Ensuring Clinical Engagement

1. Ensuring Clinical Engagement Dr David Jenner NHS Alliance GMS/PMS Lead

2. What is Happening in PCTS • All very variable but certain trends • GPs voting with their feet from PECS • More nurses/ therapists/pharmacists involved • Practice based commissioning trying to re-engage practices • Clinicians want to be engaged in the action not the bureaucracy

3. What is Happening in PCTs • Where clinical engagement strong the lead comes from the CEO and PEC Chair • In certain regimes clinicians actively excluded from key power forums • SHAs rarely recognise PEC Chairs or PECS • Managerial culture still dominant in NHS • Real problems where there are budget deficits • GMS2 attracting GPs back to practices • PCT allowances not enough for GPs-need £500 a day to compete with practice

4. Influence of GMS2/PMS2 • Plenty to do in practices • No OOH commitment • Plenty of earning opportunities in OOH • 15% increase in GP profits already • Vacancies taking longer to fill 2004 than 2003 • Tensions between PCTs and practices in some areas –enhanced services

5. Other Clinicians • Usually just glad to be given a chance to be heard • Doctors have always dominated • Leadership issues for some groups • Need to separate leadership from management e.g. nurses • Need backfill and training to make it happen • More tolerant of national policy and instruction than GPs!

6. Other Clinicians • New contract for pharmacists • Plenty of opportunities where GPs can’t or won’t deliver • New contractual options –specialist PMS • Lots of enthusiasm • BUT big workforce challenges –nurses, , pharmacists dentists

7. Primary/Secondary Care Interface • Huge barriers remain • F.Ts and PBR make this more competitive again • No sign vertical integration yet • Difficult to forge care pathways at times for financial issues • Still paternalistic consultant/GP/therapist relationship in some areas

8. know less and less about more and more tolerate uncertainty hate hierarchies hate protocols illness disorganised low risk high volume long term continuity know more and more about less and less define certainty enjoy hierarchies like protocols illness organised high risk high volume usually episodic General Practice v Consultant

9. GP Motivation • Quality of care • Quality of life • To make a difference • Individual respect • To enjoy work • To be liked by patients • Money

10. Things GPs Hate • Bureaucracy • Politics • No Reward for Increased Quality • Lack of Incentives • Lack of Staff • Short termism • Insensitive management • Being told what to do!

11. For GPS the incentives now lie in GMS2/PMS2 Not usually the PCT!

12. Other Confounding Issues • Centralist policy –independent sector • Unrealistic policy-choose and book • Post Shipman hysteria-revalidation • Risk avoidance or risk adverse culture • NHS still hospital orientated • Workforce issues • Lack of clear incentives

13. What Do We need to Do • Ideally engage Drs with other clinicians • Engage hospital clinicians with primary care • Get managers and GPs working together • Create adult-adult interactions all round • Focus around individual patient models • Don’t follow the governments management style!

14. How Can You Engage Clinicians • Practice based commissioning has a real chance • It creates local incentives that need to be guaranteed • It keeps clinicians away from most of the bureaucracy • Uses clinicians on “just enough time” basis • Help them make a visible difference • Concentrates on local issues and local patients • But how do we not disadvantage consultants?

15. How to Engage Local Clinicians • Local care pathways e.g. stroke • Local initiatives to offer new services GPSI’s • Alternative models of care and community initiatives • Peer review and clinical audit (facilitated) • Get the information right and in easily digestible form

16. How to Engage Local Clinicians • Protected time for peer review/planning • Engage with patients simultaneously • Identify “low hanging fruit” targets • Create incentives for change with team • Provide admin./managerial support • Identify natural communities • Ensure others apart Drs can be heard • Get buy in from senior management

17. How To Engage GP's • Understand them-they are all different! • Identify peer leaders and empower them • Produce quick wins • Don’t waste their time! • Reimburse their time at market rates • Compare performance with peers • Let them be advocates for patients • Set the goal but let them find the path • BE HONEST!!! NO BULL!!

18. Different G.Ps Respond to Different Incentives You Need to Include Some Incentives for Each Type!

19. Its More Than Just Doctors • More emphasis on nurses and therapists • More emphasis now on clinical teams • Practice managers key players too-engage them and you often get the practice team • But-doctors still hold the political power • Doctors still commit most of the resource • Collaboratives are key change agents now

20. Incentives • Need to focus on patient and clinically defined need • Need to be guaranteed locally • Can be real (money, equipment) or improved services • Need to benefit patients, hospitals and primary care ideally • Care needed not to create perverse elements • Should not reward under treatment

21. The Best Incentives Are • Evidence based • Agreed by local clinicians and patients in advance • Designed to reward excellence and extra work • Provide rapid return on investment • In line with national and local policy • Unlikely to increase inequities

22. Engaging Cultures • Where clinicians views are valued and encouraged throughout organisation • Good communication to all staff • Inclusiveness in decision making • Real resources to free up clinician’s time • Managerial and administrative support • Where debate is encouraged • Respect to evidence base

23. Cultures to Avoid • Bureaucracy and endless meetings • Top down management • Performance obsession • Exclusive • Deadline slipping • Secretive • Parsimonious

24. And do DH Lead the Way? • Choose and book? • NPFIT? • Primary Care Clinicians Given Leading Roles? • New Contractual Options? • New policy options? • Development programs e.g. NPDT?

25. Summary • Most clinicians are a scare resource • We need to empower them through their clinical roles • Management must be an add on not an either/or option • Adequate backfill-money and staff are vital • Remember the patient’s not professional’s needs are key-but often interlinked

26. NHS Alliance PBC Practice Network david.jenner@nhsalliance.org