Ensuring Clinical Ensuring Clinical EngagementEngagement

Dr David JennerDr David Jenner

NHS Alliance GMS/PMS LeadNHS Alliance GMS/PMS Lead

What is Happening in PCTSWhat is Happening in PCTS

All very variable but certain trendsAll very variable but certain trends GPs voting with their feet from PECSGPs voting with their feet from PECS More nurses/ therapists/pharmacists More nurses/ therapists/pharmacists

involvedinvolved Practice based commissioning trying Practice based commissioning trying

to re-engage practicesto re-engage practices Clinicians want to be engaged in the Clinicians want to be engaged in the

action not the bureaucracyaction not the bureaucracy

What is Happening in PCTsWhat is Happening in PCTs

Where clinical engagement strong the lead Where clinical engagement strong the lead comes from the CEO and PEC Chaircomes from the CEO and PEC Chair

In certain regimes clinicians actively In certain regimes clinicians actively excluded from key power forumsexcluded from key power forums

SHAs rarely recognise PEC Chairs or PECSSHAs rarely recognise PEC Chairs or PECS Managerial culture still dominant in NHSManagerial culture still dominant in NHS Real problems where there are budget Real problems where there are budget

deficitsdeficits GMS2 attracting GPs back to practicesGMS2 attracting GPs back to practices PCT allowances not enough for GPs-need PCT allowances not enough for GPs-need

£500 a day to compete with practice£500 a day to compete with practice

Influence of GMS2/PMS2 Influence of GMS2/PMS2

Plenty to do in practicesPlenty to do in practices No OOH commitmentNo OOH commitment Plenty of earning opportunities in OOHPlenty of earning opportunities in OOH 15% increase in GP profits already15% increase in GP profits already Vacancies taking longer to fill 2004 Vacancies taking longer to fill 2004

than 2003than 2003 Tensions between PCTs and practices Tensions between PCTs and practices

in some areas –enhanced servicesin some areas –enhanced services

Other CliniciansOther Clinicians

Usually just glad to be given a chance to be Usually just glad to be given a chance to be heardheard

Doctors have always dominatedDoctors have always dominated Leadership issues for some groupsLeadership issues for some groups Need to separate leadership from Need to separate leadership from

management e.g. nursesmanagement e.g. nurses Need backfill and training to make it Need backfill and training to make it

happenhappen More tolerant of national policy and More tolerant of national policy and

instruction than GPs!instruction than GPs!

Other CliniciansOther Clinicians

New contract for pharmacistsNew contract for pharmacists Plenty of opportunities where GPs can’t Plenty of opportunities where GPs can’t

or won’t deliveror won’t deliver New contractual options –specialist PMSNew contractual options –specialist PMS Lots of enthusiasmLots of enthusiasm BUT big workforce challenges –nurses, ,BUT big workforce challenges –nurses, ,

pharmacists dentistspharmacists dentists

Primary/Secondary Care Primary/Secondary Care InterfaceInterface

Huge barriers remainHuge barriers remain F.Ts and PBR make this more F.Ts and PBR make this more

competitive againcompetitive again No sign vertical integration yetNo sign vertical integration yet Difficult to forge care pathways at Difficult to forge care pathways at

times for financial issuestimes for financial issues Still paternalistic Still paternalistic

consultant/GP/therapist relationship in consultant/GP/therapist relationship in some areassome areas

General Practice v General Practice v ConsultantConsultant

know less and less know less and less about more and about more and moremore

tolerate uncertaintytolerate uncertainty hate hierarchieshate hierarchies hate protocolshate protocols illness disorganisedillness disorganised low risk high volumelow risk high volume long term continuitylong term continuity

know more and more know more and more about less and lessabout less and less

define certaintydefine certainty enjoy hierarchiesenjoy hierarchies like protocolslike protocols illness organisedillness organised high risk high volumehigh risk high volume usually episodicusually episodic

GP MotivationGP Motivation

Quality of careQuality of care Quality of lifeQuality of life To make a differenceTo make a difference Individual respectIndividual respect To enjoy workTo enjoy work To be liked by patientsTo be liked by patients MoneyMoney

Things GPs HateThings GPs Hate

BureaucracyBureaucracy PoliticsPolitics No Reward for Increased QualityNo Reward for Increased Quality Lack of IncentivesLack of Incentives Lack of StaffLack of Staff Short termismShort termism Insensitive managementInsensitive management Being told what to do!Being told what to do!

For GPS the incentives For GPS the incentives now lie in GMS2/PMS2now lie in GMS2/PMS2

Not usually the PCT!Not usually the PCT!

Other Confounding IssuesOther Confounding Issues

Centralist policy –independent sectorCentralist policy –independent sector Unrealistic policy-choose and bookUnrealistic policy-choose and book Post Shipman hysteria-revalidationPost Shipman hysteria-revalidation Risk avoidance or risk adverse cultureRisk avoidance or risk adverse culture NHS still hospital orientatedNHS still hospital orientated Workforce issuesWorkforce issues Lack of clear incentivesLack of clear incentives

What Do We need to DoWhat Do We need to Do

Ideally engage Drs with other cliniciansIdeally engage Drs with other clinicians Engage hospital clinicians with primary Engage hospital clinicians with primary

carecare Get managers and GPs working togetherGet managers and GPs working together Create adult-adult interactions all roundCreate adult-adult interactions all round Focus around individual patient modelsFocus around individual patient models Don’t follow the governments Don’t follow the governments

management style!management style!

