While assurances have been made that CCG staff will not lose their jobs and will transfer across the ICB there are no such provisions for the clinical leadership chairs. So where will they go? Some have moved to PCN roles, or are looking towards the ICS or private sector. Others are seeing it as an opportunity to retire. As much as everyone agrees that a key success of CCGs was giving voice to primary care clinical leaders, there is now a unifying concern over a loss of that leadership.
Our survey showed that 68% of respondents felt there will be a loss of clinical leadership. See box 7.
Loss of leadership
Our survey also found that just over a quarter (27%) of respondents were looking to continue in leadership roles with the ICS while the majority (36%) were not. See box 8.
The CCG leaders interviewed were concerned about the loss of experienced leaders.
North East Essex chair Dr Chowhan says: ‘Whenever you have an organisation change from one form to another, you have to think who are the people who will take that change forwards? There isn’t a mass of people with this level of experience, be it clinical or non-clinical.
‘I fear for clinical leadership, and I’m biased because obviously I’m a clinical chair and a GP, but I don’t think there was ever any thought about what happens to those experienced clinical leaders. If I speak to my colleagues, many of them have no pre-set notions of where they’re going to next,’ he says.
Dr Kong says you need ‘very knowledgeable, very skilled leaders’ at the ICB who can balance the competing needs of different places along with the needs of the system as ‘every borough might be fighting for its own inequalities, its own needs’.
‘We have eight boroughs in North West London ICS, and there’s only one [primary care board] place at the ICB. I think the anxiety among GPs, and borough-based people including residents, is “are our interests, in our boroughs, well represented and listened to?”‘
Dr Lakhani recognises this concern about the loss of influence at system level. ‘In CCG land, we ran the show. Nothing happened without GPs’ agreement. It was a rare power; a rare first in NHS history and it was used carefully and ably. But now, we’re not a membership organisation, we are one person on the board. I think people are genuinely worried about the loss of the general practice voice at system level. I don’t get a sense that people don’t want it to be clinically led, it’s how you exercise the powers and influence in the complex governance of an ICS. Time will tell whether it will remain strongly clinically led.’
He highlights the clinical and care professional leadership framework (CCPL), a policy that requires each ICS to develop a framework for clinical leadership and engagement that is signed off nationally.
‘They can’t become an ICS by just saying they’ll involve GPs. They have to say how. CCPL is going to replace the clinical leadership membership model, but ICSs are not membership organisations, they won’t be made up of GP practices. It’s a shame.’
Dr Gupta says that everything about the formation of ICB is ‘entirely silent on the non-executive side of things’.
‘It’s not just GPs. There are lay members who have been part of the system going back to the PCTs and bring a huge wealth of experience, skills and knowledge. Again, there’s nothing about the retention of the non-executive. I’ll include GPs in the non-executives.’
Dr Fernandes says there will be a loss of clinical leadership to the system as there isn’t a directly transferrable role for a CCG chair on the ICB.
‘There are only two groups of people that meet the public on a daily or weekly basis. One is GPs and the other is local authority counsellors. When we came together on the health and wellbeing board, and I’ve been vice-chair since 2012, it brought these two groups together to challenge the system. That primary care input will be less because the trusts will have a bigger say in everything and be given a bigger budget,’ he says.
In South West London, the outgoing clinical chair has set up a clinical leadership structure at borough level and at South West London level. There are clinical leads across programmes of work. But Dr Fernandes thinks they will be supporting managerial decision-making, not leading the work.
‘We’ll have to see what impact they have. But their roles will be totally different. They’re termed clinical leaders but actually they will be providing clinical advice.’ Dr Fernandes adds that this dilution of the clinical role will ‘diminish’ clinical leadership.
The survey also found that 24% of respondents face a loss of income when CCGs come to an end. See box 9.
Where next?
The top three places survey respondents said they would look to work in were an ICS role at board, place or neighbourhood level (28%), a PCN role (19%) and a GP practice role (21%). See box 10.
For Dr Fernandes it’s an opportune time to think about work-life balance as well – particularly with the challenges faced by the profession in the peaks of the pandemic.
‘People gave an awful lot in the last two years, and the clinical leaders disproportionately, because they knew what the reality was – especially where we lost GPs. That really brought it home.’
North East Essex chair Dr Chowhan says colleagues are using the time to reflect on their career and life. Some are retiring or moving to other organisations.
‘People are doing different things. Some are forming alliances or place-based groups and committees. They’re chairing those to maintain their leadership. I’m not sure if anybody is taking on ICB roles or which ICBs are taking on experienced clinical leaders, but, actually, the roles aren’t plentiful.
