Leadership for health commissioning in the new NHS.

Journal of Health Organization and Management Leadership for health commissioning in the new NHS : Exploring the early development of clinical commissioning groups in England Anna Coleman Julia Segar Kath Checkland Imelda McDermott Stephen Harrison Stephen Peckham

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Leadership for health commissioning in the new NHS

Leadership for health commissioning

Exploring the early development of clinical commissioning groups in England

75

Anna Coleman, Julia Segar, Kath Checkland, Imelda McDermott and Stephen Harrison


Institute of Population Health, University of Manchester, Manchester, UK, and

Received 4 April 2013 Revised 5 April 2013 5 August 2013 15 October 2013 Accepted 15 October 2013

Stephen Peckham Centre for Health Services Studies, University of Kent, Canterbury, UK Abstract Purpose – The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a “clinically-led” system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for “great leaders”. Design/methodology/approach – Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed. Findings – The authors found evidence of two identified approaches to leadership – positive deviancy and responsible guardianship – being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to “do things differently” to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs’ performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership. Originality/value – This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles. Keywords Commissioning, Leadership, Clinical commissioning groups, Positive deviants, Responsible guardians Paper type Research paper

Introduction The upsurge of interest in leadership in the English National Health Service (NHS) is a response to the government’s belief that stronger leadership is needed in the public sector. This is because strong leadership is seen as critical to navigating transition and uncertainty on the scale that is currently seen within the NHS (Dopson and Mark, 2003, p. 251). The authors are grateful to the participants who were very generous in allowing us access to their organisations at a time of considerable turmoil and change. The authors are also grateful to Rosalind Miller, Christina Petsoulas and Andrew Wallace for their hard work during the data collection.

Journal of Health Organization and Management Vol. 29 No. 1, 2015 pp. 75-91 © Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-04-2013-0075

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These words were written in 2003, but are equally relevant today as the Health and Social Care Act 2012 (Department of Health, 2012) instigates the most extensive reorganisation of the structure of the National Health Service (NHS) in England to date. The legislation abolished Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs), with the majority of the commissioning budget transferred to 211 newly developing Clinical Commissioning Groups (CCGs) from April 2013. These groups are now partly led by General Practitioners (GPs), and this significant structural change was justified as part of the governments’ stated desire to create a clinically driven commissioning system that is more sensitive to the needs of patients. At the same time, other parts of the NHS have undergoing parallel changes, also aimed at increasing clinical leadership of the service (NHS Commissioning Board, 2011a). In this paper we explore the early experiences of those involved with the development of CCGs, looking at how this aspiration towards a “clinically-led” system is playing out in practice. We investigate two leadership approaches previously identified in the literature as being important in the context of major change – responsible guardianship and positive deviancy (Allen and Wade, 2011). What follows is divided into five sections. A brief description of the scope and nature of the current changes affecting the English NHS is followed by a brief discussion of relevant literature relating to the concept of “leadership”. Our methods will then be described, and the results of the study reported, with a final discussion section exploring the significance of these findings for NHS policy and practice. Clinical commissioning group establishment and development The proposals contained in the Department of Health, 2012 were not discussed during the 2010 general election campaign and were not contained in the May 2010 coalition agreement (Cabinet Office, 2010, p. 24), which stated an intention to “stop the top-down reorganisations of the NHS that have got in the way of patient care”. However, within two months of the election a White paper, Equity and Excellence: Liberating the NHS (Department of Health, 2010a) was published and was followed in December 2010 by a plan for its implementation (Department of Health, Cmd 7993, 2010b). Under these proposals (subsequently legislated for in the Department of Health, 2012), from April 2013, all GP practices are obliged to belong to a CCG, which are now the statutory bodies responsible for commissioning the majority of elective and urgent healthcare for a geographical population. The groups are overseen by NHS England (previous know as the NHS Commissioning Board (NHSCB) – name changed in April 2013[1]), which is charged with ensuring that CCGs have the capacity and capability to commission services successfully and to meet their financial responsibilities. At the same time, new Health and Wellbeing Boards (HWBs) were established as sub-committees of Local Authorities, responsible for updating the local Joint Strategic Health Needs Assessment and for setting the overarching strategic direction for commissioners (Coleman et al., 2014). CCGs are the cornerstone of the Government’s health reforms, with clinicians at the front line of patient care being given a stronger leadership role in shaping and running the NHS. At the outset the language relating to developing CCGs (previously known as GP Commissioning Consortia[2]) in the White Paper (Department of Health, 2010a) was permissive, emphasising the need to allow them to develop from the bottom up, free from central direction. In October 2010 groups of GPs wishing to form a CCG were invited to put themselves forward to be “Pathfinders”, testing different design concepts and helping identify areas for learning. Early documents about the “Pathfinder” programme implied that those coming forward might be a set of early adopters (or

“pioneers”, Checkland et al., 2012), with a letter issued by Dame Barbara Hakin in October 2010 stating that:


The objective of establishing pathfinders is to empower pioneering groups of GP practices that want to press ahead with commissioning care for patients. Specifically the programme will: • identify and support groups of practices that are keen to make faster progress, under existing arrangements, and can demonstrate their capacity and capability to take on additional responsibility for commissioning services, in line with the proposals set out in Equity and Excellence: Liberating the NHS; • enable GPs, working with other health and care professionals, to test different design concepts for GP consortia [CCGs] and identify any issues and areas of learning early so that these can be shared more widely (Hakin, 2010) (emphasis added in bold).

