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The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a “clinically-led” system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for “great leaders”.

Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed.

The authors found evidence of two identified approaches to leadership – positive deviancy and responsible guardianship – being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to “do things differently” to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs’ performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership.

This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles.

The purpose of this paper is to consider how BS 11000 may be usefully deployed within a commissioning situation in the light of the Department of Health's suggestion that it represents “best practice”.

The study uses case studies from other sectors (criminal justice) and IT outsourcing to consider the nature of the commissioning relationship at the heart of the English NHS post‐2013. It looks at how BS 11000 is intended to support business relationships and how this can address potential problems identified in the case studies.

The study finds that business relationships are often regarded in a reductionist manner based on a simple contractual relationship. The case studies suggest that a richer more collaborative business relationship is required for effective provision of services. The authors suggest that BS 11000 can help organisations put in place the foundations of such relationships.

The Clinical Commissioning Groups are still being formed, and the marketplace for service providers in the NHS is expanding dramatically. This means that there are limited opportunities for studying this issue in situ, and therefore it is necessary to use case studies from other domains.

This study suggests that the commissioning relationship is more complex than a simple contractual relationship, and a genuine partnership is needed between the new Clinical Commissioning Groups and their providers.

From 2013, the NHS is intended to be a commissioner of services rather than a provider. Effective health and social care will depend upon an effective commissioning relationship.

The study provides insights from related fields into an area that cannot yet be studied itself, as it is still being formed. It has access to unpublished data from an ESRC funded study to provide new insights from a related public‐sector context.

What is our unit of analysis and by implication what are the boundaries of our cases? This is a question we grapple with at the start of every new project. We observe that case studies are often referred to in an unreflective manner and are often conflated with geographical location. Neat units of analysis and clearly bounded cases usually do not reflect the messiness encountered during qualitative fieldwork. Others have puzzled over these questions. We briefly discuss work to problematise the use of households as units of analysis in the context of apartheid South Africa and then consider work of other anthropologists engaged in multi-site ethnography. We have found the notion of ‘following’ chains, paths and threads across sites to be particularly insightful.

We present two examples from our work studying commissioning in the English National Health Service (NHS) to illustrate our struggles with case studies. The first is a study of Practice-based Commissioning groups and the second is a study of the early workings of Clinical Commissioning Groups. In both instances we show how ideas of what constituted our unit of analysis and the boundaries of our cases became less clear as our research progressed. We also discuss pressures we experienced to add more case studies to our projects. These examples illustrate the primacy for us of understanding interactions between place, local history and rapidly developing policy initiatives. Understanding cases in this way can be challenging in a context where research funders hold different views of what constitutes a case.

The purpose of this article is to delve into the precise leadership and governance roles required of general practitioners (GPs) in England as they are propelled into clinical commissioning groups (CCGs).

A conceptual framework which captures the complementary essences of both leadership and governance is developed and then used to assess the extent to which GPs will be undertaking leadership and/or governance roles under the reformed National Health Service (NHS) plan.

It is found that there are some key particular aspects of both leadership and governance which are likely to be required of GPs as they form clinical commissioning groups. These elements are identified and discussed.

Using this analysis, general practitioners, health service managers and policy makers will be able to make a more informed assessment of the roles that they will have to adopt in the future and those roles which they may find it difficult to play. GPs in future will need to expand their roles in line with new responsibilities. The ways in which, and the success with which, they discharge their new roles will depend crucially on how they, and significant others (NHS managers), understand the nature of leadership and governance.

Most analyses of the new GP commissioning consortia have focused on issues concerning size and structure of commissioning consortia, the risks involved, the population size required, and risk. This article is original in its clear focus on the teasing‐out of the distinct leadership and governance elements required under the GP commissioning arrangements.

The aim of this paper is to set out the role of clinical governance within the new commissioning framework. It starts by considering the historical development of clinical governance and lays out ideas for the new arrangements around the concept of the primary care home and concludes with challenging questions for the future.

The paper draws on the author's role and experience as a senior policy maker in the UK Department of Health.

If we are to fulfil the defined attributes of clinical governance the NHS needs to adopt a more reflective self‐auditing leadership culture. Whether that supposition is accepted or not, a set of questions arises. Why, given for instance the gross failures of care for the frail elderly, have the principles of clinical governance not been systematically embedded? Why, given the NHS can no longer be described as poorly resourced, are clinical outcomes for many conditions lagging behind equivalent international healthcare systems? Why have the improved access and clinical outcomes of recent years been dependent on political rather than NHS leadership? And why in our publicly funded NHS is there frequently a culture of regarding patients as grateful supplicants rather than true partners to whom we should account? Clinical governance for personal, population and system care. Does this represent a coming of age?

This article provides a contribution to the emerging policy debate around clinical governance in the new commissioned NHS, rooted in experience from both the clinical front line and the heart of national health policy making.

The purpose of this paper is to present the findings arising from a three year research project which investigated a major system-wide change in the design of the NHS in England. The radical policy change was enshrined in statute in 2012 and it dismantled existing health authorities in favour of new local commissioning groups built around GP Practices. The idea was that local clinical leaders would “step-up” to the challenge and opportunity to transform health services through exercising local leadership. This was the most radical change in the NHS since its inception in 1948.

