While I was a partner in general practice, we started to receive information about how we were performing compared to other practices. Whatever the data, we always looked at how we benchmarked against one particular practice. It was about the same size as ours, not far away (so serving the same sort of population), and we knew the partners well. We always hoped we would be better than them. If we weren’t it would make us think about what we could do to improve our performance. Professionals want to be the best. We were competing on excellence.

A few weeks ago we held a stock-take for all our Clinical Commissioning Groups (CCG). Our seven CCGs range from around 220k to 80k in size. In preparation, we calculated the management budget for each of them based on £25 per head of population. Using work done by the PCT Cluster on the fixed costs (governing body, staff pay etc) and regional analysis on how much commissioning functions are going to cost CCGs (not perfect but good enough), we asked each CCG to, firstly, try and simulate “going alone.”  That session didn’t last very long. Each CCG was at a table of its own. People started getting up, moving around, and having discussions. Given the facts and the problem, the mass of GPs in the room quickly assimilated that putting a quart into a pint pot was unlikely to work. By the end of the day, groups of GPs decided to stay behind and start discussions around potential mergers.

The trouble is, the small CCGs have already demonstrated real ownership and engagement with the challenges which the NHS is facing.  They pretty much all know each other in the locality. They have similar demographic and patient flows. The benchmarked information we are supporting them with has relevance and meaning – it starts discussions along the lines of “if they can do it, why can’t we?” Creating larger CCGs will help address the transactional risks clinical commissioners will face; managing financial risk, regulatory demands, and having the resource to buy in external support. What they risk losing is hearts and minds, membership, and ownership of the agenda of the CCG.

We have been round this circle once already. I helped establish and then chaired a Primary Care Group which within 2 years became a Primary Care Trust (PCT). It lasted four years before being merged. It is fascinating to see how many CCGs are beginning to replicate the PCT footprint prior to 2006. If these reforms are going to really benefit the system then we need to think about how to balance little and large; how to manage transactional risk whilst nourishing and supporting transformation. It has been thrilling to see how aligning very senior managers alongside clinical leaders in the CCGs has already wrought a transformation in attitudes towards addressing key issues from a grassroots level. There is an eruption of innovative ideas and they are being tested at a scale which permits the risk of innovation to be managed and for success to be quickly spotted and adopted by the other CCGs who are all keen to be the best. Working for the cluster I have had to let go. In essence my directorate now consists of four of us. I see my new role as coaching, facilitating, supporting, and creating with the CCGs a felt responsibility for delivering the statutory duties the PCT is still accountable for. The CCGs are leading commissioning: planning, contracting, and quality improvement. Somehow, if we are to make these reforms worth while we need to retain the benefits of small localities within the advantages of a large CCG.

To do so it seems we need to answer two key questions:

1. How do we reward the efforts of a locality if the CCG, as a whole, does not succeed?
2. How do we address the failings of a locality if the CCG, as a whole, succeeds?

We need to continue to tap into professional values and generate competition for excellence. We need to  recognise and reward excellence, and not allow mediocrity to hide. Getting this right, in my opinion, will mean we have learnt from the past and created a new dynamic for the future.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.