Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study

Abstract

BackgroundA core component of the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS.ObjectivesThis research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform.DesignThe project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons.ParticipantsIn addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies).ResultsInstances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board level, (2) mid-range operational planning and negotiation at programme board level and (3) the arena of practical implementation leadership at the point of delivery. The arena of the CCG board provided the legitimacy for strategic change; the programme boards worked through the competing logics of markets, hierarchy and networks; and the practice arena allowed the exercise of clinical leadership in practical problem-solving, detailed learning and routinisation of new ways of working at a common-sense everyday level.LimitationsAlthough the research was conducted over a 3-year period, it could be argued that a much longer period is required for CCGs to mature and realise their potential.ConclusionsDespite the variation in practice, we found significant examples of clinical leaders forging new modes of service design and delivery. A great deal of the service redesign effort was directed at compensating for the fragmented nature of the NHS – part of which had been created by the 2012 reforms. This is the first study to reveal details of such work in a systematic way.Future workFurther focus is needed on the emergent sustainability and transformation plans and the locality/hubs/primary care homes that integrate care across population groups.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context

“…The reported need to improve data availability and quality [ 21 26 71 74 75 ] is of paramount importance for the successful development of integrated care programmes and the realization of their expected benefits. Routine collection and use of data related to the triple aim, particularly on patient experience, would enable the monitoring and performance evaluation of integrated care programmes.…”

“…In regards to the reported difficulties in patient and public involvement [PPI] in the commissioning process, with the emerging ICSs such difficulties should be resolved by defining a clear plan on where, how, and to what capacity PPI will be part of the process [ 11 26 76 ]. A formalized space for PPI within the ICS structure is probably necessary for PPI to be a reality in the local commissioning process [ 77 ], and Integrated Care Boards have legal duties in this regard [ 3 5 78 ].…”

“…Healthcare commissioning is a continual multifaceted process that involves understanding of population needs, prioritising and planning the services to meet those needs, purchasing services on a limited budget, and monitoring the provision of the procured services [ 4 ]. There are multiple actors involved in this process, and the CCGs were the main actors in the commissioning decisions [ 26 ]. These groups were not structured in the same way, but they all had a commissioning directorate composed of lead commissioners, directors and managers of the different teams or work-streams (e.g.…”

Untangling approaches to management and leadership across systems of medical education

“…More recent views, including practitioners, do, however, support Noordegraaf’s conclusions. These argue that there is little coverage or opportunity to develop management and leadership skills [ 45 – 48 ] and highlight that some postgraduate (specialist) curricula are currently less fit for purpose than others in this regard [ 48 ]. In both the UK and Netherlands (and other countries) extra curricula training appears to be offering more substantial development in this area (as the paper will discuss shortly).…”

“…However, initiative specific evaluations have also highlighted certain problems, associated with the wider culture in which they occur. For instance, evidence suggests that new insights and skills may be undermined both by the cynicism of doctors’ own colleagues and ‘tokenistic’ support received from general managers [ 45 , 65 , 69 ]. More systematic reviews also suggest that many interventions are aimed at senior staff and lack a real focus on collaboration, even in countries where this is included in competency frameworks, and fail to incorporate a work based, experiential learning approach [ 55 ].…”