The Government’s responses to the consultations on the proposals were published in December 2010 (Department of Health, Cmd 7993, 2010b). This document clarified how CCGs were expected to demonstrate their capability to NHSE in order to be “authorized” (p. 92). Subsequent documents published by the NHSE[3] set out expectations about the developing structure of CCGs, in particular the appointment of senior leaders. Each CCG was expected to appoint a Chair, an Accountable Officer and a Chief Finance Officer. In general, the Chair will usually be a GP, and the Chief Finance Officer a Senior Manager with previous high-level experience of financial responsibilities within the NHS. The Accountable Officer can be a GP or a Senior Manager; if a GP is appointed to this post, CCGs are expected to also appoint a Senior Manager as Chief Operating Officer. In addition, most CCGs also have a number of local GP representatives on their “Governing Body”, alongside lay representatives, a nurse and a secondary care consultant (Checkland et al., 2012). The leadership of CCGs is therefore to be a partnership between local GPs and a number of Senior Managers. Criteria for CCG authorisation were published in September 2011 by NHSE. These are set out under six domains which are as follows. Authorisation domains (NHS Commissioning Board, 2011b)[4]: •

•

Domain 1: a strong clinical and multi-professional focus which brings real added value. Domain 2: meaningful engagement with patients, carers and their communities.

•

Domain 3: clear and credible plan which continue to deliver the QIPP challenge within financial resources.

•

Domain 4: proper constitutional arrangements with the capacity and capability to deliver all their duties and responsibilities. Domain 5: collaborative arrangements for commissioning with other CCGs, local authorities and the NHSCB as well as appropriate commissioning support.

•

•

Domain 6: great leaders who individually and collectively make a real difference.

Within each domain, aspirant CCGs were expected to produce a range of evidence, e.g. plans and proposals, examples of work undertaken and feedback from local stakeholders. It is notable for the purposes of this paper that “great leaders” has a domain all of its own, demonstrating the importance attached to this aspect of CCG development. By 1 April 2013, the whole of England was covered by 211 CCGs, some fully authorised and some with outstanding conditions and/or legal directions which were to be reviewed in the coming months (NHS Commissioning Board, 2013).

Leadership for health commissioning 77

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The nature and complexity of CCG leadership Interest in the concept of leadership has developed significantly in recent years, both within the NHS and within management literature more generally. However, “leadership” remains a contested and complex concept, with many different definitions used and approaches taken. Kumar (2013, p. 39) argues that leadership in the context of modern NHS reform is aligned with quality improvement. Nicol (2012, p. 63) summarises the skills required to provide effective leadership and management in the NHS as “broad and numerous”, including the ability to develop collaborative approaches, alongside extensive corporate knowledge and patient-centric skills, as well as appropriate personal qualities to lead. The authorisation “domains” set out in the list above suggest that leaders (both clinical and managerial) in CCGs are required to take on a plethora of responsibilities requiring multiple skills if they are to lead service improvement successfully within an environment characterised by severely constrained resources. It is thus clear that the selection of appropriate senior leaders is one of the most important early tasks for developing CCGs. It is also evident that taking on and fulfilling these multiple tasks, at the same time as meeting targets set from above, represents a considerable challenge. According to Martin and Waring (2012, p. 3), recent developments in organisation theory have given rise to an increasingly pluralistic view of what constitutes leadership, moving away from an emphasis on a formal role and position, towards a wider understanding of leadership as an activity undertaken by multiple actors at different levels within an organisation. Chemers et al. (2000, p. 27) goes further, suggesting that leadership, rather than being a formal role or job, is “a process of social influence in which one person can enlist the help and support of others in the accomplishment of a common task”. This suggests the need to develop a “leadership team” within which each individual leader (clinical and managerial) brings different skills and attributes and opens up the possibility that rank and file members of the organisation must also be encouraged to lead. Past experience of “leadership” in GP-led commissioning Research conducted during 2011/20112 by Newman (2012) in NHS Midlands and East reviewed sustainable GP leadership and associated emerging issues. This found that the availability of GPs to lead commissioning is dependent on a complex set of factors related to their dual role as both providers and commissioners of care. Issues include: practice workload; individual choice and motivation; availability of skilled GP cover to provide backfill for those undertaking CCG work; relationships with partners; and the breadth of CCG requirements. It goes on to report that GPs adopt leadership roles because they believe that their involvement will contribute to the improvement of the care of their patients and in turn gain satisfaction in doing this. However, they also identify risks for GPs, which include dropping clinical sessions (impacting on their practices and potentially carrying risks that they will lose skills), losing income, taking unpopular decisions, and taking on new statutory responsibilities. The research describes a sustainable GP leader as flexible, adaptable, resilient and who can nurture others. Gillam (2011) suggests that “successful medical managers are usually experienced clinicians with good ‘people skills’. They are also strategic thinkers and visionaries who look beyond the boundaries of their own speciality; they exhibit passion and are prepared to take reasonable risks to achieve their goals, and more importantly, they know how to engage colleagues and effect change” (p1 editorial). At the same time, we know that, as Mintzberg (1989, p. 271) puts it, “transitions tend to be prolonged and

agonizing, as the [leaders] sit suspended between its old and new forms, with one group promoting change and the other resisting it”.


Positive deviants and responsible guardians In establishing functioning CCGs, many actors have been involved, both clinical and managerial. Allen and Wade (2011) suggest that amongst these actors two distinct leadership approaches will be necessary. They state that “both responsible guardians and positive deviants can and must act as leaders in this period of transition. Positive deviants, however, will be the key to actual change, requiring open minds in organizations and faith in what might be possible” (p. 313). These approaches can further be defined as: •

Guardianship (guardians of what works, keeping things operating in times of uncertainty). Enabling others to achieve purpose in the face of uncertainty (Ganz, 2009).

