Open Access Research Leadership of healthcare...

Leadership of healthcare commissioningnetworks in England: a mixed-methodsstudy on clinical commissioning groups

Markos Zachariadis,1 Eivor Oborn,1,2 Michael Barrett,2 Paul Zollinger-Read3

To cite: Zachariadis M,Oborn E, Barrett M, et al.Leadership of healthcarecommissioning networks inEngland: a mixed-methodsstudy on clinicalcommissioning groups. BMJOpen 2013;3:e002112.doi:10.1136/bmjopen-2012-002112

▸ Prepublication history andadditional material for thispaper are available online. Toview these files please visitthe journal online(http://dx.doi.org/10.1136/bmjopen-2012-002112).

Received 27 September 2012Revised 14 December 2012Accepted 11 January 2013

This final article is availablefor use under the terms ofthe Creative CommonsAttribution Non-Commercial2.0 Licence; seehttp://bmjopen.bmj.com

1Warwick Business School,Warwick University, Coventry,UK2Judge Business School,University of Cambridge,Cambridge, UK3BUPA, BUPA House,London, UK

Correspondence toProfessor Eivor Oborn;[email protected]

ABSTRACTObjective: To explore the relational challenges forgeneral practitioner (GP) leaders setting up newnetwork-centric commissioning organisations in therecent health policy reform in England, we useinnovation network theory to identify key networkleadership practices that facilitate healthcare innovation.Design: Mixed-method, multisite and case studyresearch.Setting: Six clinical commissioning groups and localclusters in the East of England area, covering in total208 GPs and 1 662 000 population.Methods: Semistructured interviews with 56 leadGPs, practice managers and staff from the local healthauthorities (primary care trusts, PCT) as well asvarious healthcare professionals; 21 observations ofclinical commissioning group (CCG) board andexecutive meetings; electronic survey of 58 CCG boardmembers (these included GPs, practice managers, PCTemployees, nurses and patient representatives) andsubsequent social network analysis.Main outcome measures: Collaborativerelationships between CCG board members andstakeholders from their healthcare network; clarifyingthe role of GPs as network leaders; strengths andareas for development of CCGs.Results: Drawing upon innovation network theoryprovides unique insights of the CCG leaders’ activitiesin establishing best practices and introducing newclinical pathways. In this context we identified threenetwork leadership roles: managing knowledge flows,managing network coherence and managing networkstability. Knowledge sharing and effective collaborationamong GPs enable network stability and the alignmentof CCG objectives with those of the wider healthsystem (network coherence). Even though activitiesvaried between commissioning groups, collaborativeinitiatives were common. However, there wassignificant variation among CCGs around the level ofengagement with providers, patients and localauthorities. Locality (sub) groups played an importantrole because they linked commissioning decisions withpatient needs and brought the leaders closer tofrontline stakeholders.Conclusions: With the new commissioningarrangements, the leaders should seek to move awayfrom dyadic and transactional relationships to anetwork structure, thereby emphasising on theemerging relational focus of their roles. Managing

knowledge mobility, healthcare network coherence andnetwork stability are the three clinical leadershipprocesses that CCG leaders need to consider incoordinating their network and facilitating thedevelopment of good clinical commissioning decisions,

ARTICLE SUMMARY

Article focus▪ Examines how clinical commissioning group

leaders can act as relational catalysts across theirhealthcare networks as they seek to facilitatehealthcare innovation in light of the recentreform in the healthcare sector in England.

Key messages▪ The new clinical commissioning scheme fore-

grounds the need for leaders to be relational andeffective in integrating across innovationnetworks.

▪ Knowledge sharing and collaboration betweenstakeholder groups are key tasks of clinical lead-ership which play a significant role in ensuringnetwork coherence and stability.

▪ Lack of clear political direction and dialogue dis-courages network participation and catalysesinstability.

▪ Clinical leaders need to focus on aligningpatient-centred services locally as well as acrossthe network.

Strengths and limitations of this study▪ The study provides in-depth accounts of the

emerging role of GPs as healthcare networkleaders in the early stages of the new commis-sioning process.

▪ We highlight the relational focus of the networkleadership role which enables knowledgesharing, network coherence and networkstability.

▪ The use of multimethod approach (interviews,observations of CCG board meetings, extensivestudy of documentation and CCG network ana-lysis) allowed us to validate our findings andminimise bias owing to limitations of specificmethods.

▪ The on-going change in the health sector andthe political uncertainty limits the generalisabilityof this qualitative research.

Zachariadis M, Oborn E, Barrett M, et al. BMJ Open 2013;3:e002112. doi:10.1136/bmjopen-2012-002112 1

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best practices and innovative services. To successfully manage theseprocesses, CCG leaders need to leverage the relational capabilities oftheir network as well as their clinical expertise to establishappropriate collaborations that may improve the healthcare servicesin England. Lack of local GP engagement adds uncertainty to thesystem and increases the risk of commissioning decisions beingirrelevant and inefficient from patient and provider perspectives.

INTRODUCTIONFollowing the announcement of the latest NHS reform,1

the health system in England has entered a new cycle ofradical changes that aim to improve healthcare out-comes and increase efficiency. At the centre of the strat-egy proposed by the current coalition government is thegoal to ‘liberate the NHS’ by putting clinicians such asgeneral practitioners (GPs) ‘in the driving seat and sethospitals free to innovate, with stronger incentives toadopt best practice’,1 thus, challenging the way the com-missioning of healthcare services is organised and exe-cuted. In this context, the new Health and Social CareBill creates a duty for the new clinical commissioninggroups (CCGs) to ‘promote research and innovationand the use of research evidence’.The commissioning of healthcare services is tradition-

ally understood to be the process by which ‘the healthneeds of a population are assessed, the responsibility istaken for ensuring that appropriate services are availablewhich meet these needs, and the accountability for theassociated health outcomes is established’.2 Untilrecently, commissioning activities such as planning(assessment and evaluation), purchasing (identifyingand negotiating) and monitoring health services3 4 wereperformed primarily by non-clinical managers inprimary care trusts (PCTs) with little clinical input. Inresponse to that the recent reform transferred commis-sioning duties over to GPs, nurses and other healthcareprofessionals who represent a range of both providerand purchasing interests. The diversity of the actorsinvolved as well as the complexity of the tasks demands amore integrated approach to commissioning than per-formed earlier.Based on the NHS White Paper,1 apart from establish-

