Dr Kath Checkland Prof Stephen Harrison Dr Stephanie Snow Dr Anna Coleman Dr Imelda McDermott

1. Management practice in Primary Care Organisations: the roles and behaviours of middle managers and GPs Dr Kath Checkland Prof Stephen Harrison Dr Stephanie Snow Dr Anna Coleman Dr Imelda McDermott

2. Management practice in PCTsSDO 02/1808/240 Acknowledgements • We are grateful to NIHR-SDO for funding this project, and to the participants who gave up their time and welcomed us into their organisations with such generosity. We are also grateful to the advisory group who provided useful feedback on the project design and theoretical framework. • The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR SDO programme or the Department of Health. Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

3. Structure • Background • Summary of study • Results • Implications Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

4. Commissioning has ‘failed’ • 2010 Health Select Committee detailed problems with commissioning, and concluded: “Weaknesses are due in large part to PCTs’ lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management.” HSC report 2010 p3 Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

5. HSCA 2012 • Commissioning responsibility handed to groups of GPs, management provided by employed managers or by contracting with external providers (eg management consultants) • Cut managerial costs by 40%.... ‘But the need for good managers performing essential functions…will remain.’ Equity & Excellence 2010 Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

6. What is a ‘good’ commissioning manager? • Research evidence – virtually none • Wider managerial literature suggests that middle-grade managers have a significant impact on organisational performance • PBC research suggests quality of management has a major impact on PBC ‘success’ • Some evidence from contracting research about the contracting process, but research on NHS managers tended to focus on identity and empowerment, not performance or behaviour • Official guidance – focus upon ‘skills’, eg: • Strategic analysis • Negotiating skills • Ability to involve users Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

7. The study • 18 month study of middle-grade commissioning managers in PCTs • Qualitative case-study approach – 4 cases, purposively sampled (size, urban/rural, complexity of health economy) • Focus upon commissioning managers responsible for PBC and those undertaking secondary care commissioning • Interviews, observation and document analysis (150 hours observation, 41 interviews) Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

8. Theoretical approach • Focus upon managerial work • Mintzberg, Hales – what do managers actually do? ‘Managerial work is fragmented, characterised by short-lived episodes of activity, and unpredictable’. Managers’ behaviours: • representative of the ‘work unit’ • monitoring the work unit • disseminating information • networking inside and outside • negotiating ‘up’ with senior managers and ‘down’ with subordinates; • planning work • allocating resources • HR issues • problem solving • technical work Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

9. Research questions: • Which of the managerial behaviours elucidated by Hales /Mintzberg were visible in the context of commissioning? • Were there any other specific or novel modes of behaviour that seemed to be particularly important in facilitating commissioning? Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

10. Generic managerial behaviours: Management and distribution of information • Management and distribution of information • ‘up’ to senior managers • ‘down’ to subordinates So, it was decided, then, I, I produced some options, I produced recommendations and then on the basis of those recommendations, I produced an options appraisal document which then went to various boards within the PCT, around the various options that were open. [Site 1 PCT manager] I don't know whether it's just timing, but we tend to meet on the last Friday of the month and PEC, I think, meets the first Wednesday of the month, it's something like that. I have in the past written a report from the Unscheduled Care [group], what we decided, that didn't get to the PEC in time and wasn't even looked at. [Site 1 PBC GP] Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

11. Generic managerial behaviours: networking Other times, like I did yesterday, I can go and slide next to the planned care head of that particular programme and say to her, mm, this isn’t working very well, how are we going to get all these leads, these GPSIs together to do this care pathway because at the moment it’s really disparate. She was saying, I know, I said, why don’t you come to [the joint commissioning meeting]? Let’s put you on the agenda, let’s once and for all sort this out and get a clear pathway ‘cos everybody’s all over the place and it’s just arguing between themselves and nothing’s getting done. So it’s that kind of thing.[PBC commissioning manager Site 3 authors’ emphasis] Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

12. Mundane organisational factors matter.. • Hot desking • Timing of meetings • Decision-making processes – who can ‘sign off’? • Information over-load can have significantly negative effects Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