•

Positive deviancy (critical to allow the organisation to capture new ideas and innovation). Spreitzer and Sonenshein (2004) define this as intentional behaviours that depart from the norms of the referent group in honourable ways – this results in the system being disrupted but for the benefit of the organisation in the longer term. Leaders in the system who act as change agents (Allen and Wade, 2011).


Hackert and Hackert (2002, p. 450) argue that traditionally, deviance was defined as behaviour that violates the norms or that is negatively labelled and evaluated. According to Merton (1968 in Spreitzer and Sonenshein 2003, p. 208) deviance departs from institutionalised expectations. More recently, however, positive deviance has been seen as a conceptual possibility. According to Bloch (2001, p. 247), “Positive deviants are individuals who are not afraid to be different. While their colleagues may stick to well trodden paths, these trail blazers will strike out on their own and look for new, more effective ways of doing things” […] “As well as displaying a willingness to do things differently, positive deviants are focussed, persistent and optimistic in pursuit of their goals”. Storey and Grint (2012, p. 267) highlight the fact that the government set a direction of travel for the development of CCGs at the outset but did not provide a route map. Within this evolving context, “GPs will be expected to undertake some selected elements of leadership and some selected elements of governance” (p. 269) in their new roles as clinical leaders within CCGs. They argue that there are “distinct leadership and governance elements required under the [new] GP commissioning arrangements” (p. 263). These are set out in Table I. The aspects of what they term “Leadership” appear to map somewhat to the positive deviant characteristics of leadership set out above, whilst the “Governance” Leadership

Governance

Visioning/direction setting Mobilisation Scapegoat Source: Storey and Grint (2012, p. 266)

Legitimation Conformance and performance monitoring Regulation/accountability

Table I. Complementarities and tensions between leadership and governance

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characteristics map more readily onto the identified “guardianship” role. Storey and Grint (2012, p. 270) go on to suggest that the leadership pressures experienced by GPs in CCGs will be even more significant than those experienced in the past, as they will lead organisations responsible for spending the bulk of the NHS budget. There will be an expectation that they should spend more time helping to envision new and more effective care pathways and protocols and help set the direction of travel, whilst also mobilising their peers. These challenges suggest a need for “positive deviants” in the role. However, at the same time there has been increasing emphasis on the need for “good governance” in CCGs (Future Forum, 2011), suggesting a complementary need for “guardianship”. Indeed, following the initial publication of the White Paper, Equity and Excellence (Department of Health, 2010a), which emphasised the aspiration to allow CCGs freedom to develop as they saw fit, something of a backlash ensued, with significant negative commentary leading to the setting up of a further consultation process, whose report emphasised the dangers of leaving CCGs to determine their own structures: Commissioning consortia [CCGs] should not be given total freedom to determine their own governance arrangements. We recommend that they must at a minimum have a governing body, with independent membership, which holds meetings in public and consults publicly on commissioning plans. These safeguards will help secure the best outcomes for communities and guard against any conflicts of interest. (Future Forum, 2011, p. 27).

Thus, those who lead in the new system will be overseeing complex change whilst at the same time facing challenges to their own roles, their professional identity (both old and new) and their own personal beliefs. The task of commissioning is different to that of running a large organisation and according to Allen and Wade (2011, p. 311) it demands a different approach from those leading and driving the process. In the rest of this paper we explore how these tensions and challenges are playing out in practice as CCGs set themselves up and prepare to take over their new roles as clinical leaders. Methods The overall study design involved detailed qualitative case studies in eight CCGs, along with national web surveys at two points in time and telephone interviews with a random sample of CCGs. We selected a purposive sample of eight “Pathfinder” CCGs in England as participants for the qualitative case studies. In order to provide a sample that reflected the developing complexity on the ground, the sample was structured to incorporate the following dimensions: a range of geographical areas; size of the developing CCG; socio-demographic profile; numbers of associated providers and developing HWBs; and history, i.e. replication of previous commissioning administrative groupings. We also considered wave of “Pathfinder” for the developing CCG and rural/urban mix. Data were collected between September 2011 and May 2012 and the qualitative data collection included: interviews with a wide variety of GPs and managers (96 in total) associated with the developing CCG; observation in meetings (146 meetings, 439 hours); and collection of available documents. Meetings included CCG Board meetings, meetings of CCG subgroups and where applicable localities, HWB meetings and some meetings with providers. A total of 38 telephone interviews were carried out between May and July 2012. Data from the different sources were analysed thematically using Atlas Ti to help with its organisation. For further details on methods refer to Checkland et al. (2012).


This paper will focus primarily on data collected from the one to one interviews and observations at various meetings from the eight study sites and sets out ideas of developing leadership for CCGs considering the leadership role and its complexity, characteristics of managers and GPs, doing things differently to PCTs and confused messages set up as policy has evolved. Results from the research will be presented in the remainder of this paper, illustrated by quotes from interviews and extracts from meeting observations where they demonstrate a particular issue well, represent wider views or highlight an unusual viewpoint. Care has been taken that the anonymity of research participants has also been maintained in the presentation data. Therefore quotations and excerpts are labelled with an ID number and a generic description of the source, e.g. “Executive meeting” or “manager”. Results In the White Paper (Department of Health, 2010a) it was stated that the development of CCGs should be a “bottom up” process, with GPs deciding for themselves with whom they wished to collaborate and how they would go about commissioning. The only requirement initially was that aspirant groups should have a defined geographical footprint. The key factors which appeared to be at work in shaping the resulting choices were logics associated with a history of working together, along with a belief that CCGs should adopt a configuration that mapped easily onto patient flows. In many sites key individuals were also important in generating enthusiasm and pushing the group forwards. Therefore at the outset, there was (theoretically, at least) space for the “positive deviant” to try things out and encourage developing CCGs to do things differently. Which GPs are taking on leadership roles, and what approaches are they adopting? In all sites we were told that individuals matter. Whilst it may be possible to define generic skills and traits that leaders require, the specific personality, experience and approach of leading individuals were argued to be key determinants of how the process played out: My observation in terms of the emergent CCG it is really about leadership. If the leadership is good, then everything else will follow […] in terms of this CCG, it’s very well placed in its Chair and Vice Chair because both of them are very strong, capable, strategic leaders, who have, a very good view of how this could develop [Manager ID 249].

