CASE STUDY NHS East Staffordshire CCG CCG Organisational Development June 2014 Summary How can organisational development (OD) create a high performance culture? This was the challenge for East Staffordshire CCG, which sought to move away from an old style command and control approach to local healthcare commissioning. To create a new organisational culture, their OD activities focused on bringing CCG and Commissioning Support Unit (CSU) staff together, engaging the CCG s membership and investing in the next generation of CCG leaders through individual and team-based learning and skills development. Key Learning Points 1. OD activities are likely to have the greatest impact where they are practical and relevant. In this example, the process of developing joint values and common purpose was a useful way of getting CCG and CSU staff to work more effectively together. 2. Coaching and other communications and engagement techniques can be useful to clinicians and managers when working together and with CCG members. Investing in these skills can lead to productive relationships, constructive problem-solving and more effective leadership. 3. To address health system challenges CCGs need to be strong and resilient, and their leaders need to work differently. A continuous and planned investment in OD for individuals and teams can lead to the culture changes that bring about a high performing and sustainable organisation. 1
Context NHS East Staffordshire CCG covers a large geographic area with a high proportion of rural and semi-rural areas but has a relatively small population of 130,000. The CCG incorporates 90 GPs working in 19 GP practices in two localities (Burton Upon Trent and Uttoxeter). NHS East Staffordshire CCG has some major pockets of deprivation with an Index of Multiple Deprivation (IMD) score of 18.7. East Staffordshire s 2013/14 budget is 134m and has a running cost allowance of 3.33m. The CCG was formed from the previous Practice Based Commissioning (PbC) group. As a small CCG they are unable to lead on everything, so there is substantial collaboration with other CCGs, for example in medicines management, children s services, mental health and safeguarding. A particular point of interest is that some CSU staff are co-located with the CCG and seen as part of the same team. What is this case study about? What were the organisational development challenges? This case study describes the effort that has been put into enabling the joint development of CCG and CSU staff (a number of whom are co-located) and to actively developing the organisation s culture to move on from an old style command and control approach to create a high performance culture with clear ownership of local priorities and an increase in member engagement Organisational development was an issue for East Staffordshire CCG during their authorisation journey and they were authorised with six conditions, including a requirement to provide evidence of the creation of an OD Plan. The OD Plan has now been fully developed and refreshed to set out the means by which the organisation will deliver its vision, strategy and objectives [.] and progressively be excellent in the work it does 1. These six conditions have been quickly addressed. In 2012 the CCG commissioned Executive Development Consultants UK (EDC) to support their OD needs assessment and co-produce a way forward. This was done by sitting down together for a full day diagnosing, scoping and planning the way ahead. This phase of work included the use of a national self-assessment diagnostic, aligned to the authorisation conditions, governing body development sessions, and regular communication with member practices. The diagnostic process entailed looking at the challenges in the system. We were performing badly in elective and non-elective care and there were significant financial challenges. The conclusion that led us to was that we needed to be highly effective individually and together to influence the situation. Tony Bruce, Accountable Officer 1 East Staffordshire CCG, Organisational Development Plan, revision 6, March 2013 2
Of particular importance in this phase was an appreciation of the need to actively develop the organisation s culture to move on from an old style command and control approach to create a high performance culture with clear ownership of local priorities and an increase in member engagement. The CCG s term for this new culture is cultivational, a term which is intended to convey a focus on joint ownership, collaboration, matrix working, and continuous personal and team development. Some see this as close to the previous Practice Based Commissioning (PbC) way of working, but with the addition of clinicians who are empowered to act and to do so with greater speed. A clear change has been observed among governing body GPs: They ve now moved to GPs who are fully engaged, such that they recognise they are leaders to our GP colleagues. And whenever there is a new development they re ready and able to take the lead. This facilitates changes in primary care much more easily. Dr Charles Pidsley, Clinical Chair In the early stages however there was little direct continuity from the former Primary Care Trust (PCT) and initially the job was one of building an organisation from scratch with few staff to do so. The need for close working with the CSU and an OD process to support this was described by one senior manager as a blinding flash of the obvious. From a CSU perspective the Managing Director, Derek Kitchen, is clear that it isn t possible to be efficient in commissioning if commissioning and contracting are too far apart we have to work together. The features of this alignment between CCG and CSU now range from high level shared values, such as the importance of working towards better health outcomes in the local area, to the importance of symbolic details, such as ensuring all staff both CCG and CSU have the same leave flexibilities over Christmas and New Year periods. Anthony Moss who is Head of Contract Management for the CSU across South Staffordshire sits on the OD steering group of the CCG, so that our objectives are fully aligned. What OD approaches were used? Tony Bruce, the CCG Accountable Officer, has extensive OD experience and, with on-going partnership support from EDC, is well-equipped to establish and lead a comprehensive portfolio of OD interventions. In East Staffordshire these have included: Multi-stakeholder events which initially helped to establish the three-year change journey and are now used as occasional stocktaking events. These events, clarified the expectations we have as professional managers, membership clinicians, and the CSU, and help to shape our big strategic issues. A focus on the governing body covering: an initial skills audit; a survey evaluation of the leadership culture; individual self-assessments followed by 360 feedback and coaching (provided by EDC); and OD workshops. A great deal of effort has also been put into enabling the joint development of CCG and CSU staff. At an early stage the creation of a joint value statement was clearly an important activity which continues to provide an essential reference point for present day decisions and choices. It was 3
observed that the process of developing the joint values brought people together in a way that no amount of tea and biscuits ever could. Further joint work involved negotiation training to support the development of best value arrangements. All lead GPs, CCG and co-located CSU staff have engaged with Myers-Briggs Type Indicator (MBTI) profiling so that they now have a good understanding of individuals preferences, and are able to use this knowledge in team working and to maximise effective communications. One senior manager commented that as one of the few introverts people now know I ll work better if I m given time to reflect. Work with non co-located CSU staff has included speed dating sessions which participants have found to be hugely helpful in getting to know the person behind the email. These sessions have contributed to a shared resolution to speak in person or to pick up the phone wherever possible, rather than wasting time becoming confused or irritated by misunderstandings. One of the rules we decided amongst ourselves was that we wouldn t move forward on any commissioning matter until we were clear that we had a mutual understanding. That has been one of the biggest benefits to us progressing together. Sarah Laing, Chief Operating Officer A further instance of this commitment to real communication and problem-solving at the most appropriate level is the establishment of GROW buddies typically made up of a trio of clinician, CCG manager and CSU manager. These are based on an approach often used in coaching or mentoring to work round a problem solving cycle consisting of Goal Reality Options Way forward, which has the benefit of a deeper, more immediate means to address challenges and to reinforce the collective culture of the CCG. What that s enabled us to do is bring a very objective and fresh perspective to the problem-solving we need to do, rather than get bogged down in the problem as an individual. Nicky Harkness, Head of Transformation and Commissioning In all, the external spend on OD support through this period has been in the region of 50k or 1.5% of the management budget. What happened? What was the impact of the organisational development? The people we met in East Staffordshire described the experience of developing and implementing their OD Plan as a very positive one. Governing body clinicians talked about how they have come to appreciate that a medical model approach is not the only route to building a new organisation and developing the individuals within it. This work is led and co-ordinated by the Chair of the Steering Group (the grouping of CCG members), Dr Chris Gunstone, which meets monthly to maintain an overview of progress. Through the Steering Group member GP practices share accountability for decision-making at all stages of the commissioning cycle and all priority 4
areas are assigned to a lead GP. For some GPs the notion of OD is nebulous, fluffy or just plain managerial, but in reality they are able to recognise benefits which are tangible with high morale in the CCG despite the financial pressures, and GPs who continue to be committed despite other stresses in primary care. Many individuals, including the Clinical Chair Dr Charles Pidsley, are able to point to ways in which their personal leadership development has been supported by the range of OD interventions. Everyone understands that the OD Plan is a live document, regularly refreshed, which supports the achievement of the organisation s vision and strategy. Particularly for the governing body GPs, many of whom have been involved for a long time, the shift has been from a medical advisor style with the former Primary Care Trust (PCT) to a position where they are comfortable saying us and with taking leadership in a range of areas. Some of the development events which take place are for GPs and consultants only, with no managers present. Dr Pidsley is sure that these are creating much better lines of communication between clinicians in different roles. It is worth reflecting that the strong sense of purpose and commitment among those we met appears to have been achieved with relatively few formal events, albeit ones which were effective in creating new understanding and ways of working. Alongside the positive memories of these events the emphasis on working together in the day-to-day to achieve the organisation s strategy on behalf of the local area has brought with it a sense of empowerment. Managers commented that the experience of feeling invested in both for now and for the next generation of leaders contribute to an overall sense of being valued. As Emily Davies, a commissioning manager in the CCG, commented, at every level in the organisation you feel like an important cog in the big wheel. What did the CCG learn from their OD experiences? Wide engagement with stakeholders was instrumental in establishing the initial OD Plan. The CCG now has before and after culture survey data to demonstrate growing ownership of local priorities, of behaviours, and an increase in membership engagement. People we spoke to frequently referred to a sense of mutual respect, informed by clear expectations of each other. You feel like a valued team member. It s recognised that every person within the organisation is an important part of the whole. And the more we understand about each other the more productive we ll be for our patients. Emily Davies, Commissioning Manager Effective techniques for engagement and communication are understood and routinely used. Primary Care as a whole is better engaged with better attendance at meetings and a greater willingness to speak up as a consequence of the development work. Dr Charles Pidsley, Clinical Chair 5
Development of the next generation of leaders is seen as an important element alongside developing individuals and teams who are effective now. As one example Dr Chris Gunstone, Chair of the GP Steering Group, talked about how he has benefitted from coaching and from meeting people in different roles, and is now taking part in a leadership programme. Blurring the demarcation lines between the two groups of staff is such that CSU staff are expected to participate in the CCG team brief, and overall breaking down barriers (or perceived barriers) has led to a greater appreciation of each other s work. We don t see anything other than one team here. [.] We are doing some groundbreaking work here which is a fusion of CCG and CSU ideas and skills to get the experiences of patients into the commissioning process. Derek Kitchen, Managing Director of Staffordshire and Lancashire CSU The OD plan and the whole OD journey form an intrinsic and vital dimension of everything that is done by the CCG and its partners. Further knock on effects are their good relationship with the Local Area Team which the CCG is seeking to make equally developmental, and increasing collaborative commissioning through the Health and Wellbeing Board. From the CSU perspective Anthony Moss is clear that it s been successful here because of the absolute commitment of the top tiers of both organisations. At NHS East Staffordshire CCG there is a real appreciation that OD is mainstream business which contributes to better patient care now and in the future by continuously developing individuals and teams to enhance their performance. For further information please contact: Tony Bruce, Chief Accountable Officer, NHS East Staffordshire CCG E-mail: Tony.Bruce@uhns.nhs.uk 6