A Gentle Reminder: Primary Care Networks need robust General Practice.

I’ve been re-reading Julian Pratt’s ‘Practitioners and Practices’, out of a niggling worry that the funding and policy focus on PC Networks will mean yet again that the developments needed in general practice will get neglected – as if the two are not interlinked. PCNs will only work if general practice is robust, adapting, and managing and reducing demand. Julian’s book is a lovely description of the work of general practice. PCNs need a purpose – i.e. to be clear what is the work that can only be done at that scale. They should only ‘suck up’ work that cant be delivered well at a local GP practice scale. In order to have that conversation participating practices need to be clear about the work that is best done in general practice at its best, otherwise the tendency will just be to shift the burden from general practice to the PCNs, rather than to consider the work of PCNs as unique and different from the work of general practice. For PCNs to be effective and useful, General Practice to be the best it can be.

The Work of the General Practitioner (which is not just the GP)

What we find in our work in general practices is that there isn’t a consensus on GP work (what a GP should do versus another practitioner) nor what work best resides at their practice population scale.  In this diagram the blue line is the number of appointments where the GP thought that they were doing GP work.

Fig 1: London Primary Care Quality Academy one practice example of variations between GPs from 40% of my appts are appropriate to 90% are appropriate.

In the hurley burley of ‘doing’ appointments, the conversation within practices about what their work is and how they are doing it can get lost. General practice practitioners (all the professionals working in general practice) need a coherent view about the value and work of the consultation at an individual level, and the work that can be done at practice population scale, and only then can they decide what needs to be done at PCNetwork scale. It’s a messy dilemma which has the potential to predicate the biomedical work of primary care over the other domains. The biomedical work is easy to describe and to ascribe metrics too, so its easy to count and therefore becomes the dominant descriptor of the work.

So lets start with the individual work in the consultation. Back to Julian’s book – he describes the domains of the work as these:

Fig2: The practitioner as synthesiser of the four aspects in working with the body, mind, emotions and spirit of the whole person (Pratt 1995)

These domains require different relational skills that are poorly described by the words ‘diagnose’ and ‘treat’, and require the primary care clinician/ practitioner to be able to help the person understand and make sense of their experience (sometimes not described as a clinical condition) and their own role in how they both deal with this experience and make choices about it. The primary care practitioner brings caring and emotional support as much as biomedical treatment. I was struck by the value of bearing witness to the person’s struggle with their life and health, and to take this one step further, the value of the general practitioner as a healer helping the person find their inner strength and meaning. When the NHS talks about the work of primary care and individual consultation, the focus is on flow, on the right practitioner for the right work, on how to help people who struggle with life through social prescribing (as if this isn’t the work of the GP or PC practitioner).

Compartmentalising people’s lived experience further fragments their care. This seems to loose the integral importance of the healing, caring and biographical modes of being a general practitioner. This range of relational approaches, describes the craft of the general practice consultation. How this is provided varies by person and need, which is why practices need a whole range of access modes from e-consult to online appointment bookings; and consultation types and length from triaged 5 min calls to half hour regular reviews.

This model articulates the work at practice scale. PCNs will also be providing personalized bespoke multidimensional care to and with vulnerable people, but at this scale the work is described by the complexity of service that is needed. This is not ‘economies of scale’ the rationalisation of resources to drive efficiency, it is ‘working at scale. My colleague Nick Downham describes this as emerging from the support, service or innovation need that can only be achieved at a certain scale:

  • To support the maintenance of a certain technical expertise.
  • To provide depth and quality of collaboration network.
  • To reflect natural sizes of communities.
  • To support team based approaches (Team based approaches are not the same as broadening skill mix – which is generally a form of division of labour)

………in order to speed up the meeting of need.

Starting with need is critical followed by then describing what scale is best to meet that need.

Here is an example of how the system as it works now fails to meet need

Fig 3: One person’s touchpoints of hospital, community and Local authority services in 2 years.

This is how Intermountain Healthcare has worked on developing primary care teams out of need.

Fig 4: intermountain Healthcare Physical and Mental Health Integration

Starting with need and the whole relational approach to meeting needs, will help general practice determine what should reside at that level and what needs to be done at PCN level.

Working with Populations

So far I have been exploring individual need and care, but the consultation is not the only work of general practices. The work to support the health needs of the practice population as a whole is a further dimension of general practice work– often described in terms of how resources are allocated equitably, and fairly. With access organised in the way it traditionally has been the needs of the population is subverted by the needs of the individual – those that demand get more than those that might need but don’t ask. Often little time is spent in practices for instance on preventative or early needs of teenagers who rarely try and access services, and a lot on people who attend frequently.

Fig 5: London Primary Care Quality Academy – where General Practices in the Academy focus their efforts.

The work of general practice in working upstream of the presenting issues needs attention, if only to help manage the demand in later life, which means focusing on the health and wellbeing of the practice population alongside the individual.