This respondent expressed clearly the perceived importance of the particular people in their locality, over and above structures: It’s about people and inter personal relationships and trust. And so it doesn’t matter whether the PCT goes or not. It makes a hell of a difference if [individual 1] goes or if [individual 2] goes or if I go to some extent now. And all of those relationships have to be re-built and I think there’s sometimes a failure to understand that relationships and organisations are not the same. It doesn’t matter really whether the PCT is here or not, it does make a hell of a difference if people turnover so regularly that there are no relationships left. And so we’ve got to try and get some continuity in relationships because nothing works without relationships, nothing can happen that’s good. And it doesn’t matter how competent new people are or how wonderfully organised the new structures are or how well communicated that change is, if you break all the relationships nothing works until all those relationships have been built. It’s just a fact (Manager ID 244).

In our case studies, the Chair and/or Vice Chairs (most commonly GPs) were described as people who are: able to see an opportunity and grasp it; able to encourage people; prepared to step forward to do the job; possessed of a unique skill set; able to steer


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people in the right direction; able to be in control; not highly political; and not in it for the glory of the public role. In one of the smaller CCGs, leadership was described as being about persuasion and getting buy-in from people. In other sites a good CCG leader was described as someone in whom others have confidence; someone who is committed, keen, strong, capable, and dynamic; someone who has a good view of how things could develop, able to develop a good strategy; and someone who is very clear about what it means to be a GP in commissioning. It would seem from these descriptions that CCG members were looking for both positive deviancy (able to see and grasp opportunities, keen and dynamic) and guardianship (persuasion and getting “buy in”) in their leaders. Most of the GPs we observed getting involved in CCGs have had previous leadership roles, either under previous forms of clinical commissioning in the UK (e.g. fundholding and/or practice-based commissioning) or having a role in the previous primary care groups/trusts. The exception to this was one site where they made a concerted and successful effort to reach out and recruit new faces. This manager explained what a difficult task faced those becoming involved for the first time: We’re asking the GPs now because they haven’t been involved to make a huge intellectual leap very, very quickly. And it is quick to get them in a position to be in authorisation of accountable budget holders […] accountable budget holders, and accountable for the decisions, therefore, they make, not just on patient safety quality, but also on the money; a huge, huge cultural change. And, again, how many of them ultimately will be up to it, who will want to be? I don’t know (Manager, ID 2).

However, this manager from the same site explained how valuable the new GPs could be, emphasising their potential to adopt an approach that incorporated positive deviancy: The new GPs who’ve stepped up are actually […] have been really, really good and have actually added something really new. I think what you needed in a way was someone who was a brand new, fresh approach to it saying this is the new world, it isn’t just a […] the old PCT with more GPs on it, it’s a brand new world, this is GPs taking charge, let’s […] come on, let’s get involved and throw some enthusiasm on it, which is actually really, really good (Manager, ID 3).

This manager went on to explain that it is easier to recognise good leadership than it is to specify in advance what it should be: Leadership qualities are very difficult to write down on paper because they’re easier to recognise in someone (Manager ID 244).

Sometimes, the ability and confidence to challenge (a form of positive deviance) was also identified as an important characteristic of the emerging leaders: And, he’s transformational lead and he’s grit in the system, really, he’s the challenging one, He doesn’t care who he, you know, he does care, but, he doesn’t really, he’s not inhibited, at all, which is terrific! Terrific, terrific, terrific, that’s great to see and he upsets people, which, you know, upsets people I respect, as well, but, I don’t mind it (GP ID 102).

The respondent went on to describe this GP further and suggest he is an asset on various committees, especially when greater decision making is required: He does have a way, about him, that is interesting, you know, and, sometimes, from what I’ve seen of him, he, certainly, asks, probably on one of the committees, the [named committee], he asks, often, the most challenging questions and I, completely, respect that, because, he has an understanding behind him and he’s a bright lad and I’d, certainly, welcome him as part of my, you know, that committee (GP ID 102).

In other cases, people told us that it was important for the Chair and Vice Chair to have different attributes which complement each other, with one bringing the positive deviancy whilst the other supplied the guardianship:


I mean you can only comment on your own relationship can’t you, but ours works very, very well. You know, because [locality lead] is very […] he’s very visionary, clinically visionary. Very politically astute, and, you know, very good at lots of things at that sort of level. I’m the one who can do the very practical, ‘Okay. What are we going to do about this then?’ And together […] we actually work very well. Because our skill set is complementary. (Lay Member ID 247).

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Overall, therefore, respondents seemed to be identifying the need for both positive deviancy and guardianship. In some cases it was implied that this needed to be two separate people, bringing different and complementary strengths to the group. Management characteristics In addition to GP leaders, the personality and behaviours of the non-clinical managers involved was also important (Checkland et al., 2012). This respondent explained that managers needed to work carefully over time to build up the necessary relationships with the GPs: And of course, from my perspective, it was a case of what I didn’t want to be doing is going in there and suddenly saying, by the way, we should do this because actually it feels like a good thing. It was more about building those relationships up rather than suddenly saying, I think you should do this and I think you should do this and I think you should do the other. It was about pacing, which is what that was all about (Manager ID 34).

