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Clinical Engagement primary care leading by design
ANational Leadership and Innovation Agency for Healthcare
Clinical Engagement primary care leading by design
Supporting NHS Wales to deliver world class healthcare
Cefnogi GIG Cymru i gwyfl wyno gofal iechyd o safon fyd-eang
National Leadershipand Innovation Agency
for Healthcare
Asiantaeth GenedlaetholArwain ac Arloesi mewn
Gofal lechyd
Clinical Engagement primary care leading by design
iNational Leadership and Innovation Agency for Healthcare
Academic Research into Successful Strategies and Mechanisms to Infl uence and Improve Clinical
Services Provided by General Practitioners
Commissioned by:
National Leadership and
Innovation Agency for
Healthcare
Service Improvement
Bridgend Road
Llanharan
Completed by:
CRG Research Limited
25 Cathedral Road
CARDIFF CF11 9TZ
T: 029 2034 3218
F: 029 2066 7328
E: consult@crgresearch.co.uk
W: www.crgresearch.co.uk
Cardiff University
Centre for Health Sciences
Research
Neuadd Meirionnydd
Heath Park
Cardiff
CF14 4YS
Clinical Engagement: Primary Care Leading By Design
1-905456-17-4
978-1-905456-17-8
ii
Clinical Engagement primary care leading by design
iii
Cover Reference: Clinical Engagement primary care leading by design
Control: Academic Research into Successful Strategies and Mechanisms to Infl uence and Improve Clinical Services Provided by General Practitioners
Date: 14th January 2008
Final Format: Electronic PDF
Type: Academic Report
Description: The report investigates the term Clinical Engagement in the context of the NHS and draws on the international research currently available. It also includes practical examples from leading clinicians in Wales primary care
Consequence: The purpose of this document is to share knowledge across NHS Wales about the lessons from the literature available and the shared examples of practice in primary care NHS Wales. It aims to aid the future development of quality improvement through effective clinical engagement across Wales, particularly when considering clinical services delivered in General Practice.
Target Audience: Healthcare organisations and professional bodies/groups in Wales dependant on clinical engagement to effectively manage the care of patients within/across primary and secondary care.
Intended Circulation: WAG Policy Leads; Local Health Boards; NHS Trusts; LMCs; Regional Commissioning Units.
Originator: CRG Research, Cardiff University and the Clinical Support for Local Health Boards Programme, National Leadership & Innovation Agency for Healthcare
Authorisation: Chief ExecutiveNational Leadership & Innovation Agency for Healthcare
Further Information: National Leadership & Innovation Agency for HealthcareInnovations House, Bridgend Road LLANHARAN CF72 9RPTelephone: 01443 233333; Facsimile: 01443 233334
Breeda Worthington, Clinical Support for LHBs, Service Improvement Directorate:Breeda.Worthington@nliah.wales.nhs.uk
Published on: www.nliah.wales.nhs.uk
Contents
Page Number
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Our Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Background & Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Health Policy and Clinical Engagement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Health Policy from the 1980s onwards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
The Importance of Effective Engagement on Policy Developments. . . . . . . . . . . . . . . . . 15
3. England & Wales: Different Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
England: Current Developments in General Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Wales: Current Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4. Theoretical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Barriers to Clinical Engagement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5. Findings Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Clinical Engagement: An LHB Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Clinical Engagement: AN LMC Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
6. Clinical Engagement Practical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Postgraduate Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Chronic Conditions Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
7. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Appendix I: References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Appendix II: Medical Director Topic Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Appendix III: LMC Topic Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
iv
Clinical Engagement primary care leading by design
1National Leadership and Innovation Agency for Healthcare
Executive Summary
Introduction
This report sets out the key fi ndings of an extensive programme of academic research
commissioned by National Leadership and Innovation Agency for Healthcare (NLIAH) in Wales
to explore Successful Strategies and Mechanisms to Infl uence and Improve Clinical Services
provided General Practitioners and the issues that surround these in relation to supporting the
practical ongoing changes outlined in the Welsh Assembly Governments Designed for Life
agenda. The work was led by CRG Research Ltd, a research and evaluation consultancy, with
support from Professor Glyn Elwyn, from Cardiff University. The report provides an overview of
the policy context within which NHS service developments currently sit, specifi cally looking at
the literature surrounding clinical engagement. It goes on to examine the fi ndings from a series
of interviews with Local Health Board (LHB) Medical Directors, Local Medical Committees
(LMC) and a series of National Stakeholders to explore the issues surrounding engagement
within Wales. It specifi cally examines engagement in relation to the following priority areas:
referrals
prescribing practice
chronic conditions management, and
postgraduate education.
The report also highlights a series of case studies from both the literature and the interviews,
which provide illustrative examples of how engagement can be practically addressed.
Findings
The main fi ndings of the report demonstrate the lack of clarity surrounding clinical engagement
within Wales somewhat surprising given that it is a central tenet of the Designed for Life
Agenda. This lack of clarity extend particularly in relation to what it is, what it is supposed to
achieve and how best to proceed in developing it. Most importantly it is clear from the research
that there are 3 different perceptions of what clinical engagement should be that of the policy
maker, the LHB and the GP leading to confusion and in some case barriers to developing
services further. It is essential that common ground is actively explored and sought in order to
continue to promote service improvements across Wales.
This, however, must be taken a stage further and developing clinical engagement should form
a strategic part of service development within Wales in order to achieve the changes and
developments required to produce a modernised NHS. Yet LHBs face a number of obstacles
Executive Summary
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3National Leadership and Innovation Agency for Healthcare
in successfully engaging GPs including cultural and political differences, a lack of strategic
direction in relation to how engagement can be developed, limited fi nancial incentives and
variations in the level of fl exibility that Medical Directors are given to develop this further
including the opportunity to move resources from secondary care to primary care when
savings have been achieved.
However, LHBs do have a range of tools at their disposal including:
developing opportunities for open dialogue with GPs and other Practice based staff
through forums, networks and developing clinical leadership locally
providing incentives (and sanctions) to engage GPs interest
freeing up resources to provide local and individual support such a local managers to
liaise with specifi c Practices
gaining support from within the LHB at an Executive and Board level to promote
developments
developing a plan for engagement which builds on strategic priorities, and is inclusive
and realistic, and
ensuring there is ample opportunity to develop an evidence base for action.
Specifi c examples of these are outlined in more detail within the main body of the report.
In addition to the above, several models for engagement exist, including Arnsteins ladder of
engagement (1969), which can be adapted for the clinical setting to ensure:
clarity of purpose for engagement through consultation and open dialogue
an agenda that has relevance to the needs and priorities of participants on both sides
through regular interaction and discussion
the absence of any hidden agenda maintained by the relationships developed through
points (i) and (ii)
recognition of the problems and aspirations of participants and a willingness to try and
address these at least by meeting participants half way
being able to feel there is openness to ideas and innovation by ensuring that these are
developed within the agenda proposed in point (ii)
participants having decision-making powers through direct involvement in planning
processes and activities
participants being able to see tangible outcomes as a direct result of their engagement
.encouraging feelings of ownership in participants by allowing them to contribute and
develop initiatives as they expand and grow.