The final strength of general practice is the love it has for its local people, and how much general practitioners know about them. This care for, and knowledge of the place, has the mostly untapped potential of collaborating with the assets in communities to bring local people’s equal concern for their neighbours and friends into the work. This happens at the scale of meaningful communities, which is described by history, geography and identity, which may or may not reside at PCN scale. Some practices do amazing work collaborating with their community (Robin Lane, Leeds) as do some PCHomes (Fleetwood) at a larger scale. The starting point is the identity of the community not the population size.

Developing PCNs starts with understanding the work of general practice and developing practices and teams to be the very best thay can be with their local population.  

Afternote

At the outset of the book Julian identifies the influences leading to an increased emphasis on primary care in the NHS (nearly 25 years ago now) as:

  • Demographics changes and chronic illness
  • Development of tech processes reducing need to stay in hospital but increasing he need for aftercare
  • The need for generalist services as specialisms increase
  • NHS transferring transport costs to families
  • Users wanting community based services
  • An increased role for primary care in commissioning giving the potential to shape overall delivery

Sounds familiar!

In Memorium: Julian always gently reminded me to be human in my privileged work with people who are vulnerable.

Pratt, J. (1995) Practitioners and Practices. A conflict of values? Radcliffe Medical Press. Oxford.

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Social Prescribing Link Workers in the 10 year plan – who needs their help?

Intermediaries Distort

All our work on meeting need, reducing demand, spending national £s more wisely to improve care, involves collaborating with people and communities. There are warning signs in the NHS Long Term Plan that these vital lessons are being ignored. The NHS’ previous Vision (Five Year Forward View) took a more asset based approach to people who own, pay for and use health services. But the ‘old world is biting back’ – the best indicator of this is in the Plan’s section on social prescribing, where the investment is going into ‘link workers’ not developing local community solutions with local people. Our experience with colleagues such as Altogether Better, and our colleagues in Leeds Social Care is that people in communities have the assets to help each other and help themselves, and that the best thing we can do is help professionals learn how to collaborate with communities. Our models of doing this keep reverting to a dependency model or one where a person’s own assets are distorted by an intermediary. However I decided to ask a good friend and colleague for another view.

David Boyle is working with us on ‘The Asset Based Health Inquiry’ to give us his views. He sees a role for link people to enable professionals and ‘patients’ to navigate the wider landscape of support, and this is what he had to say.


I have always been a little sceptical about the idea of professional choice ‘navigators’ in the NHS. I had decided, when I was working on the issue of choice at the Cabinet Office in 2012/13 that they would not survive the next round of cuts.

So I was surprised this week, when I got referred to secondary care, to find myself calling up some professional choice navigators, part of the choose-and-book infrastructure of choice that still exists from the ancien regime. 

It was good to have someone to help me choose, but they didn’t sound terribly pleased to hear from me as a patient. Nor, of course, could they actually give me any advice.

I have not changed my views: paid link people, navigators or signposters are uniquely vulnerable in periods of austerity. There used to be navigators in the education system, but they have long since disappeared, most of them. This is certainly the second incarnation of the idea in the NHS.

So what are we to make of the NHS Long Term Plan’s enthusiasm for professional link people, about which they say this:

1.40. As part of this work, through social prescribing the range of support available to people will widen, diversify and become accessible across the country. Link workers within primary care networks will work with people to develop tailored plans and connect them to local groups and support services. Over 1,000 trained social prescribing link workers will be in place by the end of 2020/21 rising further by 2023/24, with the aim that over 900,000 people are able to be referred to social prescribing schemes by then.” 

I humbly suggest that this may be another example of over-professionalisation. You do need some skills to be a navigator, but they are mainly people skills. You need some knowledge too, but not professional knowledge. I see no reason why these should not be volunteer roles, trained up from among those who started perhaps as health champions or expert patients, and who yearn for a new challenge but who can’t, for whatever reason – age, illness, disability – go back to paid employment.

Link people to help doctors and patients navigate the resources of the voluntary sector are pretty vital, but we hardly need to wait until 2023 to organise this in GP practices. We could start training them now, without requiring permission from NHS England to do so, and without carving such a chunk of badly needed money out of our overstretched budgets (though clearly some money will be required). I hope we do.


In my view the ‘link worker’ model never the intent of social prescribing (although as many of you know – my views are that the battle for the change in relationships and power was lost at the point at which the asset based approach became ‘prescribing’ putting it firmly in the old world language of the medical model). Cormac Russel has seen this coming as the NHS swallows up a collaborative asset based process into a professionalised top down deficit approach in his blog . Becky


David Boyle is an acclaimed author and Visiting Fellow at our Health Systems Innovation Lab at London South Bank University. He is the Co-director of the New Weather Think Tank. You can find more about him here


How do Practices know how they are doing?

What data do you collect to inform your decision-making as a practice? Different colours represent different practices.

We asked some practices in a Federation to tell us what measures / indicators they collect to inform their practice decision-making in terms of how they organise (their operational management), the quality of their work, and their financial robustness. This is what they told us.

What surprised us is how little overlap there was in terms of what each practice used regularly. The range of measurement used was wide, but there was little consistency across different practices.

 

The focus of operational measurement and use of data was overwhelmingly focussed on managing the present.

Quality and safety measurement was focused on the past – i.e. the measurement created a retrospective view rather than a prospective view.