A number of managers told us that their role was crucial, because they were there all the time, whereas GPs might only be working on the CCG one or two days a week. Keeping an overview of what was going on and providing GPs with support was seen as key. Whilst much work was done via e-mail and online, we were also told by a number of managers that being physically present in a locality where they could meet with GPs and discuss things face to face remained valuable. GPs agreed, explaining that they needed managers who were there all the time and who could act as a conduit to make sure things are co-ordinated: I think the interesting thing, from my perspective, is that I work with the network manager and I think her role, within how I function in that particular aspect of the job is quite fundamental, really, because she’s at that desk all the time, and things that come through and whiz around, I’m trying to ensure [that things] go through her, not to me, so that she’s not a filter, but she’s aware of everything that’s going on, rather than just coming as an email to me (GP ID104).

Another manager explained: […] They’re [GPs] not taking the lead in the meetings and the administration and the making sure that things happen, so that still falls to us and I think that’s the intention. I don’t think there’s any intention that GPs take over administration. I think the intention is that GPs provide leadership and direction (Manager ID59).

This might suggest that currently the non-clinical managers see themselves as responsible for supplying the “guardianship” approach to leadership, making sure that the CCG operates effectively and meets the many national and local targets set. However, this “guardianship” role is also being squeezed as many ex-PCT staff have

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either moved into local Commissioning Support Units (CSUs[5]) or have lost their jobs. There is a danger that a dispersal of staff on this scale may result in a loss of experience and organisational memory which in many cases is important to the guardian leadership approach (Pollitt, 2009). Doing things differently (from PCTs) It was clear that some of our sites were keen to establish ways of working that were quite different to the ways the local PCT had previously worked. As Bloch (2001, p. 275) explains: “What it does require is a willingness to experiment, to deviate from the norms that brought about the need for change in the first place” and this was seen during our research: This whole issue is around CCGs mustn’t look like a PCT. What we’re saying here is that we don’t want to throw the baby out with the bath water and also we already don’t look like a PCT, because we’ve outsourced quite a lot of services since PCT days (Manager ID54).

Leadership styles in PCTs could be characterised as focusing upon guardianship-style leadership, with an emphasis on getting things right, ticking boxes, and formal processes (Greener, 2008). GP leaders, by contrast, appeared to be moving towards something different at least in the early stages of developing CCGs. In some cases a positive deviancy-style was observed (encouraging less bureaucracy, using opportunities to try things out, testing established norms) but at the same time having an eye to guardianship issues. For example, the following exchange was observed, pointing out how the CCG is different from the PCT in terms of getting things done more effectively: (Officer ID 287): Don’t want to recreate PCT. Take the best bits and move forward. What’s frustrating in the NHS is slow decision making. [Everyone agreed]. That’s what we need to lose. Need culture change. (GP ID 282): commented that they [the Board] is clear that they are a “doing” Board, which is different from PCT. They have to be “lean and mean” but they will get support from commissioning support. He said “we are clinically led and professionally managed” (Council of Members Meeting ID M51).

Other respondents expressed the view that times of change could provide opportunities to try doing things in new ways: And, I think, that will be well received, it’s a complete change in how things have been done, in the past, I’m not saying, old is bad and new is good, but, I do think it’s an opportunity to do things differently and keep things simple. (Manager ID115).

In some sites there was evidence that things were already changing with GPs taking the lead in decision making and contract meetings, although this had to some extent been happening in this site prior to the introduction of CCGs. However, in other sites, they were being more cautious and it was clear that their perception of a safe way forward was to make sure that all things that PCTs were doing were covered by the emerging CCG. This was recognised by managers who had been through past reorganisations and were concerned that organisational memory should not be lost: (GP ID 232) said this was not possible because of the disbanding of the PCTs. She said that this is the 7th NHS reorganisation that she has been through but that now the organisational memory resides with them. […] She said that the biggest issues would be

around finance around understanding why things are in different budgets and that people in the new organisational structures won’t necessarily know this (Members Meeting ID M52).


Additionally, it was stressed that it was not worth trying to reinvent the wheel and that where things were working it was important to retain such processes and practices. A manager suggests that changes are required from both clinical and managerial leaders for the new CCGs to work effectively. Both need to gain an understanding of each others’ current and developing roles: It’s really the cultural challenge I think, for GPs to understand what it’s like to be commissioners. The statutory responsibilities you have, you know, there are things that you must do, should do, and them understanding, I think, some of the legal frameworks and constraints. And then for managers I think the challenge has been around the shift of culture, becoming more clinically orientated, which is good (Manager ID9).

Others recognised a balance between wanting things to change but accepting that some processes would have to stay to enable the organisation to operate and be transparent in their ways of working. And some respondents were also beginning to look for new opportunities to do things differently and sometimes articulated ideas by using examples of companies’ operating outside of the NHS to illustrate the points: We have new sticks and carrots and can use these in contracts and patients have choice. Patient experience is the way forward – look at Waitrose and John Lewis. We need to build relationships and know how to get feedback appropriately (Meeting ID M41).

However, this GP suggested that bureaucracy had the potential to constrain developing leaders, although they also recognised the need for certain checks and balances: So, I’d like them [emerging leaders] to have the confidence to fashion exactly what they would like, without being too constrained by a lot of the bureaucracy that seems to be creeping in, I’m no great fan of risk management, and all this kind of business, I, absolutely and fundamentally understand it’s importance (GP ID 102).