13. ‘Animateur’ • A special mode of behaviour adopted by managers working successfully with GPs • Appeared to be associated with greater success in establishing Practice-based Commissioning • Seen in 3 out of 4 sites Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

14. Characteristics • Active management of disparate groups of people • Working to align objectives and to ensure that the right people behave in the right ways at the right time. • Objectives generally mutually determined • Aimed not simply at changing perceptions but also at bringing about specific concrete action in a specific time frame by a group of actors over whom the manager has no direct control. Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

15. Example 1:Managing email traffic So it's facilitation of the clinical input. Yes. We also with the clinicians now um, have a process in place. It started with e-mail etiquette, but I performance manage their responses as well, because I had the same two clinicians that were getting involved in everything and doing all the responses. As soon as I told the eight of them that I was monitoring who was responding to what and what the quality of the responses were, I was getting a lot more clinical input back. Q: So I suppose it goes back again to this sort of, inter-competitiveness doesn't it? A: That wasn't really competitiveness, I think it was, oh if I'm not seen to be doing what I'm supposed to be doing, what's going to happen next? Q: Yes. So it's performance regime? A: Performance managing them, yes. [Site 1 PBC manager] Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

16. Example 2: Managing a meeting A: I just knew that it was going to be a hard meeting. It was the first one, we knew [what] the attitude of the Acute Trust was to PBC and we knew what the GP leads wanted to get out of the meeting, in selecting unscheduled care as in A&E. A&E was a topic that they had problems with. They knew what they needed to do, but they couldn't get the buy-in and the joint work in to achieve it. Um, and I just thought that was the only way to go about it.It was in essence, a negotiation. We had to get them to agree to do something. Q: And where the clinicians happy, you know, the sort of, GPs the PBC leads or the ones that you chose, um, were they happy to go along with it? A: Yes, I think they thought it was funny at first and then when they saw that it worked um, we had a, like a meeting just after that Clinical Engagement Meeting, um, where they all went, 'wow, we didn't think that we'd managed to achieve what we wanted.' Because we even went in and I gave them a little crib sheet with this is our ideal and this is what we'll settle for and this is something in the middle that would be great. I mean, we'd have gone for what we could settle for, the fact that we got our ideal out of it, was, I think they were really surprised at. : Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

17. Example 3:Managing a decision-making process [PBC manager] Everything is circular. We have decommissioned something and we are the first group to do something new. So we may be in deficit but we are doing something that no one else has done.[fieldnotes PBC meeting site 3 meeting] Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

18. Important factors underlying ‘animateur’ behaviour 1 • Dual identification – managers aware of different needs/agendas and alert to necessary accommodations • Usually focused on attaining specific objectives • Deep & contextualised understanding of NHS important • Individual agency important – none of these managers trained, coached or explicitly told to behave in this way Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

19. Important factors underlying ‘animateur’ behaviour 2 • Organisational practices could have an inhibitory effect (eg office geography, hot desking, poor meeting organisation) • Autonomy required – freedom to behave creatively • Legitimacy vital. Certain amount of ‘top down’ endowment of legitimacy important, but earned legitimacy most important – fostered by early success Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

20. Is it really a new phenomenon? • ‘Leadership’? • Managers did not see themselves as leaders • Not identified by their organisations as leaders – not necessarily of a high grade • GPs saw themselves as leaders! • ‘Skilled facilitation’? Certainly used managerial skills such as facilitation, but whole greater than sum of parts. Integrated mode of behaviour that was infinitely flexible and clearly recognisable as distinct from non-animateur managers with similar skills • ‘Diplomat’? – more active and goal-driven than traditional descriptions of diplomacy Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

21. Conclusions 1 • Accusations of ‘poor management’ in PCTs were not borne out in practice • Much of what was required were ‘generic’ management behaviours • BUT commissioning managers also required flexibility and skill to ‘manage’ GPs working with them. This will be even more important in CCGs Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine

22. Conclusions 2 • Mundane organisational factors such as the timing of meetings, office geography, deciding who writes the ‘action notes’ and setting agendas really matter • Commissioning work required deep contextual knowledge of NHS AND was heavily relational. This has potential implications for the requirement to ‘contract out’ commissioning support Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine