Lunchtime Seminar Title

1. Lunchtime Seminar Title Review of the Effectiveness of DacCom Presentation: Date By: Name Presentation: 30th July 2008 By: Ian Bonny

2. Agenda Slide title should not be larger than Palatino Linotype 24pt. Scope of Review and the Journey So Far DacCom Structure DacCom Governance DacCom Strategic Direction Relationship with PCT Leadership Prescribing – A Success Story Summary

3. Scope of Review • Through a series of stakeholder interviews, to: • Review DacCom structure • Review DacCom roles and responsibilities • Review DacCom decision-making process • Include brief comparison DacCom against neighbouring commissioning bodies • Outcomes were to: • Recommend any structural changes • Recommend any changes to corporate governance • Recommend any changes to roles and responsibilities Page 2

4. Stakeholder Interviews • Twenty stakeholder interviews conducted • These included • Clinicians from DacCom • Managers from DacCom • External stakeholders such as Patient’s Representative and PCT staff • Clinicians from StAHCom and WatCom • Managers from StAHCom and Watcom

5. The Journey so far • Have achieved a great deal from a standing start • Services are being commissioned • DacCom played full part in wiping out budget deficit • Despite no previous history of collaborative working, 19 individual Practices, across a relatively large geographical area, are on the whole working well together • Strong financial management • Small, hard working and dedicated group leading activities • Commissioning environment in DacCom different from that in St Albans and Watford • Not a level playing field • DacCom has played full part across West Herts • West Herts Leads • LMC/PBC Liaison • Governance sub-committee • Clinical conclave • DacCom has taken responsibility for its actions by commissioning this review • Opportunity to regroup and address the new challenges confronting DacCom

6. DacCom Structure • Executive decision-making body too large and too unwieldy • Representative rather than functional • Too easy to block decisions • Use of Locum cover • Clinicians to give up Practice sessions • Perception that it is driven by financial considerations at expense of well-being of staff • Clinician or Management led? • PCT support staff • Fill the current Relationship Manager vacancy

7. Changes to DacCom Structure • Develop role of Chief Executive/Programme Manager • Lead strategy development process • Lead business case development • Does not need to be full time • Must be clinician or at least strong clinical background • Must have good business skills • Introduce smaller Operating Board (approx six members) • Will lead on strategy development, developing business cases, monitoring & implementation, financial management & reporting • Led by Chief Executive • Board members primarily clinical • Accountable to Executive Committee • Could also include PCT Business Manager

8. DacCom Governance • One big issue - lack of clarity • How are people elected to Executive Committee? • How long do they serve for? • How can they be removed? • How are additional people elected/co-opted? • When is the AGM? • Is lack of knowledge and awareness down to the Executive Committee or to individual staff not making the effort to keep informed?

9. DacCom Governance • Next Steps? • Original Executive Committee and Practice Agreement/Constitution both delivered what was required at outset of practice based commissioning • Commissioning world is now very different place • Re-elect Executive Committee over the next two years • Review Executive Committee roles and length of term • Develop future timetable for re-election • Re-draft the Practice Agreement/Constitution • Will need to reflect any Chief Executive and Operating Board positions

10. DacCom Strategic Direction • The perception is of a lack of strategic direction • Commissioning strategy is felt to be piecemeal and seen as knee-jerk reaction to PCT demands • Any developed strategy does not have the buy-in of DacCom people • People feel excluded from the process • A feeling that it does not accurately reflect local needs • Does not fully meet needs of PCT • Tough balancing act! • Too late to revisit current plan, but now is the time to start planning for 2009/2010 • Process must be inclusive and consultative • Outcomes must define what DacCom is about • Consider externally facilitated workshops

11. CATS • CATS may well be the worst commissioning idea to come out of the DH in some time • Evidence suggests that money is not being saved and patient access to hospitals being reduced • However, political wind is firmly behind CATS • DacCom approach is seen as obstructive • DacCom being marginalised • PCT under great pressure to implement CATS • StAHCom and WatCom implementing CATS has only served to weaken the DacCom position further • Pilot one CATS • Shape it to what Dacorum wants • If it works, great • If not, shape it into something that will

12. Relationship with PCT • Current relationship has broken down • Described as antagonistic • Characterised by lack of trust and clarity around commissioning agendas • Many issues seen as personal rather than commissioning based • Perception is StAHCom and WatCom enjoy constructive relationship due to history and favouritism from PCT • Do you want to repair the relationship? • Truth is, in practical terms you have no choice but to repair it • Consequences of not will be continued marginalisation and isolation • Basic commissioning agenda comes from PCT • DacCom cannot influence agenda from outside • Need to understand problems of PCT

13. Relationship with PCT • Must become more politically astute • Must put time, effort and resource into playing the ‘political game’ • Understand that PCT agenda is politically driven • Spend time at PCT Head Office • Schedule monthly meetings with Andrew Parker and Suzanne Novak • Darzi Centre and reconfiguration of Hemel Hempstead GH • Unless you engage the PCT these will be ‘done to you’ rather than you leading the process • Already recognising this with the Darzi Centre • Recruit PCT Business Support Manager • Not a ‘spy in the camp’ but valuable resource that will stand up to PCT on your behalf • You must make the first move with the PCT!

14. Leadership • Perceived lack of leadership • Clinical leadership • Not criticism of technical skills • Perceived lack of widespread commitment to commissioning • DacCom does not have organisation-wide entrepreneurial spirit • DacCom does not have organisation-wide “can do” attitude • Too much expected of too few people how have delivered but at what personal cost? • Need single point of leadership • Appoint Chief Executive/Programme Manager • Single person to drive DacCom commissioning agenda • Engage all Practices • Authority to make things happen • Accountable to Executive Committee

15. Prescribing • What a success story! • Learn the lessons • Clear strategic direction • Clear clinical leadership • Devoted time, effort and resource to be successful • Widespread buy-in from Practices • Clear incentives • Strong external relationships • Local hospitals • PCT • Apply this learning organisation-wide

16. Summary [1] • Develop Chief Executive/Programme Manager role • Develop smaller ‘Operating Board’ • Review current Executive Committee constitution • Re-elect Executive Committee members over next two years • Engage all Practices in strategy development for 2009/2010 • Pilot a CATS • Play the ‘political game’ and repair the relationship with the PCT

17. Summary [2] • Recruit the PCT Business Support Manager • Seize the initiative on the Darzi Centre and lead the reconfiguration of Hemel Hempstead GH • Develop a strategy to engage all Dacorum Practices in the concept of commissioning • Develop a wider clinical leadership team • Clinical leaders to give up sessions and use Locum cover on more regular basis • Learn the lessons from the prescribing project and apply them