Although Donald Rumsfeld was a US Secretary of Defence, he will probably be remembered for a statement he made in 2002 about the Iraq war, though we’ll ignore that symbolism. Anyway, this is what he said:
‘There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.’
As CCGs prepare for their formal birth, Rumsfeld’s aphorism is a useful guide to thinking about their developmental needs, as long as one adds the one missing category, the ‘unknown knowns’ - the things we don’t know that we know.
CCGs are designed to combine two important elements of healthcare into a single, seamless function. Although their stakeholders are intended to be clinicians generally, their focus is on GPs, whose key purpose is to integrate healthcare delivery with referral decisions to ensure that the services in the specialist (hospital) sector effectively and efficiently fill any gaps in primary care provision.
For jobbing GPs, there will probably be little difference in their routines; they will still see patients, and refer those who cannot be adequately treated in the consulting room. In their referral decisions, they may be expected to conform to CCG rules as to where and when patients should be sent, but other than that, the transition to CCGs may – and it’s not such a bad thing - have little impact for the ‘grassroots’ GP.
It is at the organisational level that Rumsfeld’s aphorism may have more relevance, for CCGs will need to consider the strategic and operational aspects of commissioning, and indeed make sense of the term itself. Thus for example, at an operational level they will quickly need to understand the business models of their local trusts, link service availability with local population needs, identify and fill any gaps, and develop referral policies for which their member GPs will need to become accountable.
At a more strategic level, they will need to understand how the needs of their population may be compared and combined with those of neighbouring CCGs, grapple with medical and societal trends and juggle these issues with the political pressures that will constantly intrude.
They will also need to wrestle with the issues of probity that bedevil the whole of the British welfare state, but are probably worst in the NHS, where life and death issues overlay rational decision making, whether financial, legal, or clinical.
These are just a few examples of the tasks facing CCGs; the questions they raise concern the skills needed to succeed in them, how well equipped are they in these skills, and what help will they need to develop the ones they lack?
Which brings us back to Donald and his various permutations of known and unknown. There are skills in the CCGs that are so well established that their clinicians don’t have to think about them: good general practices are so effective at understanding the interweaving complexity of patients’ physical and psychological problems and handling the uncertainties and probabilities underpinning good care care that they do these almost unconsciously. These are the skills that Rumsfeld missed out: the unknown knowns. We are so good at what we do that we forget how hard it is to do. Like experienced cyclists who gives no thought to balancing their precarious machines whilst ducking and weaving through the traffic, good primary care clinicians are unconsciously competent at what they do. We should celebrate the dedication and training needed to achieve such effortless effectiveness.
However, there are many tasks for which CCG leaders will need new skills. They (generally..) realize that they need more financial and political skills to cope with their Local Area Team, the NHS Commissioning Board and the rules and regulations that could explode around them like land mines. These are ‘known unknowns’ where they are consciously incompetent, and where training is already under way. I have slight misgivings about the nature of such training, as the need to produce programmes ‘at scale’ for so many CCG leaders and senior staff feels at odds with the highly individual developmental needs of each person; it’s important to understand accounting systems, and the latest version of the NHS Operating Framework, but it needs a defter, more crafted approach to discuss how to cope with personal and organizational politics, or how to manage the care of too many people with too little money.
Finally, there are the ‘unknown unknowns,’ those problems that only become apparent when they become apparent. For instance, it’s likely that much work will be required to manage autonomous clinicians without losing their enthusiasm and dedication, or in re-invigorating the caring culture that has been so deficient in recent years, especially when the NHS (like every other vast bureaucracy) will continue to be reductive and punitive.
But even an external dispassionate view cannot predict unknown unknowns (or they’d be known unknowns…). The challenge is to have mechanisms in place in anticipation of the new, difficult issues, less to help in solving them than to support CCG leaders as they cope with their implications: for it is when blissful unconscious incompetence (‘commissioning is just an extension of what GPs do’) turns into conscious incompetence (‘OMG, what do we do now?’) that the risks are highest of the wheels coming off the wagon. And in this case, the wagon may be CCG leadership itself as much as the mechanics of CCG function. Having high level, developmental support in place working with CCGs leaders will be crucial in allowing them to grow and mature in ability, confidence, and effectiveness.
Dr Jonathan Shapiro is an a former GP with wide experience in clinical, managerial, and academic roles. He works with policy makers, organisations and individuals to develop effective, sustainable systems with integrated clinical and managerial functions You can email Dr Shapiro firstname.lastname@example.org