The two national surveys offered an opportunity to gain some overall impressions of these actors’ insights
and assessments of some basic questions. The surveys revealed a mixed picture. There was evidence to support an optimistic view of the worth and importance of CCGs and of the role of clinical leaders, but there was also some evidence to support a more pessimistic view.
Indicators underpinning an optimistic assessment included the evidence that the majority of respondents
said that‘my CCG’ exercised more influence than the other bodies that were active in the area. Likewise,
within CCGs, there were indicators of the influence exercised by GPs. They were assessed as broadly as influential as managers. Other data pointing towards an optimistic view can be found in assessments of
who sets the compelling vision– a significant indicative role in the context of these bodies. The majority
of respondents said it was set‘equally by managers and clinicians’ and, among those who answered
differently, clinicians were more likely than managers to be named as the vision setters. Moreover, this
pattern represented a maturation of CCGs since 2014: the‘both equally’ assessment increased from
33% to 54%. Trends in communication with secondary care clinicians and with patients and the public also offered grounds for optimism. The overall assessment of the influence of clinical leadership was that they were central to nearly all service redesigns (35%) or in a significant proportion of redesigns (25%). Taken together, this suggested that around 60% of respondents claimed a key role for clinical leadership in practice.
Positive assessments of CCG influence were more often made by chairpersons and accountable officers (i.e office holders whom one might well expect would champion CCGs and indeed remain optimistic about these institutions even in the face of challenges). In contrast, finance officers and GP board members were much less inclined to offer a positive assessment. Similarly, GPs on governing boards tended to be the least convinced that GPs were influential in the redesign of services. Moreover, GP respondents reported that practice workloads were impeding engagement with clinical leadership and that, as a result, engagement with CCGs was declining. One might expect that at least GPs on the CCG board would be the prime intermediaries and communicators with other primary care clinicians, but only 40% of CCG managers made this assessment, they suggested it was done either by managers or jointly with clinicians. In addition, as collaboration (with other commissioners and with providers) has become a bigger theme in recent years, one might look to the skills of clinicians in this regard. However, the data
indicated that managers were felt to be more active in this– either on their own (43%) or conjointly with
clinicians (51%)– but with only 5% saying that clinicians were the main builders of collaborations. On the
overall assessment of the influence of clinical leadership on service redesign, this reduced somewhat (though not statistically significantly so) between 2014 and 2016. When asked if the plans for service
redesign had‘far exceeded’ tangible change, the majority (55%) agreed that they had.
0 5 10 15 20 Percentage 25 30 35 40 1 (1.0) 2 (2.0) 3 (3.0) Level of agreement 4 (4.0) 5 (5.0)
Of note was that, although respondents many were highly doubtful about the future survival of CCGs, the majority expressed their strong conviction that commissioning and related devices, such as outcome-based commissioning, were approaches worth preserving. This finding might reflect the general orientation of those persons attracted to the work of the CCGs.
To gain further insight into the actual work of clinicians in service redesign using the CCG as a potential platform for action, it was necessary to delve deeper. For this purpose we used a case study methodology. We report on the results of the case study work in the next chapter.
Chapter 4 Findings from the case studies
I
n this chapter we present the findings from the six main CCG case studies. Their geographies coveredthe North, South and Midlands of England. Rural and urban areas were covered as well as a mix of deprived and affluent areas.
The case research complemented the survey findings reported in the previous chapter by adding insight into the ways in which clinical leadership for service redesign was practised using the CCG platform. Although the cases are based around CCGs, our prime unit of analysis when researching the cases on the ground were specific service redesign attempts taking place within these settings. One or, in some circumstances, two significant redesign instances were selected for study in each of the CCGs depending
on local circumstances. This approach allowed us to move beyond abstract discussion of‘leadership’ to a
more grounded analysis of leadership in action.
Most of the research effort was directed at teasing out the origins, design and delivery of specified service redesign attempts. This allowed a focus on actor behaviours in relation to real events. The CCGs were researched as part of the context but the main focus was on the role played by clinicians and the extent to which this amounted to a process of leadership. As a result of the prime focus on acts of clinical leadership
within specific service redesign attempts, we arrived at eight‘cases’ (of leadership in service redesign),
because in two of the CCGs we tracked change leadership across two different service areas.
We found initiatives were being launched above, below and around CCGs.‘Above’ were regional
groupings,‘below’ were localities and ‘around’ were various forms of collaborations with neighbouring
CCGs, LAs, provider institutions and other agencies (including voluntary sector bodies). Some of the
initiatives studied involved a handful of collaborating managers and clinicians– often straddling primary
care and other providers in secondary care, LAs and the voluntary sector. Sometimes these initiatives were sponsored by the CCG and allocated formally to one or more clinical leads. At other times the innovations were only loosely connected to the CCG and were driven by clinical leaders from other settings, such as GP federations. The case study narratives cover these different kinds of development. Each, in their
different way, helps shed light on the contours and nature of the system– the role of the CCGs, the role
of providers and the parts played by managers and clinicians.
Although many barriers and blockages were revealed, in what follows we place special emphasis on tracking
and clarifying how some actors have shown themselves able to surmount– at least to some degree – these
difficulties. Hence, these cases offer clues to the nature of clinical leadership and thus they point to lessons
from which others can learn– whatever the particular institutional form might happen to be.
In order to facilitate cross-case comparisons, each case write-up is structured in accordance with a standard framework: the context within which the CCG operates; an account of the service redesign attempt being studied; emerging insights about clinical leadership; and the overall lessons and conclusions from the case. Systematic cross-case comparisons are made in the following chapter.