Dr Steve Lloyd, GP and Chair of Hardwick Clinical Commissioning Group, reflects on conflict of interest inherent in commissioning of services and the need to access the true patient voice.
Governance and clinicians
While clinicians understand that governance and risk are important, there is a prevailing ennui and sense that it does not involve them in meaningful way. It’s seen as being in a different orbit, with no impact on their day to day work. However, challenging decisions on the horizon for CCGs alert us that clinicians should be aware.
Firstly, there are areas of greyness experienced by all those on governing bodies that discuss commissioning issues which create discomfort, for example around conflict of interest as service providers are reviewed. This will also have important consequences for the financial stability of their practices. It’s one of the more important and live issues facing clinicians at this time. So how can governance steer CCGs through this particular minefield where members are in a position to influence both sides, and how can we engage clinicians in establishing effective governance?
The role of governance should be around clarity. Commissioners can feel uncomfortable in many settings given their roles and responsibilities. It’s all about setting boundaries. Governance should establish where you draw the lines in these kinds of decision areas that could otherwise leave you open to being challenged; it should create clarity around the grey areas, and there needs to be a degree of scrutiny.
The ways in which CCGs can delineate those boundaries through effective governance has to be a critical outcome for CCGs. Furthermore, how this transparency is articulated to ensure stakeholder confidence highlights the importance of language in governance. Clinicians need to be extremely clear where they sit in this, in order to have assurance that they are not conflicted and can confidently operate as a federation without impacting on the integrity of the CCG.
The opportunity to debate this and other issues relevant to clinicians and members of CCGs, and to shape outcomes of good governance is available through this project in the form of LinkedIn discussions, a survey, and workshop events.
Lay and patient involvement.
Secondly, we need to ensure through good governance arrangements that our patient representatives really speak for patient populations.
At Hardwick CCG, we’ve found over the first 12 months that we’ve been on a learning curve with members familiarising themselves with the healthcare system and clinicians sharing information on key issues. Looking to the future, the emphasis will shift towards how patient groups sit within CCGs in terms of being able to voice opinion. How does this operate within governance and how does a patient network group sit within a CGG structure and include patients in decision making in meaningful way and in a way that is fit for purpose? What is their constituency? How do they garner voices? How can we avoid the variance in understanding?
An outcome of good governance is to embrace the true patient voice and ensure that patient groups have an informed insight. We need the assurance that patient groups are being run well, and that views are being taken forward from that group into the governing body as a representative voice for our population and they are not only sharing personal opinion. There are some extremely good examples of patient voice gathering in Hardwick and other CCGs, but overall it is woolly at the moment. Governance needs to ensure fitness for purpose in the many.
It is my personal view that every CCG should not just rely on a practice based patient group and a prescribed lay member. An outcome of good governance is to establish a governance framework. A strategic patient group network should sit behind the lay members drawn from individual patient groups, and governing bodies feed any live issue through them for further scrutiny and input. This would draw informed patient voices into decision-making and give patients a level of ownership in a way that has never happened before. Governance will create assurance that a robust checking process is in place to run an issue through a patient group network to have an opinion, and provide crucial feedback.
How effective we have been in putting robust governance processes in place going forward will be tested in the face of difficult decisions in commissioning. Arrangements to include patient groups with a full understanding of all the issues will be tested to the extreme, with patient groups co-opted into decision making process on emotive issues such as the closure of community hospitals.
We can stimulate interest and debate with clinicians if we clarify and create concepts that are easy to clasp and firmly held in the minds of clinicians. We need to emphasise with colleagues that doing the right thing is important and that governance plays its part in this. Good governance should navigate the minefields for clinicians involved in service provider reviews and establish robust process to access true patient voices in the most challenging of commissioning decisions. Clinicians should look to the opportunities of this research to share their experiences, expectations, thoughts and recommendations with colleagues and shape good governance going forward.
- As chair of the Task and Finish group overseeing a research project on effective governance commissioned by NHS England, I urge other clinicians to engage in the survey, workshops and online discussion to identify effective governance outcomes.
Dr Steve Lloyd sponsors the NHS England Task and Finish group on CCG Governance. He has been a GP principal in north east Derbyshire for 15 years and prior to this was a maxillofacial surgeon. He is Chair of NHS Hardwick CCG, regional clinical lead on the EMAS urgent and emergency ambulance contract and clinical lead for the National Ambulance Commissioners Group. He is also a sessional operational clinical lead for Derbyshire Health United OOH provider and in the EMAS operations centre and a council member for East Midlands Clinical Senate.
Steve Lloyd is a member of the NHS Commissioning Assembly and has been involved in a number of Working Groups, including on direct commissioning and Urgent and Emergency Care.
Outside of medicine, he was until recently a senior RAF reserve officer. He is a trustee, medical adviser and a chief expeditions leader for British Exploring Society at the Royal Geographical Society.
He is a Fellow of the Royal College of Surgeons of Edinburgh, Fellow of the Royal Geographical Society, Fellow of the Royal Asiatic Society and Member of the Royal College of GPs.