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Conclusions
The report concludes that developing a more considered approach to engagement that
clearly ties into a shared agenda for modernisation is necessary to ensure the second of the
Strategic Frameworks of the Designed for Life Agenda can be met. Taking a broader, more
holistic approach to engagement could reap substantial benefi ts by supporting wider changes
within the NHS and, through dialogue with GPs and other Practice staff with changes and
developments, it will help to infl uence and improve services overall.
Although there are no fool-proof mechanisms of engagement LHBs should be looking towards
Clearly defi ning the purpose of engagement at the very start
Developing a strategy for engagement which can be explained to its members and
GPs
Ensuring the strategy takes into consideration the view points of the GP, the policy
maker and the LHB
Agreeing what the problem is prior to trying to solve it
Recognising that payment although important is only one of a set of tools to
engage GPs and it must be supported by other activities
Developing a continuous cycle of engagement which involves communication,
refreshing formats and feeding data back to GPs. Most importantly it must celebrate
success.
i.
ii.
iii.
iv.
v.
vi.
Executive Summary
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Clinical Engagement primary care leading by design
5National Leadership and Innovation Agency for Healthcare
1. Introduction
1.1 This report sets out the key fi ndings of an extensive programme of research
commissioned by National Leadership and Innovation Agency for Healthcare (NLIAH)
in Wales, to explore Successful Strategies and Mechanisms to Infl uence and Improve
Clinical Services provided General Practitioners and the issues that surround these.
The research was led by CRG Research Ltd, a research and evaluation consultancy,
with support from Professor Glyn Elwyn, from Cardiff University.
1.2 NLIAH was launched in March 2005, with the specifi c remit to provide strategic
support for the NHS in Wales, through building leadership capacity and capability
to secure continuous service development, underpinned by the optimum use
of technology, innovation, leading-edge thinking and best practice to deliver the
service change agenda. As part of its key enabling role, NLIAH has completed
Modernisation Assessments in all healthcare organisations, who in turn are
developing collaborative Designed for Improvement plans to improve services for
patients within their communities. This forms an essential part of the Designed for
Life agenda, set by the Welsh Assembly Government, to develop a world class health
and social care service for Wales. Based on 3 Strategic Frameworks, the Designed
for Life strategy sets out a challenging vision for change requiring a new approach
to healthcare, through joined-up thinking, partnership and above all a commitment to
quality service provision that continues to mature as the plan progresses.
1.3 Much of the change outlined in Designed for Life requires more focus on the local
needs in every community, with user-centred services that reduce the barriers
between services and increase integration at every point. Ultimately this means
implementing practical changes to improve the service provided at both a primary
and secondary care level, however, to do this effectively requires some essential
groundwork to ensure that these changes happen as smoothly and effi ciently as
possible and are based on best practice. One such building block is effective clinical
engagement with GPs in the areas of prescribing, referrals, unscheduled care and
chronic conditions management on the basis that if GPs are engaged in service
development then changes and improvements in these four key areas will be realised.
However, there is much confusion as to what clinical engagement actually is, what
it is trying to achieve (i.e. its purpose), and understanding the processes involved in
developing and supporting it is essential to enable the LHBs to move forward in this
area and forms the basis for this research report.
Our Approach
1.4 The agreed work plan was to:
draw out areas of evidence based best practice of clinical engagement nationally and
internationally through an extensive literature review, exploring the context and impact
of these models particularly in relation to prescribing, chronic conditions management,
unscheduled care and referrals
to map activities in the 22 Local Health Boards (LHBs) across Wales through interviews
with Medical Directors, LMC Chairs and relevant stakeholders
sample 4 LHBs for the development of short case studies.
1.5 Considerable efforts were made to contact Medical Directors and LMC Chairs.
However, there were diffi culties in accessing both groups in relation to their availability
and willingness to participate within the allotted timescale. Table 1 presents a
breakdown of sample sizes and levels of responses.
Sample Size Number of responses
Medical Directors 22 11
LMC Chairs 5 3
Key Stakeholders 2-3 2
1.6 Nevertheless, participants were well-informed and knowledgeable, providing in-
depth answers to questions wherever possible. Throughout the research, interviews
were carried out on the assurance that the information provided would be treated
confi dentially: no comments or individual views have been directly attributed and no
attribution should be inferred.
1.7 It is hoped this study will help support the development of clinical engagement within
Wales, by providing:
a contextual overview of key primary care developments within Wales and England
and the importance of clinical engagement in supporting these
providing examples of what constitutes effective clinical engagement and how this is
obtained based on the fi ndings of the literature review
a discussion of the main themes arising during the programme of interviews, and
a framework for clinical engagement based on the above.
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7National Leadership and Innovation Agency for Healthcare
1.8 The remainder of the report is structured as follows:
Section 2: Background & Context
Section 3: England & Wales: Different Perspectives
Section 4: Theoretical Perspective Application to Engagement
Section 5: Findings Interviews
Section 6: Clinical Engagement Practical Application
Section 7: Conclusions
1.9 The research team are very grateful for the advice, information and support from
the participating LHBs, LMCs and stakeholders throughout the research and would
like to thank NLIAH for their input during this piece of work. Any remaining errors or
omissions within the report are the responsibility of CRG Research Ltd.
2. Background & Context
2.1 Given that one of the main purposes of the literature review is to explore the concept
of engagement with reference to general practitioners (GPs), it would seem useful to
do two things at the outset:
offer defi nitions of engagement with a view to identifying and describing the detail of
process mechanisms, and
highlight some of the reasons for the current interest of LHBs in the engagement
of GPs.
2.2 Dictionary defi nitions of engagement for example, refer to terms such as gaining
interest, holding someones attention, involvement, participation and commitment
(Penguin 2000; Sykes 1975) which suggests a progressive aspect to the concept.
This has been confi rmed in a seminal paper by Arnstein (1969) that remains resonant
today. The paper describes a ladder of engagement, which differentiates the level
of involvement between the lower and higher rungs. In the former, there is little more
than the appearance of engagement; opportunities for active involvement are few
and sometimes inhibited by manipulative behaviours from those in more powerful
positions. It is only by reaching the higher rungs of the ladder that mechanisms
refl ecting real rather then quasi involvement begin to appear between the parties
concerned, such as:
clarity of purpose for engagement
an agenda that has relevance to the needs and priorities of participants
the absence of any hidden agenda
recognition of the problems and aspirations of participants
being able to feel there is openness to ideas
participants having decision-making powers, and
feelings of ownership.
2.3 Although the above paper was concerned with factors infl uencing citizen participation,
Arnstein had also been involved in many of the changes affecting medical education
and healthcare in the USA and there is evidence that the principles identifi ed by
the ladder, were successfully utilised in different contexts making them likely to be
relevant to this review.