We know that you get more of what you pay attention to.

So what you measure determines what you do. The metrics that shape your decision-making are important. They relate to the sort of practice you want to be, and the difference you want to make. 

This is what a group of practices told us about what they collect. It was copious, and it didn’t all add up into a comprehensive or coherent view of the practices work.

This exercise helps practices think about the data they need to be effective as a provider of care and as a business (after all, GP practices are private subcontractors to the NHS). Most of the measurement was about activity (generally managing and counting appointments), and so its no wonder this is the focus of how problems are seen, but also assumptions to where solutions lie. There was little about actual demand (need), or population health. In fact the metrics seemed to be dictated by contracts and incentive structures (namely QOF) – and not necessarily by patient need.

So where do you start as a practice? 

  1. Be clear about your purpose. What is it you want to achieve as a practice in terms of your impact on health, the quality of your services, what sort of place your practice is to work in, and your financial viability?
  2. Then set out some goals for your practice – what would the above answers look like if you were doing it all well? How would you know?
  3. Now what metrics help you understand how you are doing now, and how robust you are for the future? Think about trends as well as static points. 
  4. Finally how often do you need to review these metrics? Do you have a top 5 that you look at every week as it gives you a good ‘temperature test’? 

Here is a basic example from a practice

Raising the bar

The above creates a predominately operational view. To move to a view that helps with the improvement of core process, you would seek to create measures and information loops that help you understand variation in process capability, variation in clinical decision making and, most fundamentally, whether or not you are genuinely meeting demand (need).

This could be seen as needing a fair bit of investment to put in place. It certainly needs a little staff time each week to pull together – so essentially it costs money to create this data driven view. My view is most practices are not ‘corner shop’ businesses any more. Turnovers of in excess of £1million and 20+staff are not uncommon. The ‘work’ of general practice is complicated and patients are becoming more dependent. Given all of this, then can practice be run without a balanced measures set, i.e. run predominantly on subjective decision-making? I suspect not.

We are keen to hear examples from practices. If you would like to share your examples on this blog do get in touch.

Nick Downham Guest Blog

Setting up a Team to Develop Primary Care

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This blog sets out what is required in a team that sets out to develop primary care. I start with a brief summary of our approach but the most important section of this blog is the style of and skills in any PC development team. There are lots of PC developments going on, but it takes a mix of skills to be a really effective development partner to practices.

The Approach

We have developed an approach to Primary Care Development in the LSBU Primary Care Quality Academy that has two stages. The Lab approach is described in more detail in the next blog.

Stage One : Readiness

A combination of data work to collaboratively review demand and a practice visit to discuss the practice ‘system’.

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Which has the following specific data to understand the here and now of the practice culture, approach to access, and how its meeting/managing demand

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This is followed by

Stage Two: Delivery

A mixture of a short course, communities of practice, further data work, and on-site bespoke development.

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The Principles that Underpin How the Development Team Works

We have found that this is what it takes to do this work  in terms of principles:

  • A neutral non-judgmental partner willing to walk alongside the practices as they develop; but also rigorous and challenging/ critical friendship.
  • Start with what’s really going on in the practice using data and system maps to understand the patterns of behaviour
  • Work with their real time current issues – we start where they want to start.
  • Sort and filter all the advice available to general practice on quality and change.
  • Work with the practice as a system not a series of parts that can be fixed mechanistically – we start anywhere and go everywhere
    • across appointment systems and how people move through the system;
    • clinical and management variation in signposting,
    • referral and clinical decisions;
    • skill mix – who does what work;
    • building the assets of the communities; working with the folk who are struggling

And this is what it takes to do this work in terms of our practice:

  • A team that has expertise across all the emerging needs of the practice, with a portfolio of primary care specific methods – QI methods, Data, Citizen engagement and asset building; team development and peer decision-making; clinical variation; working as a system.
  • Build the relationships that enable them to decompress – we listen (for hours) meaningfully to their experience, assumptions and opinions.
  • Reframe the issues so that they relate directly to the practice’s business.
  • Respect their learning and creating headspace and a learning environment.
  • Secure pace and spread through Communities of Practice.
  • Work with the top of the system to generate accountability for the issues that reside at the whole system level.
  • Walk practices through their challenges, depersonalising and de-externalising them.

The Development Team needs these skills

Specific Skills:

  1. Systems Thinking and Practice: the practice is a system and it operates within a system. You need a team member who understands power in systems, how systems adapt and how best to intervene in systems. At minimum clear about Tame and Wicked issues and can help any team clarify these (Grint), Adaptive Leadership (Heifetz) and Power in systems (Oshry).
  2. Adult learning, including collaborative learning e.g. experience in Communities of Practice (Wenger) and rigour in these methods.
  3. Quality Improvement – Detailed knowledge of and experience in applying: Deming’s System of Profound Knowledge, Flow, Failure Demand, Mapping the system (providing a system map), Quality and Safety. See following section.
  4. Coproduction – experience of the full process of coproduction from co-discover, to co-design to co-deliver to co-evaluate. Co-design is not coproduction, and your team member(s) need to know the difference between Voice, Choice and Coproduction 
  5. Collaborative Communities – we work with Altogether Better as our partners in supporting Collaborative Communities. We haven’t found anyone who is as good as they are.
  6. Group Dynamics, Peer Leadership and Governance Facilitation – There are times when the owners primarily GP partners need in depth specific work on their group dynamics, how they manage power, how they take responsibility, how they make collective decisions. This is different from the day to day work we do with the practice as a whole to work as a team. This requires skills and training in basic group dynamics.
  7. Data for Quality – a team able to focus on the key facts that will disturb the system, ways of presenting data that provoke thinking and learning, and an ability not to get sucked into perpetual analysis. Analysis is attractive because if means you don’t have to act. The data team need to know at what point to expect the PC team to act. The data team has to be able to facilitate the PC team to get to the heart of the issue and then provide or support the practice to provide the data that helps answer their questions. Dashboards are not helpful. Specific data relating to specific questions that get to the heart of the practices understanding of need and flow are critical. Being able to present their clearly to complete data novices is essential. Finally they need to be able to help the practices identify and generate metrics to help them understand the impact of their changes and to be able to evaluate the usefulness of the PCQA.
  8. Great admin! Even better great admin that knows how to relate to professionals and can form good relationships with the practices and the practice admin.
  9. Project management – to keep track on progress and impact.
  10. Evaluation –skills in evaluating the whole using qualitative and quantitative data (and time to do it!)

Nick Downham, Tony Hufflet and Becky Malby

Lessons from the London Darzi fellowship

The prestigious Darzi Fellowship has now passed its 10th birthday. During that time many Darzi Fellows have experienced a unique combination of learning, development, innovation and leadership. There is an ever growing alumni of Darzi Fellows, these Fellows are a new generation of healthcare professionals, who have a clinical role or background coupled with the skills of systems leadership, and innovation.

The Darzi Fellowship is a case study in best practice for clinical leadership development. The evaluation of the London Darzi Fellowship programme carried out by Stoll et al., (2010) describes the value of the fundamental relationship between workplace and programme learning, described in the following diagram:

Eval Darzi

The report by Stoll and colleagues attributes the success of the programme (which at this stage was for doctors only) to:

  • Committed and learning oriented MD
  • Supportive Trust culture
  • Working on ‘ambitious but appropriate’ live projects
  • High quality mentoring
  • Learning programme that targets transformational change
  • Combining workplace and external learning
  • Network of support – from formal to informal social learning

As the Fellowship developed into a clinical leadership programme, and the context in which the Fellowship operated change, the design of the fellowship was iterated, and the impact remained. Conn et al., (2015) in their survey of Darzi Fellows found 94% of their 90% survey return rate reported the programme as worthwhile. 85% felt more empowered to improve health care systems, particularly through developing collaborative clinical networks.

Overall a Longtitudinal study of the Darzi fellowship (Mervyn & Malby 2017) demonstrates its effectiveness in securing clinical leadership who can contribute too and lead the Triple Aim – ensuring high quality healthcare, securing overall community health and managing costs. The study showed that:

  • Fellows are emerging as leaders, acting as catalysts for sustainable change in the healthcare environment
  • The Darzi programme continues to be successful with learning and behavioural change sustained after the Fellowship year

Malby et al (2018) found that in a review of the Darzi Fellowship “Several concurrent processes must happen for clinical LD programmes to be genuinely impactful. Leadership students must collaborate as a group or team. Innovation, the basis of systems change, is the result of a team effort. These clinical teams should be diverse, especially multidisciplinary with a level of healthy conflict, and the students must be reflective and resilient. “

The Darzi Fellowship Programme at LSBU is designed based on the principles proposed by Edmonstone (above) along with those of Swanwick and McKimm (2014) who summarize a set of principles for design of leadership development namely that they should be:

  • Practical: through the incorporation of the development of key skills such as coaching, change management, and negotiation
  • Work oriented: by including project work as a key component supported by action learning sets
  • Supportive of individual development: through 360° feedback, coaching, and mentoring
  • Link theory to practice: through the provision of selected leadership and management literature, relevant to the educational context
  • Build networks: through action learning, coaching, and social networking.

The Current Fellowship

The Darzi Fellowship supports early career clinical leaders, who take a year out from clinical training/ practice to develop their skills and capabilities in leading complex change. Fellows work on an intractable complex problem (the Fellowship Challenge) within an NHS organisation, where previous attempts to make an improvement haven’t made the difference expected; or an emerging complex problem where it’s not clear what to do. Host organisations provide an innovation space for the Fellows to test out new approaches to complex (wicked) local issues, in order to make a real difference to the quality of local health services.

The Fellowship work includes:

  • Inquiry
  • Developing a culture of change
  • Discrete projects across a system
  • Building collaborative relationships
  • Connecting theory to practice, and a better use of data in the system
  • Systems leadership

The PGCertLeadership in Health (Darzi)  takes Fellows through a journey of foundations of change, learning all the approaches needed to undertake a complex change, from scoping through to implementation and evaluation. Development of understanding of methodologies for change, personal strategies and skills for leadership including working with peers and with diversity are embedded in the programme workshops. These are applied and reviewed in Action Learning Sets and through the coaching and co-consulting sessions with Faculty where Fellows seek advice and support for the design and implementation of their change work.