Another manager discusses the legacy of past management and leadership ways of working and some of the difficulties of making the necessary changes. S(he) recognises that change will be required but at the moment cannot see how this will happen: The difficulty is that that has to be clinically led but people have been trained under the existing leadership, management leadership, to emphasising the transactional elements of contract management. And, of course, you have to write the contract in order to […] in order to ensure that your service development takes place, but […] and you have to manage that contract. But unfortunately, the kind of […] this thinking doesn’t seem to happen far enough upstream to change things at an early enough stage (GP ID 1).

Many of the interviewees expressed the difficulty they perceived as the initial freedom to develop as they saw fit (while Pathfinders) became ever more limited. In addition, despite NHS England stating on their web site[6] that “We empower and support clinical leaders at every level of the NHS through clinical commissioning groups (CCGs), networks and senates, in NHS England itself and in providers, helping them to make genuinely informed decisions, spend the taxpayers’ money wisely and provide high quality services”, some of our interviewees in the telephone


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surveys (May 2012) told us that they hoped that NHS England would adopt a “hands off” approach: […] just be allowed to get on and do the job, hard for politicians and NCB [NHSE] to keep their hands off but can’t spend all our time to provide them with data, we need to get on with the job on the ground (Tel Ints GP ID1).


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We need what a good parent is to a teenager, you need them [NHSE] to be there when you need them, you need them not to be there when you don’t need them (Tel Ints GP ID 2).

Moving goal posts As highlighted above, the initial message from NHSE was that CCGs would have the freedom to develop as they wished, with GPs encouraged to get involved and be creative, trying out new models and new approaches. This implies that “positive deviancy” is to be encouraged and rewarded. However, over time our study found that developing CCGs were subject to increasing direction and control, both in their internal development and in their freedom to act. In terms of internal organisation, far from being allowed to “test different design concepts” (Hakin, 2010), CCGs were eventually issued with prescriptive guidance about their internal organisation, which closely specified the roles required on the Governing Body including, for example, the requirement that secondary care consultants must not work locally and that primary care nurses were ineligible for membership (NHS Commissioning Board, 2011b). In addition, early encouragement to look beyond the “usual suspects” in appointing managers to work in the CCG was superseded by a prescriptive process which specified tightly who would be eligible for such posts and required applicants to be put through a “prior approval” process in which CCG leaders had no say (NHS Commissioning Board, 2012c). In terms of freedom to act, CCGs were perhaps less constrained, but still subject to increasing central direction during the research period. Two examples stand out. First, it was initially stated that CCGs could look for commissioning management support wherever they wished, “buying in” support from providers or appointing staff to work internally. The first constraint upon this freedom came from the very tight management budget that they received: […] part, part of the reason why we still haven’t worked all this out yet, is because we thought that as a large CCG we’d be doing a lot of this in-house anyway, so it came to us fairly late in the day that we would have to start thinking about externalisation of, of a lot of this (Manager, ID 171).

Later on, as the proposals for the development of CSUs (NHS Commissioning Board, 2012d) developed, it became clear that initially at least; CCGs would be compelled to buy their commissioning support from a newly constituted CSU: Well, er, again, this is difficult: the GPs want to take an open view of this and say they want to see the offers from a range of commissioning support services and be able to then choose the one that determines the most. Quite rightly what the SHA are saying is, no, we need some stability in some, um, of a, a period of, um, a period for the CSSs [CSU] to get up and running and be able to establish themselves effectively, so they need a period of at least, um, 12 months, possibly three years, where they have guaranteed business in order to get themselves going (Manager ID 171).

Second, during the research period CCGs were compelled to undertake a procurement for a new non-emergency urgent care service, known as “111”. This nationally mandated procurement was resented by some: (SHA Rep): CCGs are all about changing systems and getting better value. (GP ID286): (skeptical) this is someone else’s agenda and “it’s what we are left with”.

(SHA Rep): But presumably you wanted this given decreasing budgets. It makes sense. (GP ID282): “We are being told what to do” (re 111 procurement). “but then we know it’s not about local commissioning”.


(GP ID284): 111 procurement is incompatible with CCG philosophy (bottom up). It isn’t going to work. Part of our vision has got to be about being “evidence based” (Meeting ID M50).


It is, of course, not unreasonable for those with overall responsibility for “guardianship” of the service as a whole to seek to put in place systems that will ensure service continuity and reduce risk. However, the resulting constraints suggest that the scope for leaders to embrace “positive deviancy” or at least try out new things may be limited. Discussion and conclusions In this study we found evidence of the development of both approaches to leadership (positive deviance and responsible guardianship) by GPs and managers. As has been noted before (Coleman et al., 2009), historical experiences and previous ways of working appear to influence current developments. Initially, both managers and GPs emphasised the need for some element of positive deviancy in order to fulfil the perceived potential of the new system. At the same time, managers saw themselves as providing the guardianship necessary to keep the system functioning. However, it was also clear that, whilst early NHSE communications emphasised the ability for developing CCGs to choose their own ways of doing things, there was a subsequent shutting down of space for deviance to flourish, as CCGs came to realise that the route to authorisation required them conform more closely to models of working determined from above. The other emerging issue, common to many sites, was their desire to “do things differently” to the former PCTs. While there was recognition that some processes and systems were necessary for the effective running of the developing organisation, it was also suggested that lessons about what worked and what did not work from the operation of PCTs should be considered as CCGs are established and changes made where appropriate. Our research suggests that both types of leadership will be necessary as CCGs continue to develop. CCGs face a very challenging situation as they take over full responsibility for commissioning and in these circumstances, our findings raise some important issues which will need to be considered both by CCGs and by the NHSE. First, the “guardianship” approach to leadership will be crucial if the new system is to avoid early disasters. However, many staff carrying the institutional memory of how the system needs to function have left the NHS altogether, and others have moved from PCTs to join large CSUs, where they may well be working across large geographical areas where their lived experience of local networks will be of less direct relevance. Finding a way to capture and utilise these valuable repositories of knowledge will be vital to the success of the new system (Pollitt, 2009). Second, there is a longer term need for “positive deviancy”, as future financial pressures mean that doing “more of the same” won’t work. According to Allen and Wade (2011, p. 313) “if positive deviance can be identified, accepted, and understood then there may be exciting and innovative changes to take the management of healthcare forward”. However, to date the pressures of getting the various organisations up and running and working together, and the very detailed and bureaucratic authorisation process, have limited opportunities for positive deviancy to be developed and expressed. Storey and Grint (2012, p. 263) suggest that “the ways in which, and the resources with which they [GPs] discharge their new roles will depend crucially on how they [GPs], and significant others [NHS managers, NHSE local teams] understand the nature