2.4 The introduction to this report already indicates the signifi cance of engaging GPs in
order to promote new working practices and support networks, and for developing
mechanisms to improve specifi ed clinical services. Designed for Life (WAG 2005)
states that It is diffi cult to overstate the importance of LHBs and their clinicians
engaging with each other with particular reference to devolving more and more
i.
ii.
1. Introduction
8
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9National Leadership and Innovation Agency for Healthcare
decision-making powers to organisations on the front line. There is also reference to
the need for better arrangements for clinical engagement and that it should amount
to more than a vague sense of belonging and that it must encompass not only
GPs but also nurses, primary care practitioners and allied health professionals. The
engagement of clinicians is also linked to change management in several sections of
Designed for Life where again reference is made to the signifi cance of the role of GPs
in quality improvement and in the development and evaluation of new clinical models
of care, where a transfer of budgetary control would be expected.
2.5 The 2005-2006 Modernisation Assessment (NLIAH Wales 2006) provides a number
of engagement examples. While these are without any details of the processes or
mechanisms involved, a number of reasons are given to explain why the effective
engagement of clinicians is essential and these are repeated throughout the report:
clinicians need to be at the centre of change so their engagement is critical
identifying and involving clinical leaders is essential because they have the vision to
see what needs changing and the experience to know the source of actual or potential
barriers to change
the clinical perspective cannot be disengaged from the goal of sustainable
improvement in healthcare, and
the implementation of change will have only limited impact without engaging clinicians
making this process critical for the future of the NHS in Wales.
2.6 In summary, the engagement of clinicians is signifi cant for the future development of
the NHS; it incorporates graded mechanisms which, in the context of NHS reform, are
diffi cult to separate from implementation and change management. The engagement
process appears at fi rst to comprise mechanisms often assumed in reported
examples of involvement, resulting in the absence of any detailed description.
Nevertheless, a proper understanding of the mechanisms involved is essential since
the Modernisation Assessment mentioned above, also states that there has been a
failure to implement evidence based best-practice guidelines for improvements and
reform. It is in the context of reform that it becomes worth reviewing areas of NHS
history and policy development, particularly the roles of primary care and the GP,
which can contribute to an improved understanding of what works well/not so well,
with reference to GP engagement.
Health Policy and Clinical Engagement
2.7 Much of the shape of primary care within the NHS today is the result of a range of
factors including:
the professional and policy developments prior to and from the birth of the NHS in 1948
the most relevant being the tri-partite system which until relatively recently allowed
GPs to work independently, with no requirement to consider the resource implications
of their referral and prescribing decisions (Wyke, Mays et al 2003). It also gave health
authorities a separate responsibility for public health and arrangements for health/
social care of children and those with mental health problems
the impact of devolution which created opportunities for policy diversity, and
signifi cant changes to the GP contract - problems having emerged from the 1990
contract and the profession advocating greater fl exibility in workload, in order to
incentivise the improvement of services and enable more appropriate care for patients
with complex needs (RCGP 2007). The old contract was also said to have inhibited
the development of new services, restricted career progression and made general
practice a less attractive option for newly qualifi ed doctors.
2.8 Successful strategies and mechanisms to infl uence and improve the services provided
by GPs must inevitably sit within the existing framework in which GPs and LHBs
currently have to work, and it is worth spending a little time exploring the background
to the current political context which sets much of the scene for the primary research
fi ndings.
Health Policy from the 1980s onwards
2.9 Towards the end of the 1980s, the Conservative Governments White Paper Working
for Patients (1989) fi rst introduced the internal market and together with the separation
of responsibilities for purchasing and providing health care, the general practitioner
fund-holder was also introduced. The internal market had three main objectives:
improved effi ciency through market mechanisms and better productive processes as a
consequence of increased local responsibility
improved effectiveness by purchasing processes designed to ensure service
specifi cations were appropriate for identifi ed need, and
increased clinical accountability.
i.
ii.
iii.
2. Background & Contaxt
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Clinical Engagement primary care leading by design
11National Leadership and Innovation Agency for Healthcare
2.10 As well as the need to be able to draw up a clear service specifi cation, the purchaser/
provider split required an assessment of population health needs, as the basis for
commissioning. However, there is little evidence that the necessary skills, or relevant
data for commissioning were available at the time, or that any signifi cant difference to
the quality of provision, or to a reduction in health inequalities was made (Le Grand
et al 1998; Propper et al 2002). This probably needs to be seen as a system failure
rather than the particular responsibility of individuals and suggests the presence of
substantial gaps in up-to-date and reliable information and the necessary expertise
necessary to deal with the policy requirements.
2.11 It was suggested for example, that one of the major barriers to the development of
fund-holding was that a market system had been injected into a hierarchical and
paternalistic institution in which the providers were able to exercise veto power over
change, even though the NHS was centrally funded, directed and accountable. So
although aspects of effi ciency improved, administrative and management costs
increased with no evidence of any deliberate selection processes, or evidence that
it was less costly (Hann 2000). The NHS continued to be managed and regarded as
a public service rather than developing a business perspective, which might have
included addressing the question of what should/could be provided, within a national
budget. Concerns for equity were also raised and became linked to the so-called
two tier system where it was assumed that patients of GP fund-holders received
preferential treatment an assumption borne out by subsequent evidence, although
The Independent view in February 1997 was that the Thatcher-Clarke reforms GP
fund-holding and the quasi market were neither pernicious nor notably effi cacious
(Le Grand et al 1998).
2.12 Given the lack of any comprehensive evaluation very little reliable evidence emerged
from the early fund-holding experiences and local policy makers and managers
adapted the outlines provided in Working for Patients (1989) to suit local concerns.
But there is little doubt that GP fund-holding had been advantageous for some
patients (Dowling 1997) as it was inevitably inequitable for others (National Audit
Offi ce 1995). It is also worth noting that fund-holding did provide some introductory
experiences of business perspectives for a proportion of GP practices in Wales and
that means that with reference to engagement mechanisms, their attention had been
gained by the concept of fund-holding and they became involved in planning and
decision-making.
2.13 By the early 1990s, an increasing recognition of problems and issues facing health
service providers across the industrialised world was evident, having its roots in
concerns about escalating costs (Saltman & Von Otter 1992). The rising burden of
chronic disease generated by an ageing and diverse population for example, has
been described as the greatest challenge to health care in the UK and comparable
countries underlining the need for growth in primary care capacity (Yach et al 2004).
Other factors that were particularly relevant included:
the need to adopt a broader approach which takes account of social and cultural
factors and inequalities in health
changing relationships between patients and health care professionals, and
the widening gap between the demands made upon health-care services and the
resources available.
2.14 Attempts to improve the management and effi ciency of the NHS during the Thatcher
years had not really included a similar level of interest in improving the outcomes of
clinical care. Dawson (2001) suggested that the NHS at that time became much more
effi cient at providing health care, without knowing the extent to which the care given,
made any difference to health status and on that basis refl ected a signifi cant gap in
quality standards. It is also worth noting that attempts to defi ne quality in the NHS at
that time, included phrases such as things that work; things that people want and
getting things right fi rst time (DoH 1998a) indicating concerns for an evidence base,
for patient involvement and for a level of competence that is both effi cient and reduces
risk.