ing population needs and planning and controllingtheir budgets, commissioners must also work with awider group of stakeholders to identify opportunities toimprove value through innovation. This new approach toclinical commissioning shifts from contracting ofstand-alone healthcare services based on dyadic relation-ships to a more dynamic network-centric approach of thehealthcare system that brings together a large number ofactors to collaborate and purchase integrated serviceswhich will deliver the desired outcomes. Recent researchemphasises on the importance of networks in healthcarepractice and argues that healthcare and clinical net-works have the potential to enable multidisciplinary coa-litions to address diverse agendas and achieve best

practices. Integrating across networks, by allowing forthe people and ideas to come together, can also preventfragmentation, which has been a key challenge of previ-ous commissioning arrangements, and facilitate inte-grated care with the development of collective contractsthat can be more cost-effective and focus on new path-ways and care packages, thus, increasing the quality ofservices and outcomes.5–7

Given the importance of networks in healthcare andthe fact that innovation is inherent in, and central to,the new commissioning structure, we used an innov-ation network theory to study the newly established clin-ical commissioning groups (CCGs) (figure 2). GPleaders are seen as network leaders within their health-care service environment with CCGs being the nucleusof innovation activity. Drawing upon this theory, wewere able to obtain unique insights of the emergingleadership activities of GPs and their efforts to establishbest practices as well as to develop new clinical servicestailored to the needs of their population. We believethat this approach will shed light on the emergingforms and functions of evolving commissioning entitiesand will offer a fresh viewpoint on clinical leadership inhealthcare networks.

Clinical commissioning and healthcare networksThe success of clinical commissioning and its potentialto deliver has long been discussed in health servicesresearch. In the past couple of decades, the governmenthas endorsed and funded a number of alternativeprimary care-led purchasing schemes receiving mixedsignals from clinicians, policy makers and the public.Figure 1 provides a timeline of clinical commissioninginitiatives since 1991 when the internal market reformtook place and the separation of purchasing and provid-ing health services was introduced for the first time inthe English NHS.8

Overall, the different primary care-led commissioningmodels can be seen as part of a continuum of schemesavailable to use for purchasing healthcare services.Smith et al 9 provide a scale of the different commission-ing levels in the UK, whereby approaches vary from theindividual patient level to a whole nation’s population.As the different commissioning levels in the continuumrespond to different policies, it is expected that therewill be implications for the respective purchasing prac-tices and for commissioners. More specifically, differentapproaches to commissioning will demand the involve-ment of actors across various levels and different loca-tions. For example, GP fund holding was considered tobe much more practice-led than practice-based commis-sioning (PBC) which involved groups of practices ratherthan individual practices.10 Alternative approaches willalso lead to the formation of different clinical andhealthcare networks as a response to meeting commis-sioning challenges within the health system and bringingtogether purchasers and providers.5

2 Zachariadis M, Oborn E, Barrett M, et al. BMJ Open 2013;3:e002112. doi:10.1136/bmjopen-2012-002112

CCG leadership of healthcare commissioning networks in England



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Drawing from the historical research evidence oncommissioning organisations and their effectiveness, anumber of implications emerge for the structure, gov-ernance and size of clinical networks. For example,small, high-density networks can ensure alignment of

services with the local population needs but are oftenexpensive. Overall, there has been a trade-off betweenlower levels of commissioning and transaction costs asthe more local and smaller the network, the moreexpensive it is to maintain and deal with an increasednumber of purchasers. This issue was evident during theGP fund holding and total purchasing pilot (TPP)periods where the average size of the commissioningconsortia was small and purchasing decisions weredivided between several local commissioning organisa-tions. Having said that, general practitioner fundholdingscheme (GPFH) and TPPs were more effective indealing with a more focused set of issues and managedto reduce waiting times for patients as well as achievebetter collaboration between participating GPs.6 8 11 12

Their voluntary character, however, has created signifi-cant inequalities as those local networks that wereengaged had a clear advantage over groups of GPs thatwere not involved.In addition, as clinical networks aim to promote infor-

mation exchange and understanding between physi-cians, local government, voluntary sector and so on andtranslate this discussion into innovative healthcare solu-tions for patients, GP leaders need to develop leadership(and commissioning) skills that will enable these rela-tionships across multiple stakeholder groups.13 Ratherthan emphasising contracts and provider–purchasernegotiations, multiple stakeholders with different inter-ests need to be integrated across an emerging network.Leadership activities in the new commissioning processemphasises on sharing knowledge and managing knowl-edge flows, collaborating with colleagues and externalstakeholders and seeking advice from peers in differentclusters.

Figure 1 Clinical commissioning

initiatives since 1991.

Figure 2 Clinical commissioning groups as innovation

network leaders.





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Finally, incentives need to be embraced to motivateGPs and to influence their behaviour in their network.This can be achieved by facilitating autonomy and inde-pendence in being creative around contracting appro-priate services.14 15 In the wake of CCGs, commissioninggroups were much larger than previous clinical net-worksi and attempts were made to put financial incen-tives in place. In addition, clinical networks are primarilyled by GPs who would be managing real budgets andwill be required to join a commissioning group. Withinthis system of regulation and governance, clinicalleaders will need to balance between managerial andprofessional interests, encourage collaboration andknowledge exchange and reduce boundaries betweenpractitioners, institutions and other organisations.5

Table 1 provides a breakdown of the different primarycare-led commissioning organisations and the implica-tions for the healthcare networks that were developed.Although network leadership that seeks to achieve col-

laboration and knowledge sharing is important in thecommissioning process, research in this area has largelybeen focused on describing and comparing the differentpolicies,6 8 by measuring resource allocation and eco-nomic outcomes.16 17 Our innovation network theoryapproach will explore GP-led commissioning by lookingat knowledge mobility and collaborations in networks of

clinicians, PCTs, patients, providers and other entitieswhich play an important role in the development ofnovel commissioning arrangements and improved out-comes. We carried out research on six CCGs that exami-ned the early function and emerging forms of CCGs;analysed how CCG leads orchestrate commissioning activ-ities towards three key network leadership processes:managing knowledge flows, managing network coher-ence and managing network stability; identifiedstrengths, issues and areas for development of the newlyestablished CCGs; and contributed to the theoretical andmethodological knowledge base in the study of clinicalleadership in the context of commissioning practice.

METHODSThis study is part of the Collaborations for Leadershipin Applied Health Research and Care (CLAHRC) initia-tive, funded by the National Institute for HealthResearch (NIHR), which aims at supporting and trans-lating research evidence into NHS practice. The studyitself took place within NIHR CLAHRC forCambridgeshire and Peterborough and was facilitated bythe collaborative partnerships between the University ofCambridge and surrounding NHS organisations.

Design and theoretical frameworkWe conducted a theoretically informed, mixed-methodscase-study research across multiple CCG sites. While theresponsibilities of the CCGs (initially known as GP com-missioning consortia) are outlined in the recent

Table 1 Healthcare network implications of primary care-led commissioning organisations

Coordinating mechanism Key features

Governance and

autonomy

(Ham, Smith and Eastmure

2011; Ham 2008)

(Mannion 2011; Checkland,

Coleman, Harrison et al 2009)

(Curry, Goodwin, Naylor,

et al 2008; Smith and

Goodwin 2002)

General practitioner

fundholding scheme

(GPFH)

Market driven/emphasis on

competition, strong procurement

focus

Good for local commissioning and

healthcare practice, local coherence

Increased inequities

No clinical governance,

control of real budget,

independent body

Total purchasing

pilots (TPPs)


competition

Better integrated purchasing and

provision

Higher costs and risks

No clinical governance,

control of indicative budget,

body within health authority

Primary care trust

(PCTs)


competition, focus on

administration of purchasing

Better control, budget allocation/

management and economies of

scale due to centralisation

Less clinical input

Statutory organisation,

governed by PCT board

(includes clinical input),

own budget

Practice-based

commissioning

(PBC)


competition, transactions

oriented

Increased engagement of clinicians

Higher management and transaction

costs

Led by general practitioners

(GPs), little clinical

governance, indicative

budget, voluntary scheme

Clinical

commissioning

groups (CCGs)

Network-centric, trust,

collaboration driven with

emphasis on good

communication, some degree of

accountability

Potential to encourage innovation,

best practice, higher quality,

integration and cost-effectiveness of

commissioned services

High risk of network instability

Clinical (GP) governance,

real budget (2013),

independent body,

compulsory scheme

iThe median population covered by the 212 CCGs so far preparing forauthorization is 226 000.





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government bill, very little is known about the organisa-tional practices commissioners have adopted to developnovel local services. To fill that gap, the aim of theproject is to understand the emerging role of CCGleaders and outline their coordination activities asleaders of their health network. In this process we choseto utilise innovation network theory for two reasons.First, the delivery of clinical commissioning and develop-ment of innovative services around it requires complexcollaborations between a large number of stakeholdersincluding patients and the public, local government andauthorities, acute and other providers as well as front-line GPs, in the form of a value network. These so-calledinnovation networks are often characterised by loose,semitemporal linkages between actors who seek toemploy the right resources and engage in strategic colla-borations to deal with specific problems and developinnovative services and solutions.18 Second, this network-centric innovation model also recognises the need for aleading entity that will orchestrate the innovation activitywithin the network through a number of coordinationprocesses19 20 thus emphasising the relationships thatneed to be established. Therefore, by mapping our find-ings on this theoretical framework we were able to iden-tify various coordination processes that CCG leaders use.In addition, we are able to pinpoint particular strengths,issues and areas for further development of CCGs andidentify key leadership skills that will help GP leadsmanage their network in the future.

SamplingDuring our fieldwork we conducted an in-depth and sys-tematic study of six CCGs and local clusters (also calledlocalities) in the East of England region (sites A, B, C,D, E and F). These groups covered mixed patient popu-lations varying between 50 000 and 550 000 patients. Intotal, our sample groups covered 1 662 000 patientsserved by 208 GPs. The number of board members ofthe CCGs also varied according to the size of the popula-tion they covered with the smallest numbering fourmembers and the largest being 14. The total number ofboard members of all six commissioning groups at thetime of data collection was 63.The first wave of GP commissioning consortia took

place in December 2010 and introduced 52

‘pathfinders’ initially covering 12.9 m people. Second,third and fourth waves followed soon after and by theend of April 2011 GP commissioning covered 9 of 10people in England.ii Most of the groups in our samplewere given pathfinder status during the first two waves.Table 2 presents all the main characteristics of our CCGsand localities sample, and points to the variability ofnetwork structure. The size variation in our sample issimilar to that in the national statistics of the first twowaves (numbering 137 consortia): the average popula-tion covered per CCG was approximately 207 000 with astandard deviation of 146 000 (minimum 14 000/maximum 693 000), and the average number of prac-tices under a CCG was 30 with a standard deviation of22 (minimum 1/maximum 105).

Data collection and analysisAccess and pilot interviews were initiated in November2010 and the main data collection took place betweenFebruary and December 2011. During that time com-missioning groups were in a preliminary pathfinderstage and did not have any fund holding rights or statu-tory powers. In addition, at that time there was no offi-cial guidance from the Department of Health otherthan the initial bill and supplementary information oncommissioning. However, nearly all CCGs we examinedhad established formal operating procedures thatallowed them to function as organisations with particu-lar membership and board structure. In total 56 health-care professionals were interviewed: 35 board members(mostly GPs but also PCT employees and practice man-agers) plus an additional 21 people from various orga-nisations including acute provider representatives andhealth authorities executives. In addition, we observed21 CCG board meetings and executive committeeswithin local clusters. This helped us to witness howthese groups work in action rather than rely solely onthe espoused views of their members. We kept fieldnotes during meetings and transcribed all interviewsafter recording (apart from few exceptions). We usedATLAS.ti to categorise, code and analyse qualitative

Table 2 Main characteristics of CCGs and localities sample

Status

Pathfinder

wave

Covering

Localities

(clusters)

Board representation

Executive

support

PBC

rootsPopulation Practices

Secondary

care Nurse Patient

Site A CCG 1 300 000 30 6 N N Y N None

Site B CCG 2 550 000 60 4 N N Y N Strong

Site C Locality – 50 000 4 – N N N N Weak

Site D CCG 2 325 000 47 2 N Y N Y Strong

Site E CCG 1 230 000 27 2 Y Y Y Y Medium

Site F CCG 1 77 000 10 – N Y Y Y Strong

iiStatistics as well as interactive maps on GP commissioning consortiacan be found online at: www.gponline.co.uk.





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data including hundreds of pages of background docu-ments such as national-level policy reports, minutesfrom meetings and speech transcripts from conferencesand workshops (table 3) (figure 3).Having CCG board members as our unit of analysis

helped us to confine our research and also limit ourstudy of their healthcare innovation network to theirimmediate contacts. Moreover, GP leaders as main stake-holders also assisted us in identifying potential targets toquestion. Additional interviewees were also recognisedthrough the observation of board meetings with theintention of getting a variety of perspectives and evi-dence. Interviews usually lasted between 35 and 90 minand were conducted either by phone or in person. Wecompared organisational forms and leadership routinesacross the six groups and highlighted their variations.Key themes that emerged from the interviews werecoded according to the coordination processes with

which they were related. Based on network leadershiptheory, three innovation network leadership routineswere identified as relevant with our CCG study: man-aging knowledge flows, managing network coherenceand managing network stability.In order to provide external validity to our research

results, and debate whether the theoretical approach wehave used could be useful for the future development ofCCGs nation-wide, we presented our findings to anumber of CCG board of directors and (particularly tothose who were interested in the feedback) at a regionalevent on clinical commissioning where most of the com-missioning groups were represented.

Social network analysisIn addition to interviews, CCG documentation andother publications, we also collected responses usingan electronic survey on knowledge sharing and

Table 3 Breakdown of interviews, observations and survey response by site and type

GPs

PCT

employees

Practice

managers Hospital Other Total

Meeting

observations

Number of

board

members

Survey

participation

Site A 3 3 2 1 1 10 5 13 100% (13/13)

Site B 6 5 3 1 1 16 7 13 92% (12/13)

Site C 5 3 0 0 0 8 3 4 100% (4/4)

Site D 3 1 2 0 1 7 2 13 92% (12/13)

Site E 3 0 1 1 3 8 1 14 93% (13/14)

Site F 1 1 1 1 3 7 3 6 83% (5/6)

Total 21 13 9 4 9 56 21 63 94% (59/63)

Figure 3 Summary of the study

protocol.





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collaboration practices which were emailed to all boardmembers of the CCGs we studied. The response rate forthis was approximately 94%iii and the results helped usidentify knowledge exchange patterns among boardmembers and outside parties regarding clinical commis-sioning. We used social network analysis (SNA) todiscern the popularity of certain individuals in thenetwork and the individuals that board members go toin order to acquire advice regarding commissioningissues. More specifically, we were able to measure thenumber of ties the CCG board members have (alsocalled ‘degree’) as well as their centrality into thenetwork (also known as ‘betweenness centrality’) tounderstand which members act as brokers and have theability to transfer knowledge from other parts of thehealthcare network and across CCGs. Finally, we calcu-lated the density of the CCGs which measures the extentto which board members are interrelated and go totheir colleagues for advice. This measure indicates insomeway the good communication and team-workingactivities among CCG members.The visualisation and analysis of the CCG board net-

works were performed using Gephi 8.0.

RESULTSCommissioning context: the challenges of networkleadershipThe current commissioning context presents a numberof challenges for leaders in establishing innovation net-works. In the following analysis, we examine the dynam-ics of multiple relationships which CCG leaders neededto establish to facilitate commissioning across theirhealth networks, and in particular the need to enableknowledge exchange, network coherence and networkstability as dynamic capabilities that support innovationnetworks. We consider the CCG board relationship withPCTs, health providers and service users, frontline GPsand the broader health polity. We conclude our analysisby comparing two innovative developments in CCGboard commissioning practices in the sites studied,using them as illustrative rather than exemplars.

Establishing relationships with PCTsThere were variations in viewpoints among the CCGleaders at the six sites as to the way relationships withPCTs were managed. Leaders in some sites worked wellwith PCTs describing the relationship as cooperative andbeing ‘open’ and ‘supportive’, ‘getting better at seeingeach other’s point of view’. Some CCG leaders viewedPCT employees as a useful source of information andcommissioning expertise. A CCG board member at siteB pointed out: ‘I see my role as coordinating, havingsome ideas and then asking PCT people to develop

those ideas. There’re only so many hours in a week andI can’t do everything, so I draw on the skilled people atthe PCT’. At site C whereby leaders developed a noveland collaborative arrangement whereby GPs and PCTmanagers were paired together to form a PCT sub-committee to resolve commissioning issues. These exam-ples reveal the important role many PCT staff played asknowledge brokers who facilitated knowledge sharingand transfer across the network.At the same time, however, GP leaders were acutely

aware of the perceived limitations of the knowledge heldby PCTs in commissioning. It was generally understoodby CCG board members that PCTs were ‘being abolished[because they] haven’t delivered what [they] shouldhave done” (site B). A GP in site A was similarly criticalpointing out that: “the contracting has been poor and ithasn’t been adequately informed […] it is basically alegacy […] There wasn’t actually any thinking or deci-sion making’. Thus leaders were wary of adopting theknowledge and ideas of PCT commissioning practices.A similar dilemma was faced by the PCT staff. On the

one hand they recognised that ‘you’ve got the PCT tryingto offload its activities to the CCGs’, in a supportivemanner. On the other hand, a number of PCTemployeesfelt threatened by CCG formation and were highly awareof their own job insecurity. As a result PCT members werenot always willing to openly cooperate with CCG leaders,for example restricting funding of new commissioningarrangements. A GP described how the indifference ofPCTemployees towards the success of the CCG led to frus-tration in his board. There was a perceived view that a ‘notinvented syndrome’ limited the potential for innovation;‘nobody got the idea and they just refused to fund it’ (siteC). The wavering support of PCTs stemming from theuncertainty of their future contributed to instability acrossthe health network. There was also system-wide concern asto who would be responsible for the essential non-commissioning tasks currently being done by PCTs, andhow they would be undertaken in the new health system.This hindered the development of trust and commitmentas a critical basis for collaborative relationships with CCGboard members.Co-location arrangements further constrained (or

enabled) communication between CCG members andPCT employees, leading to misinterpretations and delaysin the transfer of information and data. One PCT dir-ector (site D) felt that their good relationship with GPleaders ‘was due to geography […] we brought the PBCsupport unit into the PCT building so they are in thesame place as us […] sitting side-by-side with the PCTstaff […Now with CCGs] that absolutely helped’. In ourresearch sample, sites that had supportive relationsbetween respective PCTs and CCGs used the PCT prem-ises to hold their board meetings. In networks whereCCGs were detached from PCTs, the board meetingswere held elsewhere (eg, in sites B and E). These resultsare reflected by the social network analysis (see compari-son between sites A and B in table 4).

iiiOut of the 63 board members who received the electronic survey 59replied. Two of the four people who did not respond were new boardmembers.





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Relating to providers and usersAs discussed later on in our vignettes, a critical CCGleadership task is embedding relationships with healthproviders within the commissioning network, integratingsecondary care provision with primary care in novelways. A CCG board member suggested: “We need to getthat relationship (commissioner-provider) off from agood start […] to sort a strategy that is going to pullthem (providers) in from the beginning [and realise]that it’s not ‘take all our money and continue to deliver asyou’ve always done’. We’ve got to do things differently”(site B). Establishing trust and adequate knowledgeexchange between CCG and provider entities remainedan on-going challenge.See online supplementary box 1 highlights multiple

instances from our analysis regarding the importance ofknowledge exchange and collaboration in enablingservice integration across primary and secondary carestructures.Further, our results from the SNA analysis showed that

there was generally a substantial lack of communicationbetween CCGs and acute providers. In our CCGnetwork sample, boards had a maximum of three tieswith acute providers; this is very low when consideringthat these relationships are at the core of clinical com-missioning and central to all the sample local innova-tions, including those summarised in the vignettes.Another important network dynamic between CCG

boards and healthcare providers related to knowledgesharing around appropriate level and type of costing datarelevant to commissioning. This lack of informationoften described as ‘a black box’ around the servicesbeing provided and their associated costs leads to chal-lenges of network level coherence of information tosupport innovation. A GP board member at site Cexplained, “we have actually no idea what the costs are ofthese pathways…it is very difficult to get any data or realinformation from [the acute provider]…they haven’t hadto share this before we can’t commission [properly]without it.” Another GP board member reinforced thateven in their own medical practice it was difficult tomanage patients’ care in a way that optimised commis-sioning efficiency; ‘When I sign the referral letter I com-mission the spending of that money, but effectively whatI’m doing is signing a blank cheque because I have noidea what the cost will be as the patient goes down thatpathway. And if say there were two competing providers… which of those two pathways would be better to useand what are the costs and the outcomes of the two

pathways, well I don’t have that information’. As discussedlater in the vignettes, comparative information and dataanalysis were important initial drivers of the innovationprocess. The tension between GP commissioners and sec-ondary care specialists is described by a PCTemployee asa conflict of interest where ‘providers want to maximisetheir income while [commissioners] want to maximise effi-ciency’ (site B).In addition to providers, users constituted another

important stakeholder that contributed knowledgetowards the commissioning process. Over half of theCCGs had a patient representative on their board (sitesA, B, E and F) to improve the final service offering. Oneof the patient representatives interviewed felt that hemade ‘direct input’ into the board meetings, and feltthat he made an important contribution as ‘any serviceuser knows what it’s like on the other side, to be on thereceiving end. They can give very practical suggestionsabout what works, what doesn’t, what are glitches in thesystem’ (patient representative, site A).However, there was voiced confusion among leaders

regarding how experiential knowledge from serviceusers should be used and incorporated into the wider,population-level commissioning agenda of CCGs. A GPleader (site C) highlighted it was a challenge to engagepatient groups into providing inputs at the locality andor CCG level: ‘Patients are not usually interested in it’,‘they are busy and do not want to do things like this’(site B), ‘patients will only be involved if there is moneyto be made’ (site A). In addition, many GPs commen-ted that when inviting patients to provide feedback ‘youget half a dozen […] with particular reason or agenda’,suggesting this form of engagement did not lead toconstructive dialogue on improving patient care. A GPfrom site B pointed out: ‘I think they [patients] are justthere representing their own views as they see it’. Eventhough the wider perception from policy documents onpublic and patient involvement in commissioning wasthat patient views were valuable, there was no mechan-ism in place to operationalise lay representation andoverall it was often carried out in a piecemeal fashion.For example, in some of the locality meetings weobserved, individuals who had the flexibility to attendwere listening attentively to discussions withoutengaging in overt dialogue. In other meetings, therewas a set time given to patient representatives topresent their perspectives. As such, several GP leadersfelt that in the current fiscal climate and organisationalupheaval, investing scarce resources in organising

Table 4 Site A and site B network ties

GP

practices

PCT (Local

health

administration)

Acute

providers

Regional

NHS

(SHA)

Community

providers

Local

authorities

Other

ties

Total

ties

Board

density

Site A 3 18 2 0 1 1 1 26 0.737

Site B 6 13 2 2 3 7 3 36 0.622





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patient groups and their input was questionable, reveal-ing the challenge in genuine public or patientrepresentation.21

Engaging with frontline GPsIn order for commissioning decisions to reflect thecorpus of primary care views across the network, CCGleaders need to find mechanisms for knowledgeexchange with frontline clinicians. As shown thoughboth case vignettes of innovations uncovered within oursample CCGs, novel ways of delivering a service or newservices entailed commitment and engagement of front-line GPs, both in providing the new ideas and also enrol-ling colleagues in the new practice. Enabling knowledgeflows across the network also enables the developmentof innovative ideas. Engagement and nurtured relation-ships with frontline GPs helps ensure that the knowledgeheld by these members is made available across thenetwork, contributes to new practices and guides theleaders’ decision making.Yet the ability to engage with front line GPs is related

to the CCG size; smaller networks can more easily bedensely connected, as it is easier to maintain ties with asmaller number of individuals. Network size in ourcontext, is directly related to the proportion of popula-tion covered as government payments follow thepatients. In the commissioning context, larger networkscreate a more stable environment (ie, network stability)as risk (in particular for financial failure) can be spreadacross the whole network. This more stable position alsoimproves the leaders’ ability to negotiate, owing to theirincreased purchasing power across the network. “There’sthis sense that we have to be big in order to have theclout to negotiate” (site B). However, as network sizeincreases, it becomes more difficult for leaders toengage with frontline members. Thus leaders also keptstressing that ‘if they [completely] ignore the size issue,they will fail to get [GPs] engaged and on board’(site B), thus, highlighting the difficulty of engagingfrontline GPs in clinical commissioning.To manage the concern of maintaining a necessary

network size, several sites developed smaller localities,clusters of practices within their network whichresolve local issues, including commissioning. Thelocalities’ leaders are typically part of the CCG board,responsible for leading the overall commissioningprocess. A GP commented, ‘[frontline engagement]won’t work at three hundred thousand [patients]level […therefore] having those sub-groups, thosecluster level groups is vitally important’ (site C). CCGsstructure reflects the tension in achieving strong localcommitment and efficiency through scale (see table 2for a summary of the range in population size acrossstudy CCGs).An important contextual feature that shaped the

network size and its membership ties was the commis-sioning history, in particular, the legacy of PBC. Eventhough PBCs never held actual commissioning funds

throughout their existence, they had established a dis-tinctive ‘organisational archetype’22 which itself was aresult of the sedimentation that took place during theorganisational changes of the reform at that time. Byand large, the specifications of the previous organisa-tional archetype (in this case PBC groups) has anapparent effect on network formation and knowledgecapability. In the reform process, change ‘representsnot so much a shift from one archetype [PBC] toanother [CCG], but a layering of one archetype onanother’ (ref. 22, p.624), so that the new entityembodies the interlacing of previous structures andrelationships with novel network features. As high-lighted in our analysis of the vignettes around innov-ation between one former PBC and a non-PBC group,legacy ties between stakeholders influenced the innov-ation process.

CCG relationship with policy and administrative authoritiesAnother significant relationship influencing the newcommissioning scheme is the relationship between GPsand health policy makers and administrators whooversee the implementation of the policy. Numerous GPleaders expressed frustration that a number of their col-leagues are hesitant to engage because of the perceivedweak engagement and lack of dialogue between policymakers (or their representatives) and CCG leaders. Onthe whole communication is seen as a one way process.During the course of the study we observed an increas-ing frustration among the CCG leaders. Several of themwho were enthusiastic and motivated early on started tobelieve that their efforts were misplaced: ‘it was clearthat there were many unfinished episodes and contradic-tions in the legislation, the Minister then turned to theprofessions in order to get their input and called thosepathfinder organisations’. A GP from site A mentioned:‘I was happy to contribute as a pathfinder under thoseterms but the pathfinders (forerunners of policy imple-mentation) were used as evidence that the professionsupported the Bill […] then I felt that I’d been trickedinto being a pathfinder’.As a result, numerous frontline GPs and CCG leaders

commented they were becoming increasingly cynicaland started questioning their engagement in CCG activ-ities: ‘We’re in between at the moment, waiting to knowwhat the new world is going to look like, and not reallybeing able to get on with things until that’s clear’ (siteA). In parallel with the uncertainty around the futureof the reform contributing to network stability, CCGleaders felt that they have little guidance from thepolicy makers regarding their new activities and respon-sibilities: ‘the government is being less than explicit’.Yet at the same time CCG leaders did not feel able toshape the strategic direction nor develop new rules forthe commissioning process, and this uncertainty wascompounded by the simultaneous restructuring ofPCTs.





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Relational dynamics of early stage innovation in two CCGnetworksIn the vignettes below (see online supplementary boxes 2and 3), we compare two interesting examples as to howrelational dynamics in nascent CCG networks surroundingsite A and site B enabled (and constrained) early stageinnovation. We develop our insights concerning the rela-tional dynamics drawing on the social network data(figure 4 and table 4) and the leadership challenges ofworking across the multiple stakeholders involved.In site A, where CCG leaders had access to compara-

tive data from across the health system, the boardleaders drew on existing strong relationships with thePCT to develop a solution in the form of joint workinggroups within the specialist areas and pathways ofconcern. The stimulus for the innovation process camefrom the available data highlighting the importance ofnetwork (in)coherence, coupled with the numerous tieswith the PCT. As can be seen from table 4 the socialnetwork analysis comparatively illustrates the numerousties among the CCG board and local health administra-tion entities (PCT) in site A (18) which is higher thansite B (13). The strong ties with the PCT was crucial inbringing together the other critical stakeholders (eg,acute providers) as the CCG board, had established tieswith other stakeholders. In addition, the density of theties across the board itself (0.737) indicates a high levelof knowledge sharing and cohesion among the CCG

leaders. This facilitated centrally coordinated action todevelop the multiple pathway groups.The social network diagram in figure 4 illustrates the

relatively uniform communication pattern across theboard; it also brings to fore the very heavy reliance on asingle knowledge broker (large blue node with highdegree and betweenness centrality in site A).Overreliance on a small number of knowledge brokersadds risk to the network, for example in the case wherethe individual should exit the network. The networkalso becomes dependent on a few individuals who areable to commit a considerable amount of time for devel-oping leadership processes.Innovation emerged in site B from a frontline GP who

recognised incoherence in one area of the network,given her knowledge of local primary-based care andspecialist care. The board in site B is characterised byhigh levels of front-line GP engagement, illustrated bothby the high numbers of direct ties to the board (6) andalso the communication intensity between those ties,with relatively thicker blue lines in the social networkdiagram between board members and GP practices, ascompared to site A. This enabled the innovation to beembedded and taken up by the GP community.However, as evidenced by the lower density of tiesbetween CCG board members (0.622) there was anelement of competition between the CCG leaders whorepresented the former PBC groups, indicated as the

Figure 4 Site A (left) and site B (right) clinical commissioning group network diagrams.





