As the number of Clinical Commissioning Groups (CCGs) shrinks and the average size gets higher, more and more smaller groups are ‘federating’ together into a larger organisation. Here we explore what lessons CCGs can learn from one of the most successful examples of a federation being formed (the six colonies coming together to form a single Australia), and from one of the least successful examples (the brief establishment of a West Indies federation).
So why did Australia succeed where the West Indies failed? A key reason was that the six colonies of Australia (Western Australia, South Australia, New South Wales, Victoria, Queensland and Tasmania) identified with the overall continent of Australia, and understood that there was a logic to them forming a federation. The need to work together to protect the vast empty area of Australia was clear. It is interesting that New Zealand chose not to join, for the very reason that they saw themselves as a different country, with a different climate and separated by the sea. They did not naturally identify with the proposed federation. It is also worth noting that while the federation is considered to be of substantial importance to many Australians today, in 1901 when the federation was formed many of the general public were apathetic to it, and more concerned with dealing with the effects of the depression of the 1890s.
The West Indies federation was created in 1958 by Great Britain to enable it to become a fully independent state. It was set up between 24 inhabited islands in the Caribbean, but there was no popular support for it. Lack of identification with the federation by both the people and their leaders was one of the key problems that the West Indies faced. People identified with the island they lived on, not the wider federation, and by 1962 the federation had been dissolved.
So the first lesson for CCGs is that the federation must make sense to the members. There must be a logic to it and some natural sense of community amongst those who are involved. Artificial constructs are much more likely to fail. CCGs that widen across county boundaries where no historic links have existed could well be storing up problems for the future.
The Australians identified some clear benefits to federation. Both Australia and the West Indies were seeking independence from England (there may be some parallels between colonial Britain and the NHS Commissioning Board!). The Australians were keen to keep out unwanted foreigners, and needed a collective approach to dealing with the unions that were operating across the colonies. There were also tariffs on the transport of goods across borders and the federation provided the opportunity to improve trade across colony boundaries.
What Australia succeeded in doing that the West Indies did not was driving the delivery of the potential benefits. The West Indies never achieved a single customs union or freedom of movement. The Australian colonies felt that if they fell on hard times that the others would come to their aid. The West Indian island states did not share such a belief. In the end the Jamaicans felt that achieving independence from England would be faster on their own than as part of the federation, and the federation collapsed.
There are some clear benefits to smaller groups federating together into a larger CCG. There is buying power with commissioning support services, or the ability to deliver all support services directly. The management allowance goes much further with statutory overheads only needing to be provided once. A larger group can have much larger and more powerful voice with external stakeholders, including the NHS Commissioning Board, the Health and Wellbeing Board, and acute trusts. And potentially most importantly the financial position is much less volatile and can be kept much more within the CCGs control for a larger federated group.
But these are only potential benefits. They do not come simply because the group is larger. The CCG has to work hard to deliver and maximise the benefits. At the same time it needs to communicate these benefits to the member practices, because as in the case of both Australia and the West Indies they are likely to be apathetic at best to the federation. Failure to do this will lead to individual groups within the federation thinking they can do better on their own, and the likelihood of the federation breaking up becomes much more real.
Australia had some strong leaders such as Alfred Deakin driving the federation. They influenced the press where they could to provide a strong, consistent, reinforcing message. The West Indies were plagued by political feuds between the influential leaders. The office of the prime minister was weak, so strong central leadership never prevailed.
Strong leadership is needed in all CCGs, but particularly in large CCGs. The Chair, Accountable Officer and whole Governing Body need to provide strong collective leadership, drive the federation, articulate the benefits of federation consistently and continually, and work together to resolve issues and disputes as they arise in a clear and transparent way. Federations are fragile, particularly in the early days, and need to be respected and treated with care. The key message from Australia in 1901 and the West Indies in 1958 is understanding that forming the federation is the point at which the real work begins.