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of leadership and governance”. It appears that CCGs (and associated organisations) will be subject to significant oversight by NHSE, with annual reviews and performance assessment against a new set of performance indicators[7]. This is necessary in order to answer concerns that have been widely expressed about the accountability of actors in the new system (Future Forum, 2011). However, it also carries with it dangers, as overzealous performance management may stifle innovation. Given the current financial situation in England, it may be that some of the savings required will not be realised until the positive deviants (if they exist in CCGs) are allowed to try things out differently in a meaningful way and take some risks in order to make the significant changes that will be required. In a recent article, Baker (2013) argues that it will be difficult for those in developing CCGs to hold onto difference, creativity and innovation and all too easy to go back to being instructed what to do from above. She goes on to argue that a mature relationship is required between CCG leaders and local NHSE teams in order to foster “can do” environments for change. Hence, the longer term question is: will NHSE allow positive deviancy to flourish, and if they do not, will GPs maintain engagement? The tenor of comments from the leadership of NHSE (Kaffash, 2013) regarding early results of authorisation process (West, 2013) suggest that there will be significant top-down management of CCGs, limiting scope for positive deviancy. This mirrors the experiences of “Pathfinder” CCGs, where their scope to “try things out, learning from each other” was increasingly constrained by imposed targets and processes from above. Vize (2013) adds that GPs leading CCGs have a very powerful lever and if top-down imposition occurs – they may walk away. Research funding The study was funded by the Department of Health via its Policy Research Programme. The study formed part of the programme of the Policy Research Unit on Commissioning and the Healthcare System. The views expressed here are those of the researchers and do not reflect the position of the Department of Health. The study received ethical approval from NRES NW ref 0375. Notes 1. Throughout the run up to the implementation of the changes, the new national commissioning board was referred to as the NHS Commissioning Board. However, in April 2013 this was changed to NHS England (NHSE). For simplicity’s sake throughout this paper we refer to NHSE, even though many of the documents referred to were issued under the name of the NHSCB. 2. For ease this paper will refer to Clinical Commissioning Groups (CCGs) despite the original documentation referring to Commissioning Consortia. 3. For a full list go to NHSE web site: www.england.nhs.uk/ 4. The Quality, Innovation, Productivity and Prevention programme (QIPP) is a national Department of Health strategy involving all NHS staff, patients, clinicians and the voluntary sector. It aims to improve the quality and delivery of NHS care while reducing costs to make £20bn efficiency savings by 2014/2015. These savings will be reinvested to support the front line. 5. CSUs refer to NHS supplied commissioning support services, to distinguish them from the wider marketplace. There were 23 “in transition” prior to operation in 2013, at the time of writing there were 18. Their functions include transformational commissioning functions, such as service redesign; and transactional commissioning functions, such as market

management, healthcare procurement, contract negotiation and monitoring, information analysis, and risk stratification. www.commissioningboard.nhs.uk/ourwork/com 6. www.england.nhs.uk/about/ 7. The Clinical Commissioning Group Outcomes Indicator Set (CCGOIS) (formerly known as the “Commissioning Outcomes Framework” (“COF”)) is aimed at supporting and enabling clinical commissioning groups (CCGs) and health and wellbeing partners to plan for health improvement by providing information for measuring and benchmarking outcomes of services commissioned by CCGs. Refer to www.nice.org.uk/aboutnice/ccgois/CCGOIS.jsp


References Allen, B. and Wade, E. (2011), “Leadership for commissioning in an era of reform”, Public Money and Management, Vol. 31 No. 5, pp. 311-314. Baker, S. (2013), “New accountability in CCG commissioning”, Health Services Journal, 7 February, available at: www.hsj.co.uk/home/commissioning/new-accountability-in-ccg-commissioning/ 5053469.article?blocktitle ¼ Commissioning-highlights&contentID ¼ 8769 (accessed 11 February 2013). Bloch, S. (2001), “Positive deviants and their power on transformational leadership”, Journal of Change Management, Vol. 1 No. 3, pp. 273-279. Cabinet Office (2010), “The coalition: our programme for government. Freedom, fairness, responsibility”, available at: www.cabinetoffice.gov.uk/sites/default/files/resources/ coalition_programme_for_government.pdf (accessed 20 December 2012). Checkland, K., Coleman, A., Segar, J., McDermott, I., Miller, R., Wallace, A., Petsoulas, C., Peckham, S. and Harrison S. (2012), “Exploring the early workings and impact of emerging clinical commissioning groups”, final report, PRUComm, University of Manchester, Manchester. Chemers, M.M., et al. (2000), “Leadership research and theory: a functional integration”, Group Dynamics, Vol. 4 No. 1, pp. 27-43. Coleman, A., Checkland, K., Harrison, S. and Hiroeh, U. (2009), “Local histories and local sensemaking: a case of policy implementation in the english National Health service policy and politics”, Policy and Politics, Vol. 38 No. 2, pp. 289-306. Coleman, A., Checkland, K., Segar, I., McDermott, I., Harrison, S. and Peckham, S. (2014), “Joining it up? Health and wellbeing in the new english national health service organisation: early evidence from clinical commissioning groups and shadow health and wellbeing boards”, Local Government Studies, Vol. 40 No. 4, pp. 560-580. Department of Health (2010a), Equity and Excellence: Liberating the NHS, The Stationary Office, London. Department of Health, Cmd 7993 (2010b), Liberating The NHS: Legislative Framework and Next Steps, Department of Health, London. Department of Health (2012), Health and Social Care Act 2012, The Stationary Office, London. Dopson, S. and Mark, A.L. (2003), “Summing up. chapter 15”, in Dopson, S. and Mark, A.L. (Eds), Leading Health Care Organisations, Palgrave McMillan, Basingtoke. Future Forum (2011), “Summary report on poposed changes to the NHS”, available at: www.dh. gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127540.pdf (accessed 4 February 2013). Ganz, M. (2009), “Distributed leadership in the Obama campaign”, available at: http://mitworld. mit.edu/video/662 (accessed 4 February 2013).