A major strand throughout the programme is developing the ability to work effectively and productively with peers from diverse backgrounds (including service users). Throughout the programme the Fellows are exposed not only to the theory of clinical leadership but also to experienced clinical leaders, who share their personal approach. This also provides a network for the Fellows for current and future mentoring.

A  critical part of the Fellowship is learning about how to coproduce change with citizens as peers – here are colleagues from the LSBU Peoples Academy who join the programme.

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The programme is congruent with the principles for effective leadership development identified in the last blog and re-listed here below:

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

  1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
  2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
  3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
  4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
  5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
  6. Personal Leadership application – knowledge development supported in its application by coaching.
  7. System mentorship to support ongoing careers and sustainability of the programme learning.
  8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.

The Darzi Fellowship will shortly open for applications at LSBU for September 2019. Please contact me if you would like to host a Fellow.

References

Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side’ BMJ 351:h5231

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health Organization and Management. Vol. 32 Issue: 6, pp.793-808

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

Stoll L, Foster-TurnerJ, Glenn M. (2010). Mind Shift. An evaluation of the London Darzi Fellowships in Clinical Leadership. London Deanery and IOE London

Swanwick T, McKimm J. (2014) Faculty development for leadership and management. In: Steinert Y, editor. Faculty Development for the Health Professions. New York, NY: Springer.

 

Does Clinical Leadership Make a Difference and how do you Develop Clinical Leaders?

ROO_0213I’m being asked about what makes effective leadership development, so here is a summary of what works! The next blog is a case study of the London Darzi Fellowship as an example.

The Impact of Clinical Leadership

Basically where there is good clinical leadership organisational performance is good – people get a better deal.

The importance of clinical leadership for healthcare change has been well described (Swanwick and McKimm, 2011, Edmonstone, 2009, Wilson et al., 2013, Malby et al., 2013). The direction of travel is clear, and to an extent this has been an ideological movement (healthcare quality will be improved and costs reduced if clinicians are at the heart of decision-making). However there is emerging evidence of the beneficial impact of clinical leadership. Kirpatrick et al (2007) conducted a National Inquiry into the relationship between management and medicine. This identified that Clinical-management engagement is often associated with a) improved productivity (through the redesign of clinical work) – Degeling et al (2003); b) enhanced capacity for change and innovation (Fitzgerald and Ferlie 2006). A number of studies have found that poor performance and clinical failure were linked in part to a ‘disconnect’ between medicine and management (Healthcare Commission 2006, Mannion et al 2005). Many have also identified a positive link between effective clinical leadership and improved patient care. There is then some evidence to suggest that improving the capacity of doctors and managers to co-produce services will add value in the system.” (p 5)

A subsequent review conducted by the Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership (West et al 2015) showed the importance of leadership in the health service. The review concluded that ‘There is clear evidence of the link between leadership and a range of important outcomes within health services, including patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care

Veronisi et al (2013) found a significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service providers, especially where doctors are concerned ‘This positive influence is also confirmed in relation to lower morbidity rates and tests to exclude the possibility of reverse causality (doctors joining boards of already successful organisations).

Overall it is now clear that high organisational performance results when good clinical engagement occurs, and higher quality care results from strong clinical leadership (Dellve et al., 2018; Reinstern et al 2008, NICS 2003).

Clinical Leadership Development

Having recognised the need for and benefits of clinical leadership, the next issue has been the readiness of the clinical professions to take on these roles. Whilst the attitude to leadership has changed, and whilst clinicians are taking up roles that embrace leadership, their development for these roles is less robust.

Leadership development and management development has long been embedded in nursing career development, and is increasingly common in medical careers (with intercalated degrees that include management). However many hospitals have little or no management or leadership development for their consultants, or directorate leads, and that is mirrored in primary care where opportunities for GPs to develop these skills has been sparse. The readiness of medicine mirrors the early ambivalence, and sometimes vociferous opposition of the profession to integrating management into its practice. As attitudes changes the development of the profession in terms of management and leadership skills has fallen behind. This is partly because the profession has taken time to realise that management and leadership isn’t straightforward ‘common sense’. Many stories of the early days of CCGs are told where GPs believed that running their own small business was adequate preparation for committing public resources through commissioning.

No matter what the causalities the reality remains that:

…consultants rarely receive leadership training and might experience problems with the transition into management roles, particularly in relation to conflicts with their other responsibilities to patients, colleagues and life outside work.’ Lewis 2013

Successful reshaping of local health systems depends heavily on the leadership of clinicians, working with partners in social care. But clinicians are rarely trained in the major change management skills they need for the task. Moreover, they get little career support for challenging perceived boundaries between clinical and management roles. Consequently the systems leadership roles where clinicians can make such a big difference may not appear to them as attractive or feasible career opportunities.’ NHS 2016

In fact according to Edmonstone (2009) “no systematic and structured national leadership development provision for doctors existed prior to 2001-2002” (p 210).