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larger blue circles in the social network diagram (site Bgraph on the right of figure 4). This influenced the inte-gration and coordination of practices across the networkas a whole, and hampered the scaling up of the innova-tive practice to other regions within the network.In both cases, the development of novel care pathways

arose from information regarding network incoherence,and a realisation that local care was out of alignmentwith care being provided in equivalent regions else-where. There was also a reliance on engaged frontlineGPs and the use of strategically reconfigured knowledgeflows to facilitate the development and delivery of a newservice. Across the innovations new practices wereknitted together from new relationships at multiplelevels; structuring knowledge in new ways enabled novelinsight as to how services could be integrated. Acting asrelational catalysts rather than necessarily involvingthemselves in all relationship building, clinical leadersfacilitated network coherence, stability and knowledgesharing in enabling innovations to emerge.

DISCUSSIONIn this study we have shown the importance of under-standing and developing a network-centric approach toclinical commissioning and the need for network leader-ship to facilitate integrated care and provide innovative,patient-centred healthcare solutions. A critical part of thenew role of GP leaders is to enable coordination and newrelationships across the health network. Our study sug-gests that they need to go beyond focusing on transac-tions and bilateral relationships to fostering knowledgesharing with multiple stakeholders, while ensuringnetwork stability and coherence. In addition to establish-ing a number of brokering ties themselves, leaders needto strategically enable adequate inter connectivity acrossthe wider system acting like a relational catalyst.

Characteristics of clinical commissioning networksRecent research and reviews have shown that commis-sioning arrangements have suffered from increasingfragmentation,6 hampered communication acrossprimary and secondary care, challenged integration ofpurchaser and provider interests,23 high transactioncosts8 and unresponsive secondary care provision.8

However, they do not have to focus only on the procure-ment and administrative aspects of commissioning.We see the evolving clinical commissioning networks

as falling within the characterisation of innovation net-works,19 whereby the coordination of network activitiesare usually performed by key entities. The newly estab-lished CCGs act as innovation hubs ensuring that infor-mation and knowledge are circulated around thenetwork to establish collaborations and warrant the cre-ation and extraction of value.20 Just as with any otherresearch of healthcare networks, clinical commissioningnetworks have the potential to generate multidisciplin-ary coalitions7 between GPs, acute providers, local

authorities and other key healthcare professionals toagree upon the services to be purchased. This network-centric approach can allow CCGs to revisit the existingclinical pathways and develop new integrated, patient-centred healthcare solutions by leveraging the structuralcharacteristics of their network—expansive, decentra-lised, open, less hierarchical, thereby providingincreased flexibility and encouraging knowledgebrokering.5

Network leadership and practice implicationsA new breed of clinical leaders is required that wouldcoordinate innovative activity and ensure healthcareservice delivery through collaborative and teamworkefforts in the broader healthcare network.24 Currentunderstanding of enabling innovation networks pointsto the importance of knowledge exchange, network sta-bility and network coherence in achieving ecosystem out-comes (figure 5).19 20 CCG leaders are required toprovide ‘subtle leadership’,25 focusing on visioning,motivating and sense-making, rather than controlling.26

Having said that, such delegative leadership from onehand can enhance social autonomy and boost innovativeoutcomes but on the other hand it may be challengedto drive knowledge integration.27 In the absence of stricthierarchies, these leaders need to develop brokeringstrategies that will not only facilitate links between stake-holders but will also couple healthcare professionals todeliver outcomes. For example, it is necessary to adopt‘soft’ strategies that will inspire people and engage grassroot GPs but might also need to provide ‘hard’ incen-tives that will motivate people to commit to qualityservice and cost reduction. We suggest that these skillsare important to re-emphasise given the historical com-missioning focus on planning, monitoring and assessing.

CCGs need to encourage knowledge exchange andcollaborationPerhaps one of the most significant leadership practicesof CCGs as innovation hubs should be to manage theflow of information and knowledge sharing across theirclinical commissioning network. Such coordination ofknowledge mobility can allow to direct efforts that willlead to strategic collaborations and synergies betweencommissioners, healthcare providers and other keyparties such as local organisations and authorities.Expansive and open networks allow for more informa-tion to travel from ‘distant’ members through knowledgebrokers who will introduce new ideas. In turn, goodinterconnectedness and high-density at the CCG boardlevel can help operationalise these ideas and translatethem to actual services. In relation to frontline GPs inparticular, clinical CCG leaders are in a position torelate to them at a collegial level, relating to their prior-ities and practice dynamics; replacing this relationalfocus with a mind-set that emphasises tasks to be accom-plished will more likely stymie engagement and innov-ation instead of helping.





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Efforts need to be aligned with patient needs and medicaldevelopmentsIn addition, GPs as network leaders must not only gener-ally encourage more involvement of PCTs, local author-ities and providers in designing cost-effective and qualitypathways, but will also need to streamline the patients’feedback and find a consistent and structured way tocapture and take into account their views. Both these‘hard’ and ‘soft’ strategies for network leadership areimperative in facilitating the development of new clinicalpractices and novel commissioning ideas. CCGs are in agood position to implement these as they are trying toestablish a new organisational form and leadership stylethat will fit the current culture which does not adhere todirective leadership, but encourages a delegativeapproach.Further, external network coherence goes beyond the

patients’ perspective. It is also necessary to followmedical and research developments, technologicaladvancements, as well as international trends and tobenchmark these with the practices and clinical deci-sions made locally. To manage coherence at this externallevel, leaders need to draw knowledge in through clin-ical, research and public health networks in a systematicway.7