2.15 In 1997, New Labour emphasised both quality and partnership working in its policies.
Amongst the priorities of the Labour government were three health policy areas
which not only had considerable impact across the UK, but from the outset generated
tensions:
political devolution to Scotland, Wales and N. Ireland
organisational reform with emphasis on standards and targets, and
a more pragmatic approach to policy formulation and implementation.
2.16 Tensions existed because on the one hand uniform one nation policies were being
stressed through new institutions such as the National Institute for Clinical Excellence
(NICE), although this applied only to England and Wales; while on the other hand,
local targets and local responses to particular circumstances were being encouraged
through developments in primary care (e.g. the GMS contract of 1990 had included
minor surgical procedures; encouragement to develop computerised data systems
and working with other agencies and health professionals to achieve integrated care).
There was also little overall agreement about focusing on primary care at this time
and some hesitation about launching into major NHS reforms so soon after the 1991
reforms.
2.17 The NHS Plan (2000) set aspirational targets for improving care, but with an emphasis
on reducing waiting times. The overall philosophy marked a clear shift away from
competition within an internal market and towards partnership between agencies;
2. Background & Contaxt
12
Clinical Engagement primary care leading by design
13National Leadership and Innovation Agency for Healthcare
and although collaboration between health and social services was not new (child
protection, mental health, disability) it was to provide an alternative perspective to
the internal market, even if the distinction between purchasers and providers was
to remain. Amongst the key principles of the NHS at that time, was seamless care
within the community, readily available information to promote greater individual
responsibility for health maintenance and prompt access to hospital based specialist
services. Emphasis was also placed on tackling unfairness, unacceptable variation
and the two-tierism of the internal market (Peckham & Exworthy 2002). Funding was
also directed to the establishment of NHS Direct and to fast track cancer services.
2.18 With regard to GPs, the work of the GP is often used synonymously with primary
care but the latter has a much wider framework and includes the roles of dentists,
pharmacists, community psychiatric services, dieticians, physiotherapists and
incorporates the role and function of social services. The Alma-Ata declaration (WHO
1978) sets primary care within the even wider framework of the social and economic
conditions of a community. For all practical purposes, the signifi cance of the GP role
has traditionally been in the personal nature of a medical generalist, knowledgeable
about a wide range of conditions that do not reach a specialist; in the fi rst point of
contact with the NHS and as the gatekeeper to secondary care. In reviewing the
defi nition of General Practice adopted by the RCGP in 1977, the Welsh Council
RCGP and Welsh GMSC in 1994 re-emphasised the importance of the core team in
the delivery of services members of which may now be quite diverse.
2.19 The New NHS provided the framework for a range of changes in the organisation of
primary care, including new career pathways for GPs such as the development of
the GP with special interests which had the potential for increasing their infl uence
over shaping the development of local primary care services allowing them a more
signifi cant role in primary care development in the context of the NHS Plan and the
more recent proposals for redesigning the NHS. An updating of a 2004 paper on the
subject of GPs with special interests, (RCGP January 2006) referred to opportunities
for specialist clinicians to treat chronic conditions within community settings, to prevent
complications that lead to hospital admissions and to reduce hospital waiting lists in
specifi ed areas such as dermatology and ophthalmology. The RCGP Information
Sheet also included a number of completed clinical frameworks and sources of
guidance about accreditation and implementation. Although in relatively early
stages of development, the role of the GP with special interests appears to provide
opportunities for both career and professional development that will contribute to
extending primary care services; the necessary arrangements for such appointments
in Wales were formalised in an Assembly Health Circular (2005).
2.20 Moreover, the introduction of Primary Care Groups/Local Health Groups meant GPs
were given the responsibility of achieving health gains within a local community and
addressing inequality (a tall order when considering the growth of the health divide
and the complexity of interactions likely to infl uence health Kunitz 2001). Improving
the development and integration of primary care and community health services,
and subsequently, becoming involved in the commissioning of hospital and specialist
services soon, however, appeared on the agenda (DoH 2002).
2.21 The introduction of the new contract in 2004, also led to some fundamental changes
with GPs asking for:
their responsibilities to be clarifi ed
the choice of opting out of providing some services
workload limits
resources to be allocated according to locally identifi ed need, and
quality care to be rewarded (Marshall & Roland 2002).
2.22 Two major shifts appeared in the new contract. The fi rst was that having had a near
monopoly of medical provision within primary care since the beginning of the NHS,
there was now a separation of services into three categories (essential, additional
and enhanced) which provided GPs with opportunities to limit demands by opting
out of (a) 24 hour cover, (b) immunisation (c) chronic disease management and (d)
contraceptive care. In essence this means that where GP practices choose to opt
out, the local PCT/LHB would have no alternative but to fi nd alternative providers,
with not altogether reliable predictions, that this would not prove to be a problem.
2.23 The second shift of emphasis was the dependence on quality rather than quantity
for income, with a particular focus on rewarding the quality aspects of chronic
disease management where the evidence suggested wide disparity between what
was currently provided and what could be provided (Seddon et al 2001) and that the
targets set had the potential to improve health outcomes (McColl et al 1998).
2.24 The view of Marshall and Roland (2002) was that substantial changes would be
necessary to achieve quality payments (comprehensive computerisation, increased
use of clinics, and probably specialisation within practices). They also argued that this
contract had the potential to sideline some of the core values of general practice
(including autonomy, personalisation and generalist care) and that continuity of care
would be more diffi cult for some patients. The targeted approach for example, that
becomes necessary to achieve maximum QOF points, can improve some quality
standards while reducing others such as personalised continuity a core value of
general practice (Windridge et al 2004). Other questions have included the degree to
which this contract provides a rewarding and fulfi lling career; whether it creates a new
challenge without losing core values and whether it has been priced inappropriately
2. Background & Contaxt
14
Clinical Engagement primary care leading by design
15National Leadership and Innovation Agency for Healthcare
leading to predictable fatigue and to progressive dilution. There is little doubt that the
current emphasis of any GP practice would be gaining the optimum quality points, which
may in the event infl uence their interest in engaging in areas of interest to an LHB.
2.25 Nevertheless, the politics of health care inevitably involves decisions to do with
taxation and the selection, utilisation and management of fi nite resources. However,
unlike other European countries, the UK seems to have avoided any public debate
about what should be available within a publicly funded NHS although the media
has highlighted political and other opinions about what should NOT be funded and
there are certainly some public wants that need further review. Continuing advances
in medical knowledge, bio-technology and communication systems have not only
contributed to the escalating costs of health care but also to the need to obtain a
balance between competing demands such as those of an ageing population, those
of parents for the technological advances in the care of the newborn, those with
signifi cant disability or those of carers supporting individuals with a signifi cant mental
health problem. Where the debate has taken place however, there are mixed views.
For example, Joan Higgins (2007) has argued that a variety of agencies should
be allowed to commission, allowing patients to chose on the basis of the services
provided while also driving a demand for better information about treatment
options, clinical outcomes and cost. David Hunter (Professor of Health Policy at the
University of Durham) does not agree that the provision of various providers is the
way to enhance patient choice saying that choice is wasteful of scarce resources
and that it is not what people want, despite what ministers insist: He argues that
personalisation is much more important than choice (ibid) a potentially signifi cant
concept for modernisation in the delivery of medical care within a primary care setting
where new contractual arrangements can potentially make it more diffi cult for some
patients to gain access to a doctor of choice or to achieve continuity of care.
2.26 The concept of value for money represents a particular kind of response to problems
about how best to allocate scarce resources not about adopting the cheapest method
but about obtaining the optimum benefi ts within a budget and paying due regard to
opportunity costs when resources are shifted away from one kind of provision to another
(Drummond & Maynard 1993). A more rigorous fi nancial environment is now embedded
within current service goals and staying within a budget is at the heart of current
policy at least in the short to medium term. A new model of provision will inevitably
generate new problems while attempting to deal with older ones, such as how best to
contain demand and perversely, Hospital Trusts have incentives to maximise activity,
while leaving LHBs/PCTs without the necessary clout to make tough decisions about
shifting the balance of resources. The escalation of fi nancial defi cits in the NHS, despite
substantial budgetary increases, certainly indicates a lack of capacity to use fi nancial
resources well, although there have been major improvements in cancer care, accident
and emergency services and patient waiting times (Chief Executive NHS 2006).
2.27 In an overview of some current issues, it was the improved understanding of the
interplay between organisational systems within the NHS, that had helped to illuminate
the contribution of systems to the development of some undesirable risky and
adverse events (DoH 2000b) and the recognition of why and how cultural changes
would be critical for properly addressing the evidence of existing inadequacies (DoH
2000a). Examples of these inadequacies included complex hierarchical and infl exible
working environments that have contributed to the failure to improve quality; and
the separation of professional groups, that has prevented the proper integration of
health and social care. Community care policies across the last two decades have,
for instance, highlighted the need for services and professionals from the NHS and
Local Authority social service departments to work together more effectively; but the
divisions between health and social care provision have remained contentious, with
detailed concerns about ineffective care at the interface evident in The New NHS
Modern and Dependable (DoH 1997). From this perspective, future quality markers
for service delivery might be expected to include interface factors such as having
a shared vision of purpose, co-terminosity within the management structure, the
manner in which a service is delivered and perceived, as well as aspects of internal
and external communication, including the quality of interpersonal relationships and
teamwork. Again, quality became a central theme of the NHS modernisation agenda
(DoH 1998a) and the phrases here included standard setting evident in the National
Service Frameworks; clinical and cost effectiveness evident in the work of NICE
and in concerns to increase patient satisfaction, including the degree to which the
experience of the health service had been a positive/negative one.
The importance of effective engagement on Policy Developments
2.28 Throughout its existence, the NHS has been in an almost a constant state of
change, with a range of initiatives designed to improve services, utilise resources
more effi ciently, overcome staffi ng shortages and develop innovative methods of
treatment and health care. Yet, fi nding mechanisms to encourage buy-in and support
the successful implementation of these changes has proved diffi cult. For example,
in 1997, the Labour Government chose one way to overcome the inequity evident in
fund-holding by modifying the concept and making it universal via the introduction of
Primary Care Groups/Trusts. Not only did this require all GP practices in England and
Wales to become involved with budget-holding organisations in one way or another, it
also provided many examples of GPs willing to become engaged in Total Purchasing
Pilot Initiatives (TPPIs) with evidence of them wanting to exert some infl uence over
service developments (Bosanquet et al 1996; Walsh et al 1999).
2.29 In reality, the TPPIs had goals and motives that were not directly related to the
purchasing of secondary care and by the end of the fi rst year nearly half the TPPIs
were using their pilot status to modify primary and community care services: some
2. Background & Contaxt
16
Clinical Engagement primary care leading by design
17National Leadership and Innovation Agency for Healthcare
GPs took the opportunity to provide a range of specialist out-patient services
themselves, or to introduce new services at the practice (Mays et al 1998). There was
also evidence that TPPIs were able to achieve increased integration between primary
and secondary care and/or between primary care and community and social services
provision.
2.30 While the evidence in reports focused on how and what services were changed, with
what results, rather then the mechanisms of engagement per se, there was certainly
evidence of gaining and holding the interest of GPs and of giving them decision-making
freedom a critical element of the engagement ladder. Many of these developments
incorporated elements of case or care management mentioned elsewhere in this
review and much of the reported achievement appeared to be linked to:
determined leadership
the acceptability of the context
good information systems
the clarity and content of objectives
the mechanisms selected to achieve goals, and
the organisational capacity of the individual TPPI those with more experience and in
a position to be more supportive, were more likely to achieve goals.
2.31 However, equally as interesting from an engagement perspective were the reasons
given to explain the relatively low overall impact of the TPPIs, including the small
number of practices involved and the unusual nature of the project, which had lent
itself to some misinterpretation. In the NHS for instance, some saw it as a refl ection
of uncertainty and no-one made it clear that this was an opportunity to learn from
experimentation. Pilot status, for example, allowed acute hospitals to resist change
successfully and some local authority managers were concerned about viability threats
to local services, all underlining important issues associated with planning, the clarity
of communication and a power-base able to shift resources. But as Wyke et al (2003)
pointed out what is remarkable is not that few signifi cant changes were made, but
that a few GPs were able, with great skill and drive, to negotiate real change.
2.32 A more recent example of how freedom and ownership can be effective in involving
GP practices in service development in this case achieving improvement in
referral processes - was reported in the Health Services Journal (Alessi 2007). GP
practices in Kingston (South London) decided that support was needed to develop
practice-based commissioning (PBC) so they set up and funded a not-for-profi t
umbrella co-operative with a Medical Director, whose role included the over-seeing
of referrals to secondary care stating that All referrals that go to hospitals within the
area covered by the co-op, go through a common source where they are clinically
triaged and if referrals are incomplete or inappropriate, they are bounced back.
Of particular interest is that most of the work undertaken by the co-op deals with
secondary care referrals, re-directing follow-up and out-patient appointments to
primary care. Dr. Alessi reported that the system has worked well not least because
GPs feel it belongs to them and that The move has improved GPs engagement in
commissioning and their relationship with the PCT and local hospitals.
2.33 The above examples, while without any detail of engagement mechanisms, indicate
that effective steps in the initial stages of the engagement process include:
clear information in this case, about current policy developments relevant to the
future of general practice
an agenda that provides opportunities for GPs to decide for themselves to ensure
commitment and feelings of ownership, and
identifying the resources necessary for planning change.
2.34 In a comparable context, the potential spin-offs of this kind of process, might include
successful partnerships with other agencies; benefi cial re-structuring of the primary
care team, improved through-put for referrals; improved relationships at the interface
between primary and secondary care and extending the range of primary care
services with integrated health and social care arrangements in place.