The research methods included two national postal surveys to all members of the boards of the local groups supplemented with 15 scoping case studies followed by six in-depth case studies. These case studies focused on close examination of instances where significant changes to service design had been attempted.

The authors found that many local groups struggled to bring about any significant changes in the design of care systems. But the authors also found interesting examples of situations where pioneering clinical leaders were able to collaborate in order to design and deliver new models of care bridging both primary and secondary settings. The potential to use competition and market forces by fully utilising the new commissioning powers was more rarely pursued.

The findings carry practical implications stemming from positive lessons about securing change even under difficult circumstances.

The paper offers novel insights into the processes required to introduce new systems of care in contexts where existing institutions tend to revert to the status quo. The national survey allows accurate assessment of the generalisability of the findings about the nature and scale of change.

The purpose of this paper is to explore the practical daily work undertaken by middle‐level managers in Primary Care Trusts (PCTs), focusing upon the micro‐processes by which these managers enact sensemaking in their organisations.

The research took a case study approach, undertaking detailed case studies in four PCTs in England. Data collection included shadowing managers, meeting observations and interviews.

The research elucidated two categories of enactment behaviour exhibited by PCT managers: presence/absence; and the production of artefacts. Being “present” in or “absent” from meetings enacted sensemaking over and above any concrete contribution to the meeting made by the actors involved. This paper explores the factors affecting these processes, and describes the situations in which enactment of sense is most likely to occur. Producing artefacts such as meeting minutes or PowerPoint slides also enacted sense in the study sites in addition to the content of the artefact. The factors affecting this are explored.

The study has practical implications for all managers seeking to maximise their influence in their organisations. It also provides specific evidence relevant to managers working in the new Clinical Commissioning Groups currently being formed in England.

The study expands the understanding of sensemaking in organisations in two important ways. Firstly, it moves beyond discourse to explore the ways in which behaviours can enact sense. Secondly, it explores the distinction between active and unconscious sensemaking.

The purpose of this paper is to explore change within the commissioning of third sector mental health services in England.

A case study methodology based on survey and interview data of a sample of third sector organisations and commissioners within an English conurbation.

Normative commissioning models based on sequential cycles were not fully implemented with the main focus being on the procurement and contracting elements. There were examples of commissioning being an enabler of service improvement but overall it seems to have been limited in its ability to bring about whole system change. Barriers included commissioners’ capacity and competence, ineffectual systems within their organisations, and fragmentation in commissioning processes between user groups, organisations and sectors.

The case study conurbation may not represent practice in all urban areas of England and there may be particular issues of difference within rural localities. The view of private and public sector providers and those working in Commissioning Support Units were not sought.

To lead whole system change the commissioning function needs to be adequately resourced and skilled with better integration across public sector functions and organisations. Greater emphasis needs to be placed on implementing the full commissioning cycle, including the engagement of relevant stakeholders throughout the process and the practical application of outcomes.

This research adds to the limited body of empirical work regarding commissioning in mental health.

The purpose of this paper is to explore the challenges that are experienced by staff responsible for commissioning liaison psychiatry services and to establish if these are shared by other health professionals.

Using a mixed-methods design, the findings from a mental health commissioner workshop (n = 12) were used to construct a survey that was distributed to health care professionals using an opportunistic framework (n = 98).

Four key themes emerged from the workshop, which was tested using the survey. The importance of secure funding; a better understanding of health care systems and pathways; partnership working and co-production and; access to mental health clinical information in general hospitals. There was broad convergence between commissioners, mental health clinicians and managers, except in relation to gathering and sharing of data. This suggests that poor communication between professionals is of concern.

There were a small number of survey respondents (n = 98). The sampling used an opportunistic framework that targeted commissioner and clinician forums. Using an opportunistic framework, the sample may not be representative. Additionally, multiple pairwise comparisons were conducted during the analysis of the survey responses, increasing the risk that significant results were found by chance.

A number of steps were identified that could be applied in practice. These mainly related to the importance of collecting and communicating data and co-production with commissioners in the design, development and monitoring of liaison psychiatry services.

This is the first study that has specifically considered the challenges associated with the commissioning of liaison psychiatry services.

The purpose of this paper is to describe the work between statutory sector partners in Staffordshire to establish a transformational rather than transactional health and well being board and its approach to resource allocation.

The paper describes the principles and process of achieving a shared ambition for Staffordshire, and the practical and strategic considerations of taking a broader and more ambitious approach than current guidance recommends.

Supporting individual organisations to achieve their statutory requirements within the context of the shared vision, and using customer insight intelligently to influence the decision‐making process, are critical to success. The challenge of moving resources in times of financial hardship and organisational flux should not be underestimated.

The process of moving resources into prevention and early intervention cannot be done in a “one size fits all” way and has to be considered as part of a differentiated approach. In addition, organisations must be willing to cede influence and resources to support the vision, thus challenging culture and traditional organisational boundaries and structures.

The process described in the paper is designed to improve health and well being for citizens in Staffordshire, tackling inequality in an integrated, targeted and proportionate way.

This is an emerging example of “whole system” integration.