Guest editorial Friday 13 May 2011: Who’s on your bus?

This guest editorial from Dr Steve Kell GP, and Chair, Bassetlaw Commissioning Organisation, looks at what separates the great from the good, and what this teaches us about clinically-led commissioning.

A few years ago, I came across a book that changed not only many of my views, but also my management style. This book was surprisingly simple, easy to read, and is one that I have shared with many others since.

Its title? Good To Great, by Jim Collins.


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Collins and his team researched what made great companies great - and perhaps more importantly, what prevented good companies from making that leap to greatness.

According to Collins, good is not enough. Indeed, his line is "Good is the enemy of Great".

So how does this concept, and the ideas within the book, relate to healthcare commissioning?  Does Collins’ theory apply to a PCT, SHA or emerging consortium?

I remember being present at the launch of ‘World Class Commissioning’ – today, that seems like years ago (and indeed it is). World-class commissioning was a lofty aim, built apparently not on targets (as we were told), but on the desire to improve commissioning to a level with the best in the world, but working more efficiently.

The name world-class told us, unambiguously, that we were not aspiring to GOOD commissioning, but to GREAT commissioning.

The same concept applies now, but with different terminology.  An article by world-class commissioning creator Mark Britnell in Health Service Journal this week implied that we should aim to commission as well as Singapore; others compare the UK to the US, Mexico, Norway, and other countries about whose healthcare I know fairly little.

I would argue that the commissioning we do locally is Good: the important question is what we can do to make it Great?

The first stage in Collins’ book is the importance of "Disciplined People".  This is arguably the most important feature – "If I were running a company today, I would have one priority above all others: to acquire as many of the best people as I could". (1)

Collins describes the importance of not only having the right people "on the bus", but of having these people in the right seats.  This is something every consortia will be doing now – building their clinical teams and working with PCTs to align staff to their roles as commissioning support.

It must not be simply about filling places on GPCC Boards, or making sure that staff at the PCT are employed: we should all focus on making sure that we work better; that people do what they are best at; and, crucially, we may need to ask people to get off the bus.

As Collins says, "People are not your most important asset, the right people are". (1)

Building a team of clinicians to commission effectively is a challenge. Asking any team of educated, often opinionated professionals to work as a team can be difficult - many who have worked with GPs will have experienced this.  

Add to this the complication that they are being asked to step outside their comfort zone in a time of uncertainty; to lead others and to work as managers as well as clinicians – and the importance of building the right team becomes clearer.

A dysfunctional group, with people in the wrong roles, will not achieve Greatness. Indeed, it may struggle to remain (or achieve) being Good.

"First Who … Then What" (1)

’The culture of an organisation is not defined by its policies or its vision statements: it arises from the people representing the organisation and their behaviour'.

Get the people right; develop as a team; and then decide how to commission in a way that is ‘world-class.’

There are certain characteristics that training cannot instill. The culture of an organisation is not defined by its policies or its vision statements: it arises from the people representing the organisation and their behaviour.

To some, these latest health reforms may offer a chance to settle scores and to be adversarial - to ‘sort out the hospital.’ In the locality where I work, we have (to date) successfully avoided this tendency, working with secondary care colleagues, local authorities and other agencies to improve patient care and pathways.

This approach has enabled us to genuinely achieve collaboration, but more importantly a set of relationships built upon mutual respect and joint aims.  No doubt, in the future, these relationships will become more strained at times. However, I am confident that we have a solid foundation to work through this and deal effectively with genuine issues. Having the right people in the team has been key to this.

Last week I attended the first Health and Wellbeing Board.  No doubt there were people around the table with significant skills, from a range of backgrounds and with a lot to contribute. The challenge for us is to develop as a team, to ensure that we have the right fit, and that we have the right people in the bus seats. After the first meeting, I am extremely optimistic.

So to NHS reform. This week has seen much debate about which professional groups should be on commissioning consortium Boards. Opinions range from consultants to nurses, from local elected councillors to patients.  Many commentators seem to have far more experience than myself.

Jim Collins, however, would no doubt argue that it matters less what background a person has or what skills they bring than whether they contribute positively to the team and are in the right roles.

Simply having a hospital consultant per se on a Board does not lead to integrated working. Neither does simply having a token patient necessarily make the Board more focused on patient needs.

A cohesive team, with authentic and owned organisational values and vision at its core – that is what is needed for us to achieve Greatness.

Rules and enforced changes may, in fact, prevent Greatness:

"The purpose of bureaucracy is to compensate for incompetence and lack of discipline--a problem that largely goes away if you have the right people in the first place". (1)

In the next blog, I will look at leadership and the importance of the "bus driver".

Steve Kell
GP and Chair, Bassetlaw Commissioning Organisation

1 - ‘Good To Great’.  Jim Collins.  Fast Company (2001)