‘That whole concept of clinical leadership – which we spent ages embedding in CCGs – feels now like a bolt-on. If you think back to the STPs, before ICSs, it was almost done in secret. It was: “Leave the clinical leaders out, we’ll figure it out and we’ll come back to them.” I think there could be a significant loss [of clinical leadership] to the system and then to the population.’
He adds that some CCG-elected members are moving into PCN CD roles but he feels they have been ‘flung in the deep end’ without the necessary experience.
‘There was an expectation from NHS England that they were going to jump in and be the CCG leaders of the future, but many of them didn’t have the experience. It’s one thing being a CD for your PCN, but answering to those outside your PCN is a different concept,’ he says. He adds that it takes one or two years to get to grips with working in a CCG and that’s with the benefit of experienced people around you – something PCN CDs did not immediately have,’ he says.
At the moment, North East London’s Dr John is supporting the newly appointed ICB chief medical officer and chief nurse but he and his colleagues are also taking time to reflect. He points out that while some colleagues will retire or go for roles in the new system, place is where there will be most opportunity.
‘Most CCG leads have always been involved with place anyway, so I don’t think it’s a major change. I think the difference will be that we will be working with a much bigger group of people.’
Dr Kong has stepped down from her CCG role in Brent, north-west London, to make way for ‘the future generation, who should step up and carry on’. She says she knows colleagues that are doing the same.
‘People like us, the older generations, should pass on our knowledge and step back and be supportive. That’s my belief; supporting the younger generations to be leaders. Although some of us have reapplied for higher roles,’ she says.
In West Leicestershire, Dr Lakhani says a substantial number of CCG GPs have chosen not to have a role and a minority have looked for continuation by leading on certain pathways.
He agrees with Dr Kong that new leaders are ‘not a bad thing’.
‘Change is good; new people are coming in, some people are staying on. There are plenty of opportunities for everyone. I would urge everybody who was involved in CCGs in any role to think about how they can contribute to the new framework.’
‘I know of at least four people who’ve become PCN CDs. Before, we had a rule that you couldn’t be a CCG lead and a PCN lead because of conflict of interest and the purchaser-provider split. So we banned them from being CDs; they had to choose.’
Although Dr Findlay says he is ‘well past retirement age’ he would be keen to be involved at county Durham level. But he admits that having been an accountable officer and then a chief officer it would be ‘difficult to work in an organisation where he didn’t have a degree of autonomy’.
Dr Gupta is heading to the private sector and is pursuing his passion for lifestyle and prevention with Oviva, which delivers behaviour change programmes for people with diabetes and obesity.
‘I am leaving the CCG commissioning space. I made that decision a long time ago. No effort was made to try to retain people like me. I don’t think any other sector would do that. It’s crazy really.’
Dr Gupta says his career path is a good example of how much experience is being lost to the NHS by this organisation upheaval. ‘My leadership training was in the NHS and then I became a CCG clinical lead and governing body member. I’m essentially going largely to the private sector. [I know of] five or six CCG governing body members who are now employed part-time by private healthcare operators. I suspect we’ll see more of that because people have skills that are available off the shelf for some of these companies. That cohort of GPs probably didn’t exist 10 or 15 years ago.’
He adds that CCG leaders may not be a natural fit for PCNs because of the adversarial nature of the commissioner-provider split.
‘[The PCN CD] is a provider role and this is a commissioner role. It is quite adversarial. Some of the hardest conversations I’ve had over the last 10 years have been commissioning primary care. They have been the most difficult and bruising.’
Dr Watt also finds it encouraging to see new clinical leaders coming through and is more optimistic about PCNs.
‘Looking at the PCN CDs, quite a lot are absolutely new to leadership, and that’s really exciting – new people wanting to do these roles, not just in general practice but across secondary care as well.’
Dr Watt is ‘exploring options’ in the new system. ‘Most of us will continue to be GPs in the systems that we are emotionally, intellectually and financially invested in. It matters to me that this works, because regardless of what role I’m in, I am still going to be working in the system. One of the reasons I went into commissioning was to deal with a sense of impotent rage. I could see the service my patients were getting was not great at times. Much of it was fantastic, but there were times where it seemed cumbersome, illogical, and not evidence-based,’ she says.
‘I want to make things better and I want a better experience for the population that I serve. One of the things that’s been really helpful as a commissioner is to be able to bring that experience into high-level meetings,’ she says. She gives an example of a patient who can’t access GP services because of fuel poverty.