The Darzi Fellowship programme (resulting from the 2008 Darzi review) originally for doctors and now for all the clinical professions, in its 10th year is the longest standing programme for developing clinical leaders in London. It demonstrates the value of investing in clinical leadership development (Malby and Mervyn 2017).

Leadership in high performing health systems is distributed (Denis et al 2011) and therefore in focusing on clinical leadership development for the future, the model of development should not just be for senior leaders but for the full range of clinical leaders, working at multiple levels and in multidisciplinary teams contributing to securing quality healthcare for all. This is supported by West et al (2015) report on leadership in the NHS which states that successful organisations are “leader-ful” not just “well led”.

In addressing clinical leadership effectiveness organisations need to provide clinical leadership in an integrated multidisciplinary model across all levels of organisational decision-making.

Effective Clinical Leadership Development Programmes

Of course effective clinical leadership development has many of the characteristics of any effective leadership development programme. The difference is the context in which clinical professionals join a leadership programme (the dominant role of expertise in the profession; the lack of prior leadership and management development in training).

At its heart any clinical leadership development programme needs to be based on the best intelligence about adult learning. This is the bedrock.

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Adult Learning

Adult learners require far more than just information; they require a myriad of teaching technologies. These adult learning principles to the design of our programme (Knowles 1984):

  • Adults need to know why they are learning something
  • Adults learn through doing
  • Adults are problem-solvers
  • Adults learn best when the subject is of immediate use

Effective adult learning programs use double loop learning methodology based on for example Kolb’s experiential learning framework (Kolb 1984), and support continued learning and development through learning communities such as action learning sets so that participants ‘learn how to learn’, and have a deeper sets of alternative ideas and behaviours from which to choose to act (Schon 1987).

Effective Leadership Development

West et al. (2015, p 3) found that across levels of leadership development programmes – individual, task-based, team, organisational, national “…there is little robust evidence for the effectiveness of specific leadership development programmes”. However there are reappearing themes such as self-awareness and personal reflection, communication, teamwork, leadership styles, a support network, duration of one year and experiential learning, in studies of the learning impact of Leadership Development (LD) programmes. (Strawn et al., 2017; Tsyganenko, 2014, Pradarelli et al., 2016,).

In a review of Leadership development programmes Edmonstone (2013 p 537) proposed the following common design principles for effective leadership development programmes:

  • “Starting with ‘what is’
  • Focusing on the end-point
  • Real time, real work, real people
  • Explicitness about underlying values
  • Addressing system-wide issues
  • Embedding development with core business
  • Embracing diversity
  • Addressing sustainability

Effective Leadership Development Principles and Practices

Overall the evidence suggests that any Clinical Leadership Programme needs to include the following:

  1. Adult learning methods in understanding distributed leadership, systems and how they work, power, approaches to quality, change management, collaborative decision-making. This means an inclusive, collaborative approach to learning events (workshops) with little didactic learning.
  2. Skills development in working with diversity and conflict, negotiation, personal resilience, change practices for wicked and tame problems, inquiry, critical analysis, reflection, learning to live with uncertainty, and working with people and communities as assets.
  3. Organisational application – a real piece of leadership change work where the clinical leader can practice their new knowledge and skills, and learn through doing and reflection, and peer review with colleagues in an action-learning approach.
  4. Clear mentorship of the clinical leader in their own organisation as they learn to apply their new learning in practice, providing air cover for the clinical leader to experiment with new skills and practices.
  5. Leading as peers – using the clinical leadership learning group as the case material for understanding how to work as clinical peers in a distributed leadership model.
  6. Personal Leadership application – knowledge development supported in its application by coaching.
  7. System mentorship to support ongoing careers and sustainability of the programme learning.
  8. Opportunities to build networks for personal development and support beyond the programme, and in support of the organizational change effort they are leading.

References

Baker GR, Denis J-L. (2011) Medical leadership in health care systems: from professional authority to organizational leadership. Public Money and Management. 31:355–362.

Berwick DM, Nolan TW, Whittington J. (2008). The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769

Conn, R., Bali, A. & Akers, E. (2015) Taking time out of training to shed light on “the dark side Available at: http://careers.bmj.com/careers/advice/Taking_time_out_of_training_to_shed_light_on_%E2%80%9Cthe_dark_side%E2%80%9D# (Accessed:10/01/18)

Darzi, A. (2008). NHS Next Stage Review Leading Local Change. London: Department of Health

Darzi, A., Quilter-Pinner, H., Kibasi, T. (2018) Better health and care for all: A 10-point plan for the 2020s. The final report of the Lord Darzi Review of Health and Care. Institute for Public Policy Research. June

Degeling, P., Maxwell, S., Kennedy,J., Coyle, B. (2003)  Medicine, management, and modernisation: a “danse macabre”? British Medical Journal, 2326(7390): p. 649-652.

Dellve, L., Strömgren, M., Williamsson, A., Holden, R.J. and Eriksson, A., (2018), ‘Health care clinicians’ engagement in organizational redesign of care processes: The importance of work and organizational conditions’, Applied Ergonomics68, pp.249-257.

