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Taking the lead


28 July 2015

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The establishment of clinical commissioning groups (CCGs) thrust GPs into key system leadership roles; very much in contrast to both their training and previous management experience.

The establishment of clinical commissioning groups (CCGs) thrust GPs into key system leadership roles; very much in contrast to both their training and previous management experience.
This is not the first time that GPs have had to adopt leadership roles. The establishment of GP fundholding over 20 years ago gave many GPs insight to exercising influence across their local health economy. Many received great satisfaction from the fundholding experience, and mourned its passing. Furthermore there have been a strong cadre of GPs who have embraced CCG leadership roles, while others have kept their distance.
CCGs as membership organisations have therefore met the needs of a wide range of GPs for their level of engagement in leadership. Some have sought top leadership positions and have been successful in exercising system leadership; others have stood back and taken on this role locally. All have been challenged to change ‘the way we do things around here’ as resources declined and expectations increased.
This article explores the adaptation of GPs to their role within CCG leadership. We will discuss the contrasting of these two roles, what this means for the exercise of leadership, and how the NHS Leadership Academy is providing support.

CCG leadership by GPs
GPs are, in effect, small business entrepreneurs. They run their own firms and have considerable autonomy, contracted and incentivised to provide services to patients on behalf of the NHS. As leaders of CCGs, however, their role could not be more different. The key differences are summarised in Table 1.


The challenge here is for GPs to move from behaving as ‘GPs who are commissioners’ to ‘commissioners who have experience as GPs’. In this way they can put ‘clinical’ in commissioning without defaulting to their trained GP behaviours.
To develop the comparison of these roles, we suggest that GPs need to go from:

  • Dealing one to one with individual patients within the bounds of a surgery to considering priorities for population health across a whole geographic area.
  • Taking a patient through a pathway that meets their individual needs to taking a ‘balcony’ view on the whole health and social care system.
  • Focusing on small business tasks around the patient and their needs to process flows across disease and illness pathways.
  • Working with a small group of partners to influencing strategic stakeholders across commissioning and providing in health and social care.

By taking on the leadership role in CCGs, and contributing clinical insight to the commissioning process, GPs have to use a wide range of skills, which stretch their leadership capabilities, including:

  • Influencing – a multiplicity of stakeholders including providers, members and the public.
  • Leading – a multi-disciplinary team of professionals across a wide range of disciplines.
  • Analysing – population level data and setting commissioning priorities.
  • Engaging – a wide range of bodies, members of the public, politicians and media.
  • Contributing – to organisation and system governance and priority setting.

What does this mean for GP leadership?

Exercising GP commissioning leadership
There are three key inter-related aspects of GP commissioning leadership to explore.

1. Team leadership
This takes the GP from ‘small business leader’ to leading a larger CCG. Granted, some CCGs are relatively small, but irrespective of organisation size, the role is significantly different. CCG staff must exercise system leadership, and need directed activities that embrace the commissioning cycle, as illustrated in Figure 1.


In exercising this CCG team leadership role, GPs will need to draw on the knowledge and skills of team members. The GP leader will therefore need to think strategically, take a system perspective, and guide team members in the implementation of the governing body vision. This type of leadership role is what Jim Collins discusses in his book, Good to great. It describes a level five leader as someone who, “builds enduring greatness through a paradoxical blend of personal humility and professional will”.
CCG leadership also means influencing membership, and this requires an equal measure of clinical thinking and influencing skills that draw on both hearts and minds – understanding the nature of the change needed, and communicating this to GPs who may be sceptical of the direction of travel; this builds trust that will enable the harder decisions to be made.

2. System leadership
This is about generating the impetus for change, gathering together partner organisations in a coalition for creating and communicating the vision, and empowering others to act on the vision. The Better Care Fund (BCF) has been the first test of system leadership for many CCGs, and the process proved challenging to reach an agreement. Resource reallocation is naturally difficult, and when resources are limited, the ‘too big to fail’ acute sector will be reluctant to see this shift to the community. Beyond the BCF, two new initiatives will focus the minds of GP leaders on their system leadership role: co-commissioning and new models of care resulting from the Five Year Forward View. GPs in this system leadership role will therefore need to project their presence and influence, so that commissioning comes to the fore and drives system change.

3. Communication
This goes hand in hand with engagement of patients and communities, CCG members and staff, providers, and system partners like local government and politicians. Building on this vision, the challenge will be to bring a clinical dimension to decision making that brings the patient perspective to the fore. This will require a presentation of the facts behind the need for change, and a vision of what the change will deliver.  

NHS Leadership Academy
NHS England commissioned the NHS Leadership Academy to develop a bespoke programme to complement the current cadre of programmes. The pilot launched in January and is aimed specifically for aspirant/current GP leaders in the roles of clinical chair and accountable officer.
As we know classroom based learning is not enough, the learning needs to be put into real life opportunities. Importantly the programme is enhanced with coaching sessions and action learning sets to further develop the reality of tackling the complexities of the clinical leadership role. The academy works with 10 local delivery partners (LDPs) and these local leadership organisations have also been supporting clinical leadership development. Here’s what the North West Leadership Academy have been doing.

North West Leadership Academy
In addition to the work of the academy, the North West Leadership Academy has since supported the establishment of CCGs focused on the development of their current and future leaders. These programmes provide individuals with insight to their leadership needs and potential, and include mentoring that supports bespoke development plans for each participant.
One participant commented: “I found the assessment centre superb and prepared me incredibly well for my formal assessment with Hay Group in my successful application for chair… I have progressed from GP to board member and more recently to chair. There is a palpable difference in how I function now compared to five years ago, and the support from the North West Leadership Academy really has helped get me here.” Dan Bunstone, chair, NHS Warrington CCG.
Should you wish to find out more about how the National Leadership Academy can help with this development, please contact mike.chitty@leadershipacademy.nhs.uk l

John Deffenbaugh, NHS Leadership Academy, faculty.
Caroline Chipperfield, NHS Leadership Academy, clinical commissioning leadership programme lead.

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