Clinical Commissioning Groups - To Authorisation and Beyond

healthskillsbegin with the end in mind

Clinical Commissioning Groups

To Authorisation and Beyond

begin with the end in mind

healthskills2-14 The Crescent, King Street, Leicester LE1 6RX

t: 0800 652 3322 e: [email protected] www.healthskills.co.uk


Clinical Commissioning Groups hold the key to the future of the NHS. We are already on the the journey from clinical engagement to full authorisation of CCGs. A journey that is likely to present us with numerous hurdles and challenges. A journey that will only be successfully completed with enthusiasm and commitment of frontline clinicians, managers and local people.

Clinical Commissioning in Action 2012NHS Clinical Commissioners

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The authorisation process is a significant first milestone for all Clinical Commissioning Groups on the journey to becoming a successful clinician led organisation. However, it isn’t the ‘end itself’; it is only the beginning of an exciting journey to transforming commissioning processes and collaborations to improve health outcomes for the local population.

We have been working with over 40 aspirant CCGs since 2010, helping them to reach this first important milestone, and to plan their development beyond authorisation. This booklet captures some of those stories to illustrate the range of external support that aspirant CCGs find helpful to extend their internal organisation and leadership capability.

All CCGs are using the 6 domains of authorisation as their roadmap for development. We have used the same roadmap to capture the stories:

Strong clinical & multi professional

focus

Authorisation

Meaningful engagement with patients,

carers and their communities

Clear and credible plans

Proper constitutional

and governance arrangements

Collaborative arrangements for commissioning

Great leaders who individually and collectively can make a real

difference

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Developing a Membership Organisation: Defying Gravity

Organisation culture emerges from a number of sources – one of the strongest is the beliefs, values and assumptions of the founder organisations. This became evident in

one of the CCGs we had been working with.

The CCG covers a large urban and rural population in the Midlands with 50 member Practices organised into 4 localities, each with a locality lead and clinical lead with places on the CCG Board. One of the key aims of the CCG is to be “clinically led and locally focussed”.

The CCG had operated in shadow form for a number of months coping with a range of pressures as the organisation formed. Some clinical leads on the Board were voicing concerns that the aspiration to be locality led was not felt in reality and that the CCG did not feel very different from the ‘old PCT days’. This was causing tension at both locality and Board level with some ‘management versus clinician’ disquiet raised.

The Board asked Healthskills to support development to re-engage Practices.

Our Approach

Our first step was to explore the issue with the locality and clinical leads; confidential 1:1 interviews with each leader began to help us and them to understand the extent of the challenge and strength of feeling across the localities. We also began to map the similarities and differences across each locality.

Strong clinical & multi professional

focus

Authorisation

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We used this data in a workshop with the locality and clinical leads to reflect back our observations and scope potential actions they could take to actively shape a culture of engagement across localities and the CCG as a whole. As well as driving immediate actions, the workshop enabled the clinical and managerial leads to:• explore the extent of the issue together, reviewing the causes and impact of behaviours• define the different roles of the governing body and the localities • shape a shared understanding of how as leaders, each can help to shape organisational culture.

One strong concern from that session was that locality meetings, a key touch point between the Board/management team and the member practices, needed to be improved urgently as one of key levers to help reshape organisation behaviours. We ran a series of refreshed locality meetings that would help to reshape the process.

The Outcome

The locality meetings have been ‘re-booted’, providing an engaging and dialogue driven opportunity for the member practices and governing body to meet, discuss and co-design solutions. The locality leads have developed a clearer idea of their role and impact and we are now working to develop their own facilitation skills to enable the meetings to be self-sustaining in style and approach.

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A Vision for Public & Patient Engagement (PPE)The CCG has 28 member practices and covers an urban population of about 190,000

in an affluent part of Outer London. Healthwatch have had an active involvement with the CCG for two years. The Health and Wellbeing Board has been functioning since 2010.

The GPs have a vision for public and patient engagement and empowerment that takes them beyond anything that has previously been achieved. They looked for external support to help them to develop a shared view of the key steps and processes that would take them to and beyond the thresholds of authorisation.

Our Approach

It was important to establish a ‘guiding coalition’ from the beginning which involved lead clinicians, Healthwatch champions and lead managers including the PPE and the Communications Leads. This group met with a Healthskills team member with experience of developing innovative approaches to PPE.

The group soon realised that they needed to think about both the transactional and transformational processes. They had to ensure that they had collected the evidence that demonstrated a good track record and that substantive processes and procedures are in place, at the same time as ‘dreaming a dream’ that would take them beyond the current expectations and aspirations.

