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10th May 2011

GP Commissioning; Uncertainties and Opportunities

By now we are all aware, to some extent, of the various challenges and opportunities falling out from the proposed radical changes to NHS Commissioning. Impact Consulting work with leaders and teams from across a wide spectrum of NHS organisations, on both provider and commissioning ‘sides’, which helps us establish an overview of the background issues – as well as the unique perspectives of the different ‘participants in change’. These include Foundation Trusts, PCTs in transition, Third Sector and Local Authority bodies poised to ‘pick up some of the pieces’ as well as, of course, the emergent GP Commissioning Consortia.
Unsurprisingly, this quarter has seen us place a particular emphasis on such emerging Consortia, and the challenges they face. At the beginning of the year we conducted a regional survey into both GP and PCT Commissioner’s views on the nature of these challenges and the implications for ongoing leadership development amongst GPs. This was useful information to help guide development centre design, for prospective Consortium Leaders, and also to assist in the design of new Consortia Boards and their associated governance structures and processes

GP Survey; The unknown unknowns

Impact Consulting conducted a regional survey into both GP and PCT Commissioner’s views on the challenges facing emerging GP Consortia and the implications for ongoing leadership development amongst GPs. The survey output made for fascinating reading and the respondent profile in itself spoke volumes. The vast majority of responses were from senior commissioning staff, from PCTs in transition, anxious for their concerns to be taken on board. There were disappointingly few responses from GPs, despite the direct impact these changes will have on them. It is not clear whether this indicates a lack of interest or a sense of denial or doubt as to whether these planned changes will actually take place at all.

Many specific and useful suggestions were made with regard to development needs, but the underlying view brought to mind Donald Rumsfeld’s memorable ‘unknown unknowns’ – in that many GPs and prospective leaders of new consortia may not have yet realised just what it is that they don’t yet know! Fundamental to this are the implications of their required shift in perspective, moving from ‘patient advocate’, with emphasis on clinical governance, to ‘holders of the purse strings’, with emphasis on commercial imperatives and issues of corporate governance. Focus will need to move from individual patient needs to ‘big picture’ concerns, regarding wider population health levels. In addition, effective relationships need to be established both within consortia and with a whole range of prospective partners and stakeholders – in addition to preparations to field the inevitable negative media interest further down the line, when the honeymoon period is over and the impact of any budget limitations, on the patient service experience, is firmly ‘their fault’.
In terms of development needs, respondents saw the main concerns as being around Leadership skills – especially strategic thinking and decision making. Increased awareness of how the wider NHS economy actually operates was seen as an imperative as well as increased recognition of localised challenges and opportunities. Inevitably there were practical issues of concern, such as ability to establish effective and appropriate governance procedures, as well as a specific ‘to do list’ of hard skills, such as: contracting procedures; legal requirements (ie: “to keep out of jail”); and basic people, change, project and risk management skills.
However, equal and sometimes greater emphasis was put on the ‘soft’ interpersonal skills, both with regard to prospective provider partner relationships and stakeholder engagement, and within the consortia themselves. The latter is likely to require abilities in consensus building and conflict management, balancing the needs and demands of individual GPs and Practices with those of the overall ‘organisation’. Impact Consulting’s particular role, in this respect, is to help bring into play awareness and management of ‘Emotional Intelligence’ in this arena. Clients have found this concept to be a really helpful lever in the development of a wide range of interpersonal skills, particularly amongst clinical leaders.

GP Consortuim Board Development -Building flexibility to deal with change

Insight and learning from our recent GP survey has been invaluable in helping in the design and development of an emergent GP Consortium Board in the Northwest Region. Impact Consulting recently helped support a Board Development Team through this process. Initially, their effectiveness had been somewhat undermined by individual insecurity and group uncertainty as the recognition dawned of the scope and complexity of the challenges ahead – especially in the absence of clear guidance from the DH. This was countered by establishing a clear vision for the Board, and for healthcare within the consortium footprint, through use of a ‘future basing’ exercise – to help establish objectives and a strategy for moving forward. There were distinct advantages in starting with a relatively clean slate, in terms of outlook, and the group were able to move beyond ‘institutionalised constraints’ which might block progress within established organisations.

The view was that as flat a structure as possible was required for the Board, with a determination to minimise the need for excessive bureaucracy and ‘top down’ control, while maximising opportunities for constructive challenge. Garrett’s Board Tasks model was used to explore the workings of an effective board and the demands most boards face in reality, coupled with examples of where boards have failed spectacularly, and why. The main tension is generally one of balancing the demands for ‘conformance vs performance’ – ie: trying to satisfy requirements for accountability with the needs for policy development and proactive positive change. Focus was placed on maximising opportunities for strategic thinking and planning, within board meetings, by driving management and operational issues down to a sub-board. The structure of the final Board is planned to consist of a Chair (GP) and one tier of board members, at least two of which will be GPs (including the mandatory roles of Accountable Officer and Caldicott Guardian). The executive roles, of Finance and Operations Managers, will be filled by non-clinicians with previous relevant experience. From the governance perspective, two functional boards will report to the Operations Manager (Clinical Board, including Health and Wellbeing Board and Social Care reps, and non-clinical functions) and, in addition, representatives from the Public, Local Authority and the Clinical Board will sit on the main board – operating in a non-executive capacity (as ‘scrutineers’).

The key issues of learning here were around recognising where specific skills were required within the Board and ensuring these were selected for effectively. This highlighted the requirement for professional support in this process, eg: identifying and selecting the key skills and competences and experience within an assessment centre designed for this purpose. However, an internal question this and other emergent boards will face is whether key positions should be filled through appointments (by the Board Development Team) based on proven ability, or through a system of voting by the Consortium as a whole. This brings us back to our initial problem around the dangers of ‘unknown unknowns’ and the implications of important decisions being made without a real understanding of the implications.

Background Challenges
As a backdrop to all this, the PCT ‘mother ship’ is generally experiencing plenty of problems of its own during the period of transition. Although the senior staff of the PCTs we work with are fully committed to continuing to ensure positive outcomes for patients, the survey revealed numerous and inevitable issues around low morale and de-motivation – and possibly in some cases resentment towards new consortia who will take their jobs. The challenges of operating under these circumstances are legion and it is hard to sustain the critical mass required to ensure a professional legacy is delivered to the emergent consortia. PCTs often have no substantive CEO, with key staff being lost almost daily (along with their organisational memory), and conflicts often abound. Inevitably there are issues around who holds the mandate for various functions during the transitional period and tensions are involved in just keeping the show on the road – often against a backdrop of financial challenge.

Future support
Clearly there is a need for hard skills training within emergent Consortia – for example in budgetary awareness and management techniques. We provide support in helping to identify the skills required and offer approaches to both selection and development built around current financial constraints and the budgetary requirements of sustaining talent management into the future.
Our main area of support to emergent consortia is around the use of Emotional Intelligence in addressing the whole range of interpersonal challenges they face – with regard to stakeholder and partner engagement and in balancing the needs of the consortium with those of its GP members.

However, prior to all this is the need to help consortia build the kind of Boards which will help reinforce success, a clear vision of the future and a strategy to get there and sustain effectiveness. As one concerned respondent to our survey stated: “Please remember, it is no good commissioning care for today without making arrangements for care tomorrow”.