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Gillam, S. (2011), “Teaching doctors in training about management and leadership”, British Medical Journal, Vol. 343, available at: www.bmj.com/content/343/bmj.d5672 Greener, I. (2008), “Decision making in a time of significant reform: managing in the NHS”, Administration & Society, Vol. 40 No. 2, pp. 194-210. Hackert, A. and Hackert, D. (2002), “A new typology of deviance: integrating normative and reactivist definitions of deviance deviant behaviour”, Deviant Behavior, Vol. 23 No. 5, pp. 449-479. Hakin, B. (2010), “Letter to SHA Chief Executives”, Gateway Ref: 14695.


Kaffash, J. (2013), “NHS Commissioning Board ‘to impose individuals on CCGs’”, Pulse, 21 January, available at: www.pulsetoday.co.uk/news/commissioning-news/nhs-commissioningboard-to-impose-individuals-on-ccgs/20001553.article Kumar, R. (2013), “Leadership in healthcare”, Anaesthesia and Intensive Care Medicine, Vol. 14 No. 1, pp. 39-41. Martin, G. and Waring, J. (2012), “Leading from the middle: constrained realities of clinical leadership in healthcare organisations”, Health, October , pp. 1-17, available at: http://hea. sagepub.com/content/early/2012/10/08/1363459312460704 Merton, K. (1968), Social Theory and Social Structure, Free Press, New York, NY. Mintzberg, H. (1989), Mintzberg on Management: Inside our Strange World of Organisations, Free Press, New York, NY. Newman, P. (2012), “Sustainable GP leadership for commissioning”, Health Services Journal, 20 November, available at: www.hsj.co.uk/resource-centre/leadership/sustainable-gpleadership-for-commissioning/5051421.article NHS Commissioning Board (2011a), “Developing the NHS Commissioning Board”, Gateway Ref 16222. NHS Commissioning Board (2011b), “Developing clinical commissioning groups: towards authorisation”, Gateway Ref 16367”. NHS Commissioning Board (2012a), Board paper – NHS Commissioning Board Authority. NHSCBA/13/04/12/1. CCG authorisation: draft applicants Guide. NHS Commissioning Board (2012c), “Clinical commissioning groups HR guide”, May. NHS Commissioning Board (2013), “Clinical Commissioning Groups Authorisation outcomes Wave 4: Summary of the decisions of the CCG Authorisation Sub-Committee held on 6 March 2013”. NHS Commissioning Board (2012d), “Developing commissioning support: towards service excellence (Appendix A)”, February, available at: www.england.nhs.uk/resources/css (accessed 15 July 2013). Nicol, E.D. (2012), “Improving clinical leadership and management in the NHS”, Journal of Healthcare Leadership, Vol. 4, pp. 59-69. Pollitt, C. (2009), “Bureaucracies remember, post-bureaucratic organizations forget?”, Public Administration, Vol. 87 No. 2, pp. 198-218. Spreitzer, G. and Sonenshein, S. (2003), “Positive deviance and extraordinary organizing (chapter 14)”, in Cameron, K.S., Dutton, J.E. and Quinn, R.E. (Eds), Positive Organisational Scholarship: Foundations of a New Discipline, Berrett-Koehler, San Francisco, CA. Spreitzer, G. and Sonenshein, S. (2004), “Toward the construct definition of positive deviance”, American Behavioral Scientist, Vol. 47 No. 6, pp. 828-847. Storey, J. and Grint, K. (2012), “Will GPs ‘lead’ or ‘govern’ the new clinical commissioning groups?”, Leadership in Health Services, Vol. 25 No. 4, pp. 263-272.


Vize, R. (2013), “Have NHS managers got the right skills?”, available at: www.guardian.co.uk/ healthcare-network/2013/jan/24/nhs-managers-right-skills (accessed 4 February 2013). West, D. (2013), “Three CCGs issued with legal directions”, Health Services Journal 25 January, available at:www.hsj.co.uk/news/commissioning/three-ccgs-issued-with-legaldirections/5054122.article


Further reading NHS Commissioning Board (2012b), “Clinical Commissioning Group Authorisation outcomes wave 1. Summary of the decisions of the authorisation sub-committee held on December 5 2012”, available at: www.commissioningboard.nhs.uk/files/2012/12/ccg-w1-outcome.pdf (accessed 20 December 2012).

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Corresponding author Dr Anna Coleman can be contacted at: [email protected]

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