The group met 3 times during a 6 month period. They developed a shared understanding of the current PPE infrastructure, and the future needs for the CCG as regards PPE. Connections to the commissioning cycle, the constitution, governance, and service change/re-design were all considered.

Meaningful engagement with patients,

carers and their communities

Authorisation

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We played a role supporting both the group and individuals overcome barriers that were holding them back, by:

• coaching members of the group to build confidence

• benchmarking with innovative practice elsewhere

• constructively reviewing the CCG’s current PPE documents and strategy

• designing practical tools for the CCG to collate their PPE evidence for authorisation

Above all, we aimed to transfer skills and knowledge building the CCG’s internal confidence and capability to champion PPE and involve a wider group of clinicians.

The Outcome

In practical terms the CCG now has:

• an exciting PPE strategy with measurable outcomes, that has full approval of the CCG Governing Body and key stakeholders such as Healthwatch

• A contextually focused PPE toolkit which GP practices are implementing

• A process for stakeholder engagement, and on-going communications

• The skills and confidence to run workshops with a wider group of multi professional clinicians to implement their exciting vision

Of greatest importance there is a strong group of local PPE champions including clinicians, managers, Healthwatch representatives and a confident PPE Lead.

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Building a Culture of GovernanceThis is an inner city CCG, with an affluent and mobile population with pockets

of extreme deprivation, and circa 200,000 residents. A clinical leadership team that are committed to developing a fully inclusive, open and transparent decision making processes.

Our Approach

In partnership with the CCG and with the support of a legal advisor we engaged all GPs and practices in a dialogue to develop the constitution and inter-practice agreement. Various iterations were developed for further discussion before formally being considered by the Council of Members for final ‘sign-off’ by all practices. LMC representatives were fully involved in the dialogue.

The CCG Governing Body also took 2 days out for development. During this residential workshop we used a library of ‘what-if’ scenarios and case-studies to explore and rehearse a variety of potential governance challenges and issues. This helped clinicians understand that governance isn’t just about

Clear and credible plans

Authorisation

...governance isn’t just about ... systems and processes – it is just as much about attitude and behaviours

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what they often saw as overly bureaucratic systems and processes – it is just as much about attitude and behaviours. The scenarios also gave an opportunity to explore decision making boundaries and processes between the Council of Members (viewed as the engine room of the CCG) and the Governing Body to whom the Council have delegated responsibility to execute the strategy.

The library of scenarios is continually being added to, and used in short development seminars with both the Council of Members and the Governing Body.

The Outcome

The CCG has a robust constitution and Interpractice agreement that has full ownership of the member practices and support of the LMC. Governance is understood and valued by both clinical and managerial leaders. Potentially challenging governance situations will be faced with some experience and shared understanding.

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Commissioning support to CCGsThis suburban CCG had had a deep dive extraction of activity information to

review and reflect on commissioning over the last five years and understand the activity profile through their main providers. This analysis raised concerns about data

relating to maternity, medicine, pathology and ophthalmology and the activity profiles in the local acute trust. There

was a need for a reinterpretation of data as the provider had shifted to a new information system that had “buried bad news” and was perceived as potentially being used as a smokescreen.

The CCG needed support to build confidence in dealing with the Trust to review these issues and required someone with experience to provide additional capability and capacity into the CCG. We identified a member of our team who has experience in both acute provider and commissioning organisations, to work alongside the CCG.

Proper constitutional

and governance arrangements

Authorisation

We identified a member of our team who has experience in both acute provider and commissioning organisations, to work alongside the CCG.

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Our Approach organisations• Data analysis – looked for trends in the data and anomalies in the patterns – we brought both

primary and secondary experience, and so were able to look at data from both sides.

• Working with the CCG senior team and Governing Body to improve understanding of the data and confidence in their commissioning approach

• Working with the provider trust to understand data and flows and agree rectifying actions

• Helped the CCG to buildrelations with CSU – providing insight and expertise in acute contracting and facilitating some of the personality issues across the organisations

The Outcome

• The CCG entered into new dialogue with the Trust, and came to an agreement on improvements in the pathway

• Data was proven to be invalid, and paid for activity that wasn’t delivered was refunded to the commissioner

• Improved the confidence of the CCG Governing Body and senior team in understanding and interpreting data and better understanding the revised NHS acute contract

• Development of a set of revised ‘smarter’ local quality KPIs to include in the acute contract

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Collaborative CommissioningWe were asked by two neighbouring inner city CCGs to help them begin their work to develop collaborative commissioning arrangements. The key drivers for the work were:

• A wish to do what they do better and more formally

• Be clearer within collaborative areas on:– Mutual benefits– Scale– Shared understanding of that delegated responsibility– Principles of co-design

• they needed to learn from previous success and blocks to develop a way of working

They were clear that the tone for joint working would be set from the top and so asked Healthskills to work with the two CCG Governing Bodies.