How Can You Engage How Can You Engage CliniciansClinicians

Practice based commissioning has a real chancePractice based commissioning has a real chance It creates local incentives that need to be It creates local incentives that need to be

guaranteedguaranteed It keeps clinicians away from most of the It keeps clinicians away from most of the

bureaucracybureaucracy Uses clinicians on “just enough time” basisUses clinicians on “just enough time” basis Help them make a visible differenceHelp them make a visible difference Concentrates on local issues and local patientsConcentrates on local issues and local patients But how do we not disadvantage consultants?But how do we not disadvantage consultants?

How to Engage Local How to Engage Local CliniciansClinicians

Local care pathways e.g. strokeLocal care pathways e.g. stroke Local initiatives to offer new services Local initiatives to offer new services

GPSI’sGPSI’s Alternative models of care and Alternative models of care and

community initiativescommunity initiatives Peer review and clinical audit Peer review and clinical audit

(facilitated)(facilitated) Get the information right and in easily Get the information right and in easily

digestible formdigestible form

How to Engage Local How to Engage Local CliniciansClinicians

Protected time for peer review/planningProtected time for peer review/planning Engage with patients simultaneouslyEngage with patients simultaneously Identify “low hanging fruit” targetsIdentify “low hanging fruit” targets Create incentives for change with teamCreate incentives for change with team Provide admin./managerial supportProvide admin./managerial support Identify natural communitiesIdentify natural communities Ensure others apart Drs can be heardEnsure others apart Drs can be heard Get buy in from senior managementGet buy in from senior management

How To Engage GP'sHow To Engage GP's

Understand them-they are all different!Understand them-they are all different! Identify peer leaders and empower themIdentify peer leaders and empower them Produce quick winsProduce quick wins Don’t waste their time!Don’t waste their time! Reimburse their time at market ratesReimburse their time at market rates Compare performance with peersCompare performance with peers Let them be advocates for patientsLet them be advocates for patients Set the goal but let them find the pathSet the goal but let them find the path BE HONEST!!! NO BULL!!BE HONEST!!! NO BULL!!

Different G.Ps Respond to Different G.Ps Respond to Different IncentivesDifferent Incentives

You Need to Include Some You Need to Include Some Incentives for Each Type!Incentives for Each Type!

Its More Than Just DoctorsIts More Than Just Doctors

More emphasis on nurses and therapistsMore emphasis on nurses and therapists More emphasis now on clinical teams More emphasis now on clinical teams Practice managers key players too-engage Practice managers key players too-engage

them and you often get the practice teamthem and you often get the practice team But-doctors still hold the political powerBut-doctors still hold the political power Doctors still commit most of the resourceDoctors still commit most of the resource Collaboratives are key change agents nowCollaboratives are key change agents now

IncentivesIncentives

Need to focus on patient and clinically Need to focus on patient and clinically defined needdefined need

Need to be guaranteed locallyNeed to be guaranteed locally Can be real (money, equipment) or Can be real (money, equipment) or

improved servicesimproved services Need to benefit patients, hospitals and Need to benefit patients, hospitals and

primary care ideallyprimary care ideally Care needed not to create perverse Care needed not to create perverse

elementselements Should not reward under treatmentShould not reward under treatment

The Best Incentives AreThe Best Incentives Are

Evidence basedEvidence based Agreed by local clinicians and Agreed by local clinicians and

patients in advancepatients in advance Designed to reward excellence and Designed to reward excellence and

extra workextra work Provide rapid return on investmentProvide rapid return on investment In line with national and local policyIn line with national and local policy Unlikely to increase inequitiesUnlikely to increase inequities

Engaging CulturesEngaging Cultures

Where clinicians views are valued and Where clinicians views are valued and encouraged throughout organisationencouraged throughout organisation

Good communication to all staffGood communication to all staff Inclusiveness in decision makingInclusiveness in decision making Real resources to free up clinician’s timeReal resources to free up clinician’s time Managerial and administrative supportManagerial and administrative support Where debate is encouragedWhere debate is encouraged Respect to evidence baseRespect to evidence base

Cultures to AvoidCultures to Avoid

Bureaucracy and endless meetingsBureaucracy and endless meetings Top down managementTop down management Performance obsessionPerformance obsession ExclusiveExclusive Deadline slippingDeadline slipping SecretiveSecretive ParsimoniousParsimonious

And do DH Lead the Way?And do DH Lead the Way?

Choose and book?Choose and book? NPFIT?NPFIT? Primary Care Clinicians Given Primary Care Clinicians Given

Leading Roles?Leading Roles? New Contractual Options?New Contractual Options? New policy options?New policy options? Development programs e.g. NPDT?Development programs e.g. NPDT?

SummarySummary

Most clinicians are a scare resourceMost clinicians are a scare resource We need to empower them through their We need to empower them through their

clinical rolesclinical roles Management must be an add on not an Management must be an add on not an

either/or optioneither/or option Adequate backfill-money and staff are Adequate backfill-money and staff are

vitalvital Remember the patient’s not professional’s Remember the patient’s not professional’s

needs are key-but often interlinkedneeds are key-but often interlinked

NHS Alliance PBC Practice NHS Alliance PBC Practice NetworkNetwork

david.jenner@nhsalliance.orgdavid.jenner@nhsalliance.org