ensuring clinical engagement dr david jenner nhs alliance gms/pms lead
TRANSCRIPT
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
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