Our Approach

We initially worked with the two CCG Chairs, Managing Directors and OD leads to identify key issues and the benefits and risks of collaboration.

Benefits• More influence• Increased effectiveness• Better value for money due to increased capacity• Wider range of skills and expertise• Overcoming artificial boundaries• Demonstrate equity

Risks• Potentially slower• External stakeholders take a broadbrush joint

view of the two organisations over every issue• Potential challenge as to why the two CCGs are

not merged• Potential loss of creativity

Collaborative arrangements for commissioning

Authorisation

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We developed a useful visual aid with this smaller group to identify an operating model:

A workshop enabled the two Governing Bodies to test 3 key collaboration issues:

Integrated Care Pilot

What is our shared risk appetite? How do we manage that? How do we create synergies?

Urgent Care Centre

What governance and accountability arrangements do we need to have in place to hold each other and the system to account?

Diabetes Pathway

How do we jointly manage leadership and engagement?

The Outcome

The two CCGs have developed a collaborative commissioning approach for key areas with:

• Clear criteria for what constitutes joint working

• Defined roles/structure/governance

• Agreed ways of working for governing bodies, management teams and constituency

CCG A CCG B

Size of the

overlap will

depend on the issue

Drivers for working inc interface services

Tensions to separate from HA, HWB and others

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Clinical Leaders for the Future

An inner city CCG with a diverse, mobile population, circa 305,000 residents, committed to improve the health and wellbeing of its population. Enthusiastic and

driven, they opted for wave 2 authorisation

Whilst, there is a well-established clinical and managerial leadership team, it was recognised that succession planning was fundamental to longevity and success for the organisation.

Our Approach

In partnership with the CCG, we developed a 4-month leadership programme aimed to equip future leaders with the knowledge and skills to drive the commissioning agenda forward. The programme included individual 360° feedback; interactive workshops and commissioning-based projects. The executive clinical leads identified core topics for participants to scope and provide recommendations, including workforce education, IT and screening. Each project was sponsored by an executive lead to ensure recommendations, which were reviewed at a strategic level.

...succession planning was fundamental to longevity and success for the organisation.

Great leaders who individually and collectively can make a real

differenceAuthorisation

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The Outcome

The CCG has a cohort of enthusiastic and engaged CCG members, including GPs, nurses and practice managers, committed to driving forward commissioning. The research from the projects displayed energy and passion to bring about real change and improvements in healthcare. With the aim of reducing emergency admissions and avoidable amputations, one group created an informatics template to improve real-time communication between foot health services and primary care,.

The programme had an attendance rate of over 90%, and all participants unanimously stated they would recommend it to their colleagues: “Do it, it will change you.”

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About Healthskills

We bring a range of experience, tools and techniques to support CCGs in the preparation for Authorisation and Beyond. We can help by providing experts to increase your capability and capacity, and facilitators to enable effective relationships and processes.

Our areas of expertise include:

• Clinical engagement • Collaborative commissioning • Contract Management and Analysis• Governance development• Individual and Team Coaching• Leadership Development • OD Planning• Partnership working• Pathway re-design

• Public and patient engagement • Quality and safety governance and processes• Staff engagement• Senior team – building capability and an

effective team• Stakeholder engagement• Succession Planning

• Supplier management

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Our team includes clinicians and managers with considerable experience of working with primary care and commissioning development over the last 15 years.

Our team are drawn from both the public and private sectors, and enjoy working with pioneering organisations with ambition and drive to radically transform local services.

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Quite simply, Healthskills shaped our many ambitions into a clear and practical package of support. They enabled us to be ready for authorisation giving appropriate challenge & support and we are able to trust their excellent advice. We have established a great partnership and look forward to an on-going relationship.

Dr Phil MooreInterim Chair (Clinical)

Kingston CCG

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Get in touch with us.

Anne Toftsm: 07860 630264

t: 0800 652 3322

e: [email protected]

Ann Hepworthm: 07867 538165

t: 0800 652 3322


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healthskills2-14 The Crescent,

King Street, Leicester LE1 6RX

t: 0800 652 3322


w: www.healthskills.co.uk

Clinical Commissioning Groups - To Authorisation and Beyond

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