In summary
Policy developments openly acknowledge the central role of general practice for the
new NHS, emphasising the role of professional leadership to support change
The new GMS contract indicates a signifi cant shift away from the traditional provision
of primary care with the need for a change in perspective to optimise the contribution of
general practice for the reconfi guration of the NHS
The literature provides insuffi cient detail to identify mechanisms used for engaging GPs
although aspects of implementation suggest particular processes for their effective
involvement
Translating engagement across these different levels and structures within the NHS is
diffi cult and linking the engagement process with policy development raises a number of
signifi cant issues including:
Access to quality evidence
The role of professional leadership
Assessing contextual factors and delineating what seems best for patients and is likely
to be achievable
Clarity with regard to purpose and goals
Freedom for clinicians and GP practices to make decisions that are relevant to local need
Organisational and cultural diffi culties which prevent effective integration of health and
social care and infl uence the interface between primary and secondary care
The need for radical responses to ensure future sustainability of the NHS.
2. Background & Contaxt
18
Clinical Engagement primary care leading by design
19National Leadership and Innovation Agency for Healthcare
3. England & Wales: Different Perspectives
3.1 The ongoing policy changes since the 1980s in both England and Wales, particularly
the implications of the more recent Wanless Report (2004) for reconfi guration and
reform, mean that motivational incentives and market mechanisms have been re-
visited in the recognition that engaging and supporting primary care has become
essential in terms of:
improving the quality standards of clinical practice and reducing inequity
reducing the workload of secondary care by moving tasks into more appropriate levels
of provision within primary care
progressing the interface between health and social care to ensure integrated provision,
particularly for those with long-term chronic medical conditions, those with signifi cant
mental health problems, those in need of community based palliative care and those in
older ages groups who are frail and at risk of a sudden breakdown in health.
3.2 Placing increasing levels of public choice and end-user involvement at the heart
of the NHS necessitates the substantial reconfi guration of services, requiring the
commitment and talent of the individuals working within healthcare. However, given
the diversity of the NHS not only across specialities, but organisations and now
across devolved countries developing effective mechanisms to do this has proved
diffi cult. The advent of devolution and increasing powers of the Assembly Government
- to reform and restructure the NHS in Wales and place more emphasis on local
solutions - has meant substantial differences in delivery and service development
when compared with other parts of the UK, presenting a number of challenges, but
also several opportunities such as cherry-picking best practice for engagement and
implementation from other areas and other countries.
3.3 Understanding the contextual differences between England and Wales (most notably
the role of PBC and the impact of the revised GP contract) may provide insights into
how the issues surrounding GP clinical engagement could be addressed particularly
in relation to prescribing, referral management, chronic conditions management and
unscheduled care. This section provides a brief overview of the current situation in
England and Wales and goes on to discuss the role of the GP within the NHS.
England: Current Developments in General Practice
3.4 In England, The NHS Plan (DoH 2000b) had provided for an expansion in primary
care but it also provided a framework for service development based on the principles
of access, patient information and public involvement, together with an expansion of
high quality services, modernisation of primary care settings, continuing education
and training and addressing health inequalities. A signifi cant element of policy
development was the need to ensure a more effi cient response to the needs of
specifi ed vulnerable groups and managing their continuing care as far as possible in
the community.
3.5 A shift of emphasis was clearly evident in the DoH document Creating a Patient Led
NHS (March 2005) which pointed to changes in the function of Primary Care Trusts
(PCTs) and Strategic Health Authorities (SHAs). Local communities were to work with
SHAs to consider the roles and responsibilities of different organisations in the area,
the three priorities being:
reducing inequality and promoting health improvement
securing safe and high quality services for the population, and
emergency planning.
3.6 There was also a commitment to develop the commissioning process, aimed largely
at increasing the range of primary and community services available, improving the
management of referrals between primary and secondary care and ensuring that
SHAs and PCTs were fully prepared for their new roles, in a similar way to those from
NHS Trusts. However, if most were either insuffi ciently experienced or inadequately
prepared for their roles in the fi rst place, it is not very clear who was going to be in a
position to undertake this preparation, unless agencies were to be involved from the
private sector.
3.7 There is very little reliable information about the effectiveness of new models
of commissioning services, or on whether apparently comparable international
programmes can be replicated in the rest of the UK (Singh 2005). By 2006 there had
been a reduction in Primary Care Trusts in England from 302 to 152 and Strategic
Health Authorities from 28 to 10 (Hawkes 2006), mainly to attain a more effi cient
population base for planning, provision and administration. Although PBC was
introduced into England in 2005 (alongside the introduction of payment by results)
the DoH (2004) notes on engaging practices in the commissioning process, provided
little more than an explanation of its overall purpose, as well as the allocation and
forfeiting arrangements for the budgetary processes: an initial assumption that there
would be no diffi culty in engaging GPs in developing commissioning processes, or
evidence that communication about purpose, opportunities, processes, potential
i.
ii.
iii.
3. England & Wales: Different Perspectives
20
Clinical Engagement primary care leading by design
21National Leadership and Innovation Agency for Healthcare
benefi ts to patients, was inadequate. Poor communication about the purpose of Trust
action in Sunderland for example, seems likely to account for the local uproar in 2006
after a GP left his position as principal in a comfortable neighbourhood in 2004 to
become a salaried GP in a practice that had relied on locums for 30 months. After
successfully turning the practice round in terms of standards and meeting patient
expectations, he found that the Trust had decided to put the practice out for tender,
including private enterprises and large healthcare organisations (Kmietowicz 2006).
This suggests that:
patients do not have as much choice as they thought 1200 signatures (practice
population under 4000) were obtained in 3 weeks in support of retaining their new GP
communication about the remit of alternative provider medical services had not had
suffi cient clarity, and
there had been insuffi cient engagement between the PCT and GP leaders certainly
insuffi cient opportunity to suggest alternatives to meet the stated objective of the PCT,
which was to move the practice into independent status.
3.8 Advice about techniques for PBC, alongside evidence of a shift away from evidence
based practice, towards concerns about the design of services, appeared
subsequently in Care and Resource Utilisation (DoH 2006) where again the
signifi cance of commissioners working with their PCT was underlined with reference
to clinicians being in the best position to ensure patients being treated in the right
place at the right time; as well as ensuring that suffi cient alternatives to hospital
admission exist within primary care or the community. Best practice in these areas
was seen very much in the developmental stage and although largely concerned
with increasing effi ciency, success is linked to clinical engagement and rather oddly
to gaining ownership of clinicians. With regard to the process of engagement the
language used adopts very simplistic principles such as:
clinical engagement can be ensured by inviting clinical representation early in the
process
information requirements will ensure that adherence can be identifi ed, clear and
agreed
processes will be described
potential benefi ts to patients will be outlined
issues will be discussed, and
the most appropriate intervention must escalate the issue.
3.9 Given this guidance it would be diffi cult to assume that the important upper rungs of
the ladder of engagement mentioned in Section 2 are in evidence. However, clinical
leadership, clarity, good relationships, good communication systems and building
i.
ii.
iii.
primary care capability/capacity are mentioned elsewhere in the document as critical
for successful implementation.
