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

2. What is Happening in PCTS All very variable but certain trends All very variable but certain trends GPs voting with their feet from PECS GPs voting with their feet from PECS More nurses/ therapists/pharmacists involved More nurses/ therapists/pharmacists involved Practice based commissioning trying to re- engage practices Practice based commissioning trying to re- engage practices Clinicians want to be engaged in the action not the bureaucracy 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 Where clinical engagement strong the lead comes from the CEO and PEC Chair In certain regimes clinicians actively excluded from key power forums In certain regimes clinicians actively excluded from key power forums SHAs rarely recognise PEC Chairs or PECS SHAs rarely recognise PEC Chairs or PECS Managerial culture still dominant in NHS Managerial culture still dominant in NHS Real problems where there are budget deficits Real problems where there are budget deficits GMS2 attracting GPs back to practices GMS2 attracting GPs back to practices PCT allowances not enough for GPs-need £500 a day to compete with practice PCT allowances not enough for GPs-need £500 a day to compete with practice

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

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

6. Other Clinicians New contract for pharmacists New contract for pharmacists Plenty of opportunities where GPs cant or wont deliver Plenty of opportunities where GPs cant or wont deliver New contractual options –specialist PMS New contractual options –specialist PMS Lots of enthusiasm Lots of enthusiasm BUT big workforce challenges –nurses,, BUT big workforce challenges –nurses,, pharmacists dentists pharmacists dentists

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

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

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

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

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

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

13. What Do We need to Do Ideally engage Drs with other clinicians Ideally engage Drs with other clinicians Engage hospital clinicians with primary care Engage hospital clinicians with primary care Get managers and GPs working together Get managers and GPs working together Create adult-adult interactions all round Create adult-adult interactions all round Focus around individual patient models Focus around individual patient models Dont follow the governments management style! Dont follow the governments management style!

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

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

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

17. How To Engage GP's Understand them-they are all different! Understand them-they are all different! Identify peer leaders and empower them Identify peer leaders and empower them Produce quick wins Produce quick wins Dont waste their time! Dont waste their time! Reimburse their time at market rates Reimburse their time at market rates Compare performance with peers Compare performance with peers Let them be advocates for patients Let them be advocates for patients Set the goal but let them find the path Set the goal but let them find the path BE HONEST!!! NO BULL!! 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 on nurses and therapists More emphasis now on clinical teams More emphasis now on clinical teams Practice managers key players too-engage them and you often get the practice team Practice managers key players too-engage them and you often get the practice team But-doctors still hold the political power But-doctors still hold the political power Doctors still commit most of the resource Doctors still commit most of the resource Collaboratives are key change agents now Collaboratives are key change agents now

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

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

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

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

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

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

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