Denis, J.-L., & van Gestel, N. (2016). Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Services Research16(Suppl 2), 158. http://doi.org/10.1186/s12913-016-1392-8

Edmonstone, J. (2009) Evaluating clinical leadership: a case study. Leadership in Health Services, Vol.22 Issue: 3, pp.210-224,

Edmonstone, J (2013) What is Wrong with NHS Leadership Development British Journal of Healthcare Management Vol 19 No 11 p531-538

Evans, E.J (2004). Thatcher and Thatcherism (the making of the contemporary world). 2nd Edition. Routledge

Fitzgerald, L., Lilley, C., and Ferlie, E., Addicott, R., McGivern, G., Buchana,D. (2006) Managing Change and Role Enactment in the Professionalised Organisation. National Co-ordinating Centre for NHS Service Delivery and Organisation R & D. London.

Healthcare Commission (2006) Annual Health Check. London.

Kings Fund (2011) The Future of Leadership and Management in the NHS. No more heroes. Report from The King’s Fund Commission on Leadership and Management in the NHS p ix

Kirkpatrick, I., Malby, R., Dent, M., Neogy, I., Mascie-Taylor, H., Pollard, L., (2007), National Inquiry into Management and Medicine: Final Report, Centre for Innovation in Health Management, University of Leeds, January

Lewis, M. (2013) Reflections on a changing role in clinical management. International Journal of Clinical Leadership 17 (4): 227-234

Malby, R., Mervyn, K. and Pirisi, L. (2013), ’How professionals can lead networks in the NHS’, International Journal of Leadership in Public Services, 9(1/2) pp. 4-4.

Malby, R., Mervyn, K., Boyle, T (2018) Darzi Clinical Leadership Fellows: an activity theory perspective. Journal of Health organization and Management. https://doi.org/10.1108/JHOM-05-2018-0133

Mannion, R., H.T.O. Davies, and M.N. Marshall, (2005) Cultural characteristics of “high” and “low” performing hospitals. Journal of Health Organization and Management, 19(6): p. 431.

Mervyn K, and Malby, B (2018) Longitudinal Study of the Impact of the London Darzi Fellowship Programmes. Years 1 – 8. London South Bank University.

McNulty T, Ferlie E. (2002) Reengineering Health Care: The Complexities of Organizational Transformation. Oxford: Oxford University Press

L.J. Millward., Bryan, K. (2005),Clinical leadership in health care: a position statement, Leadership in Health Services, Vol. 18 Iss 2 pp. 13 – 25

NHS (2016) Developing People – Improving Care A national framework for action on improvement and leadership development in NHS-funded services. National Imporvement and Leadership Development Board.

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Noordegraaf M. (2011) Risky business: how professionals and professional fields (must) deal with organizational issues. Organizational Studies.  32:1349–1371. doi: 10.1177/0170840611416748

Pradarelli, J.C., Jaffe, G.A., Lemak. C.H., Mulholland, M.W. (2016), A leadership development program for surgeons: First-year participant evaluation, Surgery, 160(2) pp. 256-263

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Strawn, K., McKim. A.J. & Velez, J.J. (2017), Linking Experiences and Outcomes within a Postsecondary Leadership Development Program. Journal of Leadership Education, 16(1) pp. 34-46

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Primary Care & Scale. Who should we be collaborating with?

Screen Shot 2018-06-15 at 16.42.13Seduced by Structure

As we wait for the next round of policy papers on the size and shape of GP practice organisations and primary care teams, I’m struck by how much structure always becomes the answer. Many reshaping documents start with the structures of the institutions rather than the identity and capacity of communities, and yet General Practice has grown out of communities, and practices are deeply embedded in their local place.

I thought it would be useful to offer a view about scale from the place of relationships and needs, rather than institutions and structure. But first of all the practices need to be ready to collaborate.

The Fantasy of the Future

The next seduction is to get into a fantasy about how fast the primary care system can move into these new collaborations. The starting place for the policy is well functioning practices with increasingly complex work, whereas many practices aren’t at the starting blocks yet.

Any development of ‘at scale’ collaboration needs the bedrock of efficient practices working with resilient communities.

We know that practices that are adapting effectively to the context of increase complexity [London Primary Care Quality Academy]:

  • Use data to understand presenting needs, review activity and improve the flow through the practice system. Understand their demand and ways of meeting that demand (data capture of patterns of demand and flow in the practice; how they offer appointments and who gets turned away; understanding the profile of their frequent attenders; and their low attenders; number of DNAs.
  • Collaborate with communities to coproduce services locally
  • Use their skill sets more effectively to meet need (diversify their workforce)
  • Use their contact time with patients more effectively (triage, mixed model of appointments)
  • Improve their back office functions to work efficiently (managing the paperwork)
  • Reach out to partner with other providers to manage complex health (care homes, social care, third sector, mental and acute health).
  • Learn fast, looking for examples outside their practice to steal with pride; establishing peer review for their clinical practice across professions. They test and prototype new ideas and check the impact on their demand and capacity using data.

