Caroline Chipperfield explores the conditions, culture and climate leaders will need to be able to flourish in the commissioning climate.
As health care moves towards a focus on wellbeing for citizens, clinical commissioning is becoming increasingly critical. The procurement of services from NHS partner organisations or the private or voluntary sector, health and wellbeing boards assess what populations need in terms of health and care. Contracts are drawn up and procured and providers are held to account for delivery and quality.
Commissioning can never be an exact science but the better developed the knowledge of the demographics of the local community, the more accurate you can be. It’s about much more than contracting too; it’s about quality assurance and value for tax payers’ money. My view is that we need to improve the way that we commission whole population health services at the moment; we still have a tendency to look through a health lens but there’s an opportunity to work more closely with local government, for example. It should be about public health, social care, education, schools, and what we’re doing for the whole area, its demographics and its economy.
We’ve currently got a very confused system that prohibits truly joined up working. Primary care homes are coming in; there are vanguards, new care models, the Sustainability and Transformation Plan (STP) footprint (the geographic areas in which STPs will be delivered) and the bigger acute footprint. We’re also trying to commission at different levels – national regional and local.
In some cases, STPs are shifting towards what’s known as accountable care organisations which will look at whole population health. This means providers and commissioners will be better-integrated, and that for me needs to be the future of NHS commissioning. Arguably it should be jointly done with local authorities and health and wellbeing boards. In some shape or form we’re still spending public money, so we still really need to know that it’s being spent sensibly and with quality in mind.
I absolutely support the view of NHS clinical commissioners that commissioning should be clinically led. This means it’s professionally driven and professionally engaged with clinicians, including AHPs and nurses. This is what the clinical commissioning groups (CCGs) have been trying to do since they were set up in 2012.
Empowering leaders to lead collectively
CCGs are member-led, so decision making rests with members. As a CCG leader, you’re going to need to be confident enough to influence without authority. As well as it being about engagement and buy in and working with your members, it’s also about clear communication skills and being more strategic; you’re not just working in health.
The Academy – in partnership with other organisations – aims to empower commissioning leaders to lead collectively in a very complex landscape by drawing on their engagement and influencing skills. In many cases a general practitioner is an entrepreneur of a single practice, working for themselves. When they move into a clinical commissioning role they have to start thinking about making decisions on behalf of the population without losing their entrepreneurial nature. The real test is exploring the meaning of being a systems leader; how does someone lead collectively, making decisions based on what’s best for them and their organisation rather than what’s right for the system?
There are three particular ways in which the Academy – and our network of Local Leadership Academies – is able to support STP leaders. Our Future Clinical Commissioning Leaders programme includes:
- A full development centre
- The opportunity to have a leadership 360 based on the Healthcare Leadership Model and the chance to reflect on one’s own leadership style and what that means
- Involvement from existing clinical leaders, who talk to the group about their experiences
- A look at the more practical side of commissioning, such as dealing with conflicts of interest and what it means to commission against a quality framework
That’s the journey we take our participants through; development, exploring their leadership style, the practicalities of clinical commissioning and what it means to be a systems leader. We then take that forward into action learning sets.
We’re also offering STP footprints the opportunity to nominate seven senior leaders from across their organisations to apply for the next Nye Bevan programme intake at a significantly reduced cost. This model of delivery has already been successfully adopted by other STP footprints across the country, resulting in:
- Enhanced shared learning for the individuals, through a blended approach of experiential residentials, high quality online materials and facilitated peer-assessment
- Immediate application of learning to improve and further develop the footprint and the organisations within it
- Improvements in system-wide collaboration and networking
Thirdly, working locally with the Local Academies, we’re developing bespoke system development support for leaders across the whole footprints.
Some of the colleagues who work with us are newly-appointed to governing bodies and haven’t done much leadership development before. We give them the time and space to actually think about what their system might need.
The future of commissioning
We need to continue to move in the direction of place-based decision making, looking at it from a population health basis. There’s much to learn from local government, which looks at the public health agenda and works with schools on issues such as obesity.
Utopia for me is that commissioning is led by strong, clinically lead commissioners that have a collective, system leadership perspective. I’d like to see us engage more with the population and citizens. The public may come out with an alternative that perhaps we haven’t even thought of. There will be some difficult decisions because we might not be able to afford to do everything we’ve always done. How do we decide on what might be some of the things we continue to do or what can we potentially do differently?
Leadership development will be around communication, building relationships, building trust and building networks. It will be doing it very differently to how perhaps how we’ve done things in the past – moving into a future generation of population health commissioning. Some of the work I do with leaders is around the vision, the shared purpose. Just because something makes sense intellectually, you have to constantly think “what does that mean in reality to my organisation, my staff and my system and the population?”
The Academy will continue to work with NHS England, NHS Improvement and others to create a regulatory environment that works around systems as opposed to individual organisations. That’s where the work of developing people, improving care (and the fifth condition, which is around developing a different regulatory environment which the regulators are all signed up to) will really come into its own. We need to create the conditions, culture and climate for leaders to be able to flourish in a very different way in the future and people were recruited twenty years ago for a very different way of working. It’s our role to support leaders to create the space and time to do that.
If a trust is challenged then actually it’s a whole commissioning system role to support that trust. It isn’t just a single organisational problem; it’s a system opportunity to make the difference when there’s a challenge.
I’m also hopeful that actually we can start to think about the regulatory environment across systems, whether that’s accountable care systems or STP footprints. If we don’t, transformation can’t happen.
STP leaders will need to be thinking about how they support their local delivery systems, and through programmes such as The Nye Bevan programme, I’m hoping the Academy can also play a critical supportive role here too.