenge, a social responsibility but also a huge privilege and leadership opportunity for general practice. It is also the only possible or realistic answer to how we can create a sustainable NHS.