CCGs need to evolve and mature, NOW!

I have writEvolutionten before about the difference between ‘unconscious incompetence’ and ‘conscious incompetence’, and how one has to recognise a deficiency before one can address it, but I have rarely seen such an acute example as the one that currently exists in the CCG world.

As new organisations, often incorporating senior GPs with little if any experience of strategic leadership, it is perhaps not surprising that CCGs have taken time to grasp the breadth and the depth of the issues that face them; not only are they notionally responsible for an annual budget of over £60 billion of public money, they have to ensure that their own primary care house is in order, and deliver a degree of corporacy amongst their members that has never even been envisaged, never mind achieved.

However, now that they are nine months into their first ‘live’ year, one might have hoped to see more recognition of these issues, and a wealth of initiatives both locally and nationally to try to jolt the young groups into a maturity that admittedly needs to be well beyond their years. It is disappointing therefore to note that (certainly in my universe), there appears to be little if anything happening at a systemic level. The Leadership Academy seems intent on setting up a production line to manufacture senior leaders (an oxymoronic concept if ever there was one), and attracting mainly managers from provider organisations.

Others that might be expected to be compiling effective, accessible programmes to fast track CCG development (NHS Confed? BMA? RCGP? NHS Clinical Commissioners?) seem at best merely to be considering setting up such initiatives. They appear to be more concerned with meeting DH/NHS England operational edicts and maximising contractual benefits, beginning to replicate what CCGs were intended to end once and for all: doing things right at the expense of doing the right things.

In the meantime, NHS England, in its unreconstructed macho fashion, is starting to exert more direct pressure in the only language that its political masters seem able to understand: reductive operational targets. The whole notion of culture change and clinically led progress is rapidly being diluted, to be replaced by structures that will look more and more like PCTs, or the even older Health Authorities.

So what is required? The first thing is for CCGs themselves to recognise the need for internal development; even in my own small way, I have been trying to encourage the development of locally focused leadership programmes, learning sets, even stand alone workshops for CCG staff and their members to start to get to grips with the agenda, but it is proving to be a steeply uphill task. CCG chairs and accountable officers should think about resourcing such work themselves, as large scale mass produced products can never achieve the kind of cultural and organizational ‘fit’ change that a ‘bespoke’ programme can. The larger players (see above) should support and facilitate these local processes, and some central resourcing would be very helpful to oil the wheels and get the show on the road.

Do it now, applying a bit of welly to the process, and progress will be satisfyingly fast; leave it much longer, and those in the rank and file of the CCGs, the GPs who really need to ‘think differently’ to achieve systemic change, will have lost interest and gone back to the day job. Without them, not only will CCGs not succeed, the ‘supply side’ drivers (hospital crises, by and large) that have steered the NHS for so long will come to dominate even more strongly, with the only levers available to control them being the traditional blunt, insensitive, centrally controlled levers that have never really worked.

As the adage has it: ‘if you always do what you’ve always done, you’ll always get what you’ve always got.’ Isn’t it time that CCGs started taking control of their own destinies?

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Urgent or important? The CCG imperatives

CoveyI don’t usually have much time for self help books, and much of Stephen Covey’s ‘Seven Habits of Highly Effective People’ is fairly self-evident; it’s not exactly rocket science.

However, his famous ‘urgent/important’ matrix does come to mind when looking at the way in which the NHS operates; indeed, the matrix seems to apply to most public services. It is a pictorial diagram (see above) which essentially divides life’s tasks into four quadrants. These range from those that are not urgent and not important, and should thus be given extremely low priority, like washing the car (pretty obvious really), to those that are both urgent and important, like putting out the chip pan fire, that need to be completed as soon as possible (not too difficult to understand either).

It’s the ones in-between that are more interesting: Covey makes the point that urgency tends to trump importance, so that tasks that are urgent but unimportant are given disproportionate priority over those that are important but not urgent, which are all too often ignored. It may be so in our personal lives, where things done for the sake of appearance are all too often given priority over the things that actually need to get done, and it certainly applies to life in the NHS.

Thus for example, reporting the handling of a patient’s complaint seems to take precedence over the handling of the complaint itself, just as when we were children, keeping our rooms tidy was seen as being more important than playing the interesting games that would get them in a mess in the first place.

Much of this dissonance comes from the issue of power and agenda setting. When we were children, it was our parents who did both, and for CCGs, it seems to be almost everyone else that has the power and drives the agenda: NHS England, the area team as their local incarnation, even the local acute Trusts seem to be able to impose their priorities onto the new clinical commissioners. This has meant that many of the CCGs have been spending the last six months adhering to due process and meeting externally imposed targets –  all of which are urgent – at the expense of maturing as commissioners, and developing their working relationships – all of which are important.

The imbalance of power that leads to this distortion of priorities underpins many relationships (personal as well as in business), but is particularly pronounced in the public sector, where political pressures (often manifested in the media) are expressed as well as financial ones. It is a truism that ‘he who pays the piper calls the tune,’ but when he who pays the piper also lays down the law and feels the need to respond to populist prejudices, then the piper is bound to find it difficult to produce new tunes or even refine the old ones.

In NHS terms, we can see the consequences of this phenomenon in a number of ways; for many CCGs, the urgent daily pressure to meet an endless series of operational targets (mainly financial, but also based on clinical and administrative activity) has subsumed the important task of developing a sustainable strategic approach to the delivery of services. The constant need to tick all the short term boxes puts at risk the underlying purpose of CCGs, which is to get to grips with the commissioning agenda: rationalising the delivery of health services so that the NHS has a chance of coping with the pressures of future demand.

The external pressures are also constraining many CCGs from prioritising their own development in terms of both time and money; many have set up novel management arrangements for their senior teams, but these need developing and honing. Perhaps more importantly, CCGs all need to work with their members to change the whole nature of the relationships between individual GP practices and their CCG, so that they fulfil the promise of marrying local implementation for their individual patients with more strategic planning for entire populations.

Of course, it’s easy to criticize other people’s policies, and the reality is that political and financial imperatives have to be met. So how can the important match the urgent? From my perspective, the answer is for the Centre (NHS England and the area teams) to forge their links with the CCGs based less on micromanaged targets, and more on agreed outcomes. Once a CCG has agreed to deliver some broad, population-based outcome objectives with an appropriate budget, then it should be left to the CCG to manage its operational delivery without its ‘parents’ looking over its shoulder all the time, and telling it to ‘go and tidy your room.’

Whether as maturing teenagers or NHS agencies, the key is to feel that we are acting on what we feel is important, not what we are told by others. If the NHS perpetuates the current situation, where CCGs are all doing what others feel to be urgent, then the future of the new system will be short lived indeed; however, if CCGs are allowed to decide their own set of urgent and important priorities within a broad national framework (and budget), then the system will do what was intended: better care, more locally and efficiently delivered, on a more sustainable basis.

A version of this article first appeared in Pulse on 24 September 2013.