Develop incentives and accountability for network stabilityNetwork stability is imperative in any organisationalcontext, so a critical leadership task for network leadersis to promote it at any cost.19 The risk to unstable innov-ation networks is inherent owing to their flexibleless-hierarchical nature, which is necessary to encourageinnovative activities based on ad hoc collaborationsbetween different parties in the healthcare ecosystem. Inthat sense there is a trade-off between ordered relation-ships (that are forced from top down) and looselycoupled interactions that emerge from the personal

incentives of the collaborators. However, excessiveerosion of network relationships can lead to a state ofinstability, thereby reducing the value and innovationoutput of the network.28

In this context, clear financial incentives and transpar-ent accountability mechanisms have the ability toprevent discouragement and distrust in the network. GPleads and the concerned polity need to keep networkmembers motivated to engage with the commissioningactivities and be encouraged to share their ideas andknowledge and establish collaborations with otherparties. In addition, some degree of accountability thatwill be open, transparent and comprehensible to every-one needs to be in place to manage risk and sharing ofthe rewards and value. These activities motivatemembers and will sustain their efforts while contributingtowards the stability of the overall commissioningnetwork (box 1).

CONCLUSIONSIn conclusion, clinical commissioning leaders can play acritical role in the coordination of healthcare innovationnetworks through a number of processes which includemanaging: knowledge flows, network coherence andnetwork stability. Building relational capabilities in adelegative and directed manner is an important leader-ship issue for CCGs in establishing and expanding theirnetworks with local health administration, NHS provi-ders and other stakholders. To achieve this they willneed to assign and exploit knowledge-brokering rolesand leverage good communication between their boardmembers and others outside their board to bring newideas into the group, facilitate new synergies and alli-ances, and allow for projects that take advantage of theavailable resources. In addition, they need to identifyand assess pre-existing relationships, which have

Figure 5 Main implications for

developing healthcare network

leadership in clinical

commissioning group.





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institutional influences on them (eg, PBC groups), thatthey can capitalise upon while incorporating the views oflocal stakeholders as well as patient and public voice in asystematic way. Finally, technology can play a key role in

disseminating practices and knowledge by creating inte-grated information repositories where commissionerswill be able to access the necessary intelligence and evi-dence to support their work.

Acknowledgements We thank the board members of the clinicalcommissioning groups (CCGs) for their participation as well as the rest ofhealthcare professionals that agreed to be interviewed for this project. Theauthors would also like to thank Celine Miani for her help on data collectionand for providing administrative aid during the research project.

Contributors EO and MB contributed to the research proposal, applied for theCLAHRC grant, and conceptualised the study. MZ, EO and MB completed thedata collection. All authors contributed to the analysis of the data, the writingand revising of the paper. EO is the guarantor.

Funding This work was funded by a research grant from the Collaborationsfor Leadership in Applied Health Research and Care (CLAHRC) initiative, andthe National Institute for Health Research (NIHR). The funders were notinvolved in the selection or analysis of data, or in contributing to the contentof the final manuscript.

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed

Data sharing statement No additional data are available.

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Box 1 Summary of emerging key policyrecommendations

Overall network leadership strategy▸ GPs need to realise their new role not only as clinicians but

also as coordinators that will lead the healthcare network inboth a delegative and directive manner.

▸ Build a strategy around clinical commissioning that willinclude not only developing collaborative relationships andknowledge sharing with PCTs and local authorities but alsothe inputs of patients and the public (healthcare ecosystem).

▸ The CCG board should develop 'soft' strategies that willinspire and engage front-line GPs at the grass roots level andprovide 'hard' incentives that will motivate people to committo quality service and cost-effectiveness. Implementation ofsuch a strategy should include a system of measurement andaccountability.

▸ Integration of primary and secondary healthcare activitieswhich delivers not only a more cost-effective service, but cru-cially ensures a patient-centric pathway service too.

Managing knowledge mobility▸ Identify well-connected individuals who maintain extensive

advice and knowledge-sharing networks. Because of their con-nectedness, knowledge brokers in the network are expected tobring novel information to the group as they have access to alot of people outside their cluster, potentially allowing forbetter commissioning decisions.

▸ Considering the importance of the brokers (who may be clini-cians, practice managers or PCT directors) in circulatingknowledge, it may be justified to develop personal coachingand training sessions to improve individual brokeringperformance.

▸ Developing digital networks and technological infrastructurecan play a key role in disseminating best clinical practice andvaluable knowledge by creating large integrated informationrepositories where commissioners will be able to access thenecessary intelligence and evidence to support their work.

▸ Apart from knowledge circulation that encourages healthcareservice innovation, GPs will also need to translate and inte-grate this knowledge into their commissioning practice.

Managing network coherence▸ CCGs need to streamline the patients' feedback and find a con-

sistent and structured way to capture and take into accounttheir views.

▸ Following medical and research developments, technologicaladvancements, as well as international trends, will help bench-mark and increase the quality of clinical decisions madelocally.

Managing network stability▸ Establish a transparent clinical commissioning vision and

values that will promote trust and collaboration among GPsand other healthcare professionals. This will also indirectlypromote knowledge mobility and network coherence.

▸ Health policy and leaders need to provide clear incentives aswell as evident accountability mechanisms to establish trustand prevent discouragement.





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22. Cooper DJ, Hinings B, Greenwood R, et al. Sedimentation andtransformation in organizational change: the case of Canadian lawfirms. Organization Stud 1996;17:623–47.

23. Ham C, Smith J, Eastmure E. Commissioning integrated care in aliberated NHS. London: The Nuffield Trust, 2011.

24. Lee TH. Turning doctors into leaders. Harv Bus Rev 2010:50–8.25. Orton JD, Weick KE. Loosely coupled systems: a

reconceptualization. Acad Manage Rev 1990;15:203–23.26. Ancona D, Malone TW, Orlikowski WJ, et al. In praise of the

incomplete leader. Harv Bus Rev 2007;February:1–9.27. Gebert D, Boerner S, Kearney E. Fostering team innovation: why is

it important to combine opposing action strategies? Organization Sci2009;21:593–608.

28. Lorenzoni G, Lipparini A. The leveraging of interfirm relationships asa distinctive organizational capability: A longitudinal study. StrategManage J 1999;20:317–38.





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