Martin McShane: Adapting

Martin McShaneEvery two months I get to sit down with the GP Chair and Chief Operating Officer from each of the Clinical Commissioning Groups (CCGs) in Lincolnshire. Ever since the reforms were announced we have retained a focus on delivery. We have thought of the development of the CCGs as revolving around delivery. There is no point to a CCG unless it is driving delivery. At the meeting we look at delivery and the development of the CCG.

This is made easier by the fact that we built the plan for 2010/11 up from the CCGs. Well, we tried to. It wasn’t easy as some things were county wide issues, often driven from above as part of national or regional policy and they have had to be ‘federated’. We use a programme management office (PMO) to keep track of the entire portfolio of projects we are using to drive change and a performance management dashboard to track the impact they are having on emergency activity, planned care, prescribing and the money. The PMO and dashboard are web based, which means we can access it pretty much anywhere (even on an iPad). It isn’t perfect and we have learnt loads from trying to make it all work. It is, however, good enough to help ask each other the right questions. I am beginning to learn there are rarely answers – only better questions.

What has been exciting has been seeing how aligning experienced and skilled senior managers to work alongside GPs has wrought a cultural change. This has also sparked innovation. In fact I was struck by how what was happening fitted with the Palchinsky principles which I first read about in Tim Harford’s book Adapt. The principles are quite simple:

1. Seek out new ideas and try new things
2. When trying something new, do it on a scale where failure is survivable
3. Seek out feedback and learn from mistakes as you go along

Individually, the CCGs are each trying new ideas. Some are their own ideas, some are taken from elsewhere. One CCG has got all their practices to review all their referrals, every week, in-house. They don’t stop or triage referrals; they simply get the team to discuss each and every one. The impact has been significant, as doctors come out of their foxholes and share experience and knowledge and reduce variation – appropriately. The way our CCGs have used the new Quality and Outcome Framework indicators, relating to prescribing, referrals and emergency admissions, has been to support CCG delivery. One CCG has set up a social network to embed involvement of all practices in the workings of the CCG. Two CCGs are piloting the use of the Pathfinder software. Another CCG has led the way in systematic screening of older people and developing an integrated approach to the management of the frail elderly. There are other ideas and initiatives. Done across the whole of Lincolnshire some of these innovative ideas would be risky but, given the size of most of our CCGs and ownership of the initiatives by the member practices of the CCG, they are more likely to succeed and also obey Palchinsky’s second principle. The cluster is positioned to help with the third principle and facilitate spread if something works and can be adopted.

It all feels a bit messy and to get this to happen needs good performance monitoring and collective focus and ownership of national, regional, cluster and CCG goals. It does, however, feel different. Maybe CCGs can really help the NHS adapt?

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.