This is the ‘Readiness Stage’, the foundations that practices need before they start collaborating (and merging/ partnering), because this stage exposes the nature of the actual work in practices, and where best the practice teams can intervene, and therefore where they need to collaborate to provide the best option. It also requires practice members to work collaboratively together, beyond the individual roles but as peers to bring all their experience and ideas as a team.

What Scale for What Work?

There are four main resources that secure health and wellbeing in communities –the community itself, the NHS, local government and the third sector. You can’t change General Practice without consideration for the other groups.

In my view there are these ‘scales’ for primary care service development:

Screen Shot 2018-06-14 at 13.48.10

Scale 1: The Community: Up to circa 14,000

General Practices grew out of local communities. These communities have natural boundaries, characteristics, relationships and resources. They have stories they can tell about themselves as a community. They recognise people from their community as being one of them. Most communities are at a scale of up to circa 14,000. This is the size of a small town. Go beyond that and people don’t feel like they are part of something they can identify with – it becomes something others ‘own’ and belong too. They don’t feel that its something they can contribute too.

At 30-50K scale that is the current favourite scale, people don’t identify themselves as a community, there are conflicting stories and different cultures. They see people as ‘other’ and its not a size that generates any sense of belonging.

The NHS could be seen as having generated an over dependence on its services borne out of the founding principles of the NHS ‘Can do, Should do’ and medical model ideology. There are many proponents of the assets that communities can and should bring to their health, and examples emerging beyond social prescribing (language that is laden with the intent that power stays in the hands of the prescriber see Corman Russell’s blog on this),to a partnership model with communities that has the potential to reduce demand.

There are masses of assets in communities or perhaps more accessibly – people who want to volunteer and help each other. We need these people to help with the volume of ‘patients’ presenting with ‘trouble with life’. This has to be the bedrock of any further ‘at scale’ working . See my previous blog on Reducing Demand in Primary Care.

Primary care for the future needs to be built out from resilient communities. So this is the first productive scale for primary care.

Scale Two: The Locality: 30-100K

(a) Across General Practices

At 30-50K

At this scale you can generate efficiencies in the Practice Business Model:

  • Sharing back office functions
  • Sharing workforce (particularly non-GP professionals and receptions staff)
At 30-100K

At this scale collaborating practices can provide some diagnostics, and more specialised rapid assessment and treatment functions to support GP/ Primary care teams work. See the work of Eastleigh Southern Parishes Locality

Aligning with Care Homes

Care homes provide better care where they are aligned with a practice. Within a borough a practice could specialise in this service for a geographical areas akin to Localities.

(b) As part of Integrated Teams

When you have resilient communities working to support local health and wellbeing, and you have functioning general practices, alongside collaborations for business efficiencies, then the next step is how to collaborate with other service providers to manage complex conditions, to prevent people with complex needs becoming unstable.

At the moment there seems to be a focus on growing these collabortions out of primary care, rather than developing integrated MDTs that bring the best of the skills needed from all service providers locally to bear on the complex needs of specific population groups e.g.

  • People who are frail
  • Adults who have both mental and physical health needs
  • Young people with both mental and physical health needs
  • People who have trouble with life which means they can’t cope with their health issues

These different groups require different MDTs with different skills and leadership. The General Practice team are members not neccessarily the leaders. For these teams the GP and practice members are peers in the team. As yet there is some way to go before we have the level of self-organising integrated MDTs that can work collaboratively with devolved authority to support people who have complex needs, preventing them from moving from stable to unstable. The MDT will have different professions taking the lead dependent on the severity of need. So for combined mental and physical health, it could be the community nurse at the lower levels of severity, a GP at a mid level but a Psychiatrist at higher level of severity. People with complex needs do need algorithms that identify the intensity and level of expertise of support required see the Intermountain work (Reiss Brennem at al 2016 ) and Western HealthLinks, Australia.

We at LSBU London Primary Care Quality Academy have the early ideas for the model here:

Screen Shot 2018-06-14 at 14.36.48

Scale 3: The Borough : 150K – 350K

At Borough scale there seem to be two main functions:

  • Some service delivery potential across a larger population.
  • Business Intelligence and Learning : A ‘Collaborative’ where members can work together to spread and share intelligence and to learn. This is in effect a development agency for the NHS in that place. Here Primary Care teams are supported by an Research and Development Team. Every industry needs its R&D function to innovate and adapt. Borough level organisations (e.g. Federations) can partner with AHSNs and CCGs to secure the best business intelligence (data) for quality, and to secure organisational development programmes for member teams, and clinical / professional leadership programmes for leaders.

All of these scales require different relationships:

Screen Shot 2018-06-15 at 15.43.32

And therefore different organisational forms:

Screen Shot 2018-06-15 at 16.06.44

And therefore different personal development capabilities:

  • At the Community and Practice level teams need good management development, team working and coproduction.
  • At the partnership level people leading these need good leadership skills for effective organisational collaboration.
  • At the locality scale people need peer leadership capabilities.
  • For the Borough scale people leading these need good Network Leadership skills.

As you can see a one-size-fits all approach might suit the NHS, but what’s needed is Collaborations borne from an understanding of need, and development to support the nature of that collaboration.

Do get in touch if you are interested in this work.

Becky