3.10 By July 2006 Ministers were claiming practice based commissioning in England was
surging ahead in the face of fi gures showing that around only 40% of Practices had
taken it up (DoH Press Release July 2006). Moreover, many GP Practices had done
no more than take up an inducement of 95p per patient to produce a commissioning
plan with Pulse (July 6:1) reporting one GP saying that this required no more than
an evening and a couple of sides of A4. By the end of the month however, 65%
of Practices had achieved this initial step, although an indicative budget with costs
and potential savings had only been made available to about 20% of Practices
somewhat limiting the practical benefi ts of the exercise (Comerford 2006). However,
given that 70% of any savings would go straight to the commissioning Practices, there
seemed to be little incentive for PCTs to invest further resources in promoting the
involvement of GPs, with so little for them to gain in relation to their own budgetary
control requirements. It has also been said that while Hospital Trusts remain in
the driving seat, determining the speed and direction of such changes, policy
development will continue to remain in the hands of organisations already found
wanting highlighting the apparent inability of PCTs to shift resources between the
different contexts of provision (Hawkes 2006).
3.11 Further development of PBC has led Jones and Lakasing (2007) to argue that the
term PBC has become a misnomer given that PBC is now the same size as the
recently deceased PCTs and runs the risk of inheriting all the weaknesses that
contributed to their demise including:
limited clinical involvement
weak leadership and decision-making, and
poor fi nancial management relative to commercial practice (Audit Commission 2006)
3.12 Berwick (2007) however sees tremendous amounts of progress in eight years of
modernisation citing more reliable care for some clinical conditions and signifi cant
reductions in waiting times. He argues that policy reform since 1998 should be seen
as temporary and experimental, leading to modifi cation or abandonment; and that
experimenting with alternative suppliers leads only to rapidly rising costs without
much value for patients. He also sees huge potential for integrated care adding value
to service provision and expresses his disappointment that so far this has not been
captured by the NHS reforms or the GP contract. Of special interest is his emphasis
on the development of relationships between clinicians and nurses and between
managers and clinicians so that collaborative thinking leads to collaborative patient
management between primary and secondary care. Again such arguments point
to the importance of articulating the detail and parameters of a problem to resolve;
3. England & Wales: Different Perspectives
22
Clinical Engagement primary care leading by design
23National Leadership and Innovation Agency for Healthcare
giving relevant professional groups the opportunity to identify and critically appraise
the advantages and disadvantages of alternative options, selecting the one most likely
to optimise benefi ts to patients within a specifi ed context, and the responsibility to
implement, manage and evaluate change.
3.13 As GP practices exploit available resources to expand services and drive up practice
profi t, it is perhaps worth questioning the potential nature of competition from a
private sector that maybe waiting in the wings. The example from Derby indicates
how relatively easy it was for an outside organisation United Health Europe (UHE)
- to successfully outbid an experienced GP practice team linked into University
based support. UHE does however state that it has considerable expertise in the
commissioning processes of more than 40 countries with a range of health care
systems. Simon Stephen, the President of UHE and visiting professor at LSE has
said that UHE has a lot of insights to share and that PCT commissioning has failed
because people back away from saying that what is being offered by a Trust, is not fi t
for purpose meaning that what is being offered does not now fi t the current plan for
service reform and reconfi guration and without modifi cation will no longer be funded.
Of course if Trusts and PCTs have not engaged at the highest level during planning
stages for aspects of reform, then Stephens responses are predictable. On the other
hand, there is also likely to be a major power-base differential between long-standing
(Hospital Trust) and relatively new organisations (PCT/LHB), particularly when one
incorporates the infl uence and power base both public and professional - of medical
and management heavyweights, while the other indicates major gaps in expertise.
3.14 In a review of PBC development in and around London however, a Kings Fund
research programme found that greater freedom had resulted in the development of a
number of different commissioning models including:
the single practice model, the multi-practice model where a formal collaborative
agreement existed but degrees of individual autonomy were retained
a practice contractor model where personal medical services were sub-contracted to
salaried semi-autonomous clinical staff
the limited company model - a body corporate which contracts to provide personal
medical services using salaried GPs who may also own and direct the company; and
the NHS Trust model where a community or acute NHS Trust contracts to provide
services employing GPs (Lewis & Gillam 2003).
3.15 Although this kind of development suggests that in a major conurbation with general
practice set in contexts of wide social, economic and cultural variation, different
models will develop with no reason to assume that one model is more likely to be
successful than another, again indicating that successful engagement of GPs involves
freedom to make decisions within a local context. The report does not however
provide any descriptive detail of the mechanisms for engagement and there has been
insuffi cient time for any useful comparative evaluation of the models selected.
3.16 It is clearly important, however, for commissioners to continue building up expertise in
order to increase their effectiveness in getting what is wanted, for example with regard to:
integrated health and social care for those with mental health problems
shifting resources between primary and secondary care, and
ensuring that evidence of clinical effectiveness is built into the commissioning process
(Klein 2006).
3.17 The lack of power and expertise to obtain what is wanted by a commissioning practice
continues to be problematic. Accepting what is on offer, particularly when faced
with Hospital Trusts trying to meet targets and reduce substantial budget defi cits,
continues to suggest signifi cant gaps in experience and skill to confront the issues
and move forward. There also seems to be the potential for a confl ict of interests in
the recent DoH advertisement for private companies to provide specialised services
for PCTs such as data harvesting and analysis, population risk assessments, service
evaluation, redesign and procurement the last potentially adding to any perceived
diffi culties with regard to engaging GPs in practice development or commissioning
processes if the agenda is not an open one.
3.18 Leadership in commissioning requires pulling organisations into the future by creating
a positive view of what a primary care organisation can become i.e. recognising their
potential, their current priorities and problems while indicating the benefi ts of change;
and simultaneously providing support and incentives during the period of transition
(Titchy & Divana 1990). According to Chris Ham (2007) however, there is a paradox
within GP practices, which is likely to interfere with the engagement process: they
are often staffed by a mix of innovators (who need support) and conservatives (who
need challenging). The Sainsbury Centre for Mental Health (2001) has identifi ed some
key issues for effectively dealing with such issues:
articulating achievable goals likely to benefi t patients, so that success is experienced in
reasonable time.
dealing early and effectively with actual and potential stumbling blocks by offering
support and/or incentives;
mobilising staff energies by helping to locate one element of a service where change
would make a positive difference;
retaining and developing good-quality staff by supporting professional development
and career progression.
3.19 It is not unreasonable to conclude that central government policy development in
England has traversed full circle to emerge with a much more radical form of market
i.
ii.
iii.
3. England & Wales: Different Perspectives
24
Clinical Engagement primary care leading by design
25National Leadership and Innovation Agency for Healthcare
oriented health service provision than in the 1980s. However, the implications of
repeated re-organisation and dramatic shifts in policy are likely to have resulted
in a degree of cynicism and if this view is widespread amongst GPs in Wales, the
approach to engagement must take it into account, recognising it as an actual
stumbling block that needs addressing sooner rather than later by the quality of
communication and the effort put into developing positive and productive working
relationships, together with an open agenda.
In summary
The power differentiation between hospitals and PCTs has had a negative infl uence on
the commissioning process in England
There is evidence of growth in the private sector but a lack of clarity about their role and
function and how this is evaluated within a local commissioning organisation
A lack of expertise in essential roles for commissioning remains in evidence
The process details of clinical engagement in policy documents is not especially helpful
Evidence indicates that some GP practices have successfully engaged in diversifi cation,
requiring a culture shift involving additional business skills as well as team-playing and
collaborating with other agencies
Opinions differ about the meaning and benefi ts of patient choice.
Wales: Current Context
3.20 From the beginning of the NHS there have been differences in the organisation
and delivery of health care services between the four countries comprising the UK;
although England and Wales have had essentially comparable operational structures.
Improving clinical effectiveness has, in fact, been on the Welsh Agenda since the mid
1990s with An Initiative for Wales (1995) highlighting four principles:
clinical practice should be based on (good quality) evidence of effectiveness
the patients view of the results of treatment or care should be given signifi cant weight
research and development, education, audit and information programmes should
support the initiative, and
more attention should be given to setting standards and assessing achievement.
3.21 The NHS in Wales underwent revision before the Assembly was established by
reducing the number of Trusts from 26 to 16 and the 1997 White Paper A Voice for
Wales defi ned its health remit in terms of monitoring the health of the population,
determining the scale of fi nancial resources for health and the identifi cation and
promotion of good practice. Since 1999, however, devolution has enabled the Welsh
Assembly Government to introduce structural change and to reform, and it now
plays a central role in health policy development, as well as holding LHBs and Local
Authorities to account.
3.22 The drive for excellence in Wales is refl ected in the twin track approach adopted in
Improving Health in Wales (2001) fi rstly tackling causes of poor health and secondly,
focusing services on results. It also refers to clinical governance as the lynch pin of the
quality strategy a legal duty since the Health Act 1999 to put and keep in place
arrangements for the purpose of monitoring and improving the quality of healthcare.
3.23 From the outset, and unlike the English focus on PBC, the process of partnership
has been the central tenet for achieving change and development and The NHS
Plan for Wales (WAG 2001) underlined the partnership approach, both for improving
services and the nations health. It stressed that alignment of services was critical for
supporting partnership arrangements that would reduce costs by sharing resources
and administrative tasks, and would help to prevent the advancement of one service
to the detriment of another. Health Challenge Wales (2004) re-emphasised the
benefi ts of partnership by encouraging organisations to work more closely together
rather than separately, with the aim of ensuring integrated health and social care
provision in primary care and the community.
3.24 According to Health Challenge Wales, public health methods were to be adopted both
nationally and locally to ensure that a rigorous local needs assessment provides the
3. England & Wales: Different Perspectives
26
Clinical Engagement primary care leading by design
27National Leadership and Innovation Agency for Healthcare
basis for being certain that local people are supported appropriately to promote and
maintain their own health; that clinical and professional leadership is strengthened and
that services are re-cast so that the same high quality provision would be obtained at
home or locally, quickly passing to specialist care when needed although there was
limited detail about what activities would actually be required on the ground to achieve
these goals. Capacity problems in secondary care were highlighted in A Question of
Balance (2002) drawing attention to the need to use hospitals in a different way and
to the implications for primary care, in terms of future planning, shifting resources,
improving information systems and again placing an emphasis on integrated health
and social care re-emphasised in later design components.
3.25 Similarly, in 2004, the Wanless Report confi rmed that the current systems for the
delivery of health and social care were no longer sustainable in their present form
and that maintaining the status quo was not a viable option. The report went on to
identify particular problems such as fragmentation of specialist services and the
misuse and dilution of clinical expertise placing clinicians in a central position for
future modifi cations to service provision, providing they are willing to engage in the
processes needed for these design changes. There are currently no mechanisms
in place to promote a more integrated approach to health and social care (NLIAH,
2006) and resolving the interface issues between primary and secondary care, the
Local Authority and LHBs, is critical for the emergence of a more fl exible, joined up
approach to primary healthcare.
3.26 Designed for Life (2005) had recognised a need to take stock and to learn from
others while continuing the transformation process adopting a new planning system
to accelerate the transition to a restructured design for delivering health and social
care one that included the closure of smaller hospitals and expanded primary
care provision while reducing administrative costs by linking GP practices together,
supported by Resource Centres. However the extent to which this has happened is
open for debate and it raises some questions in relation to the barriers preventing this
agenda from being taken forward.
3.27 In the face of these proposed changes, as well as those in the new GP contract, the
traditional notion of the GP as an autonomous and independent practitioner reacting
to the demands of individual patients, must now seem obsolete. But GPs are now
theoretically at least in a vastly improved position to develop special interests, to
infl uence the focus and direction of primary care development and to provide better
quality of care by being part of a multi-disciplinary network, with linking partnerships to
a variety of community based support services.
3.28 From the point of view of GP engagement, the Projects supported by the Inequalities
in Health Fund (WAG 2005) required partnership working and indicated that GP
practices are interested in engaging in service development when both the practice
and patients benefi t. That is to say, their interest was gained, examples of successful
applications to the Fund resulted in increased resources such as a branch surgery
in a deprived area, more practice nurse and dietician time and computer based
registers which made the call and re-call of patients at risk of coronary heart disease
much easier. This in turn resulted in the effective implementation of National Service
Framework Standards, increased clinic throughput and a reported signifi cant increase
in the achievement of GMS quality standards, enhancing practice income. One
Project involved every practice in Carmarthen.
3.29 The Modernisation Assessment of 2006 confi rmed the recognition that for clinicians to
be involved in change, they need to be able to see that improvements to professional
practice result in accompanying benefi ts for patients. With reference to LHBs and
clinicians engaging with each other to achieve policy objectives, the assessment is
less clear about both the processes of engagement and the objectives, although there
is a clear expectation that such engagement includes primary care practitioners other
than GPs.
3.30 More recently, the One Wales (2007) document, developed as a result of the Labour
and Plaid Cymru Groups coalition in the National Assembly, emphasises the rejection
of privatisation of services and provision of services based on a market models, yet
again demonstrating the very different approach to NHS reform proposed within
Wales in comparison to England. These differences raise a number of challenges
requiring new ways of thinking in relation to developing services further and
although not explicit within the document will rely on concerted efforts to promote
clinical engagement in order to achieve its ambitious aims.
In summary
Wales has chosen the path of partnership rather than PBC to address aspects of
reconfi guration for NHS sustainability, but there is little real evidence of sustained
innovation, with no new models of chronic care and few developments have taken place
because of the lack of budget and ongoing engagement of practitioners to help support
these changes
Furthermore the interface between health and social care remains a huge issue for
attaining integrated care
GP practices in Wales are interested in developing primary care services providing the
benefi ts for patients and for the practice are evident but at this point in time there is
some uncertainty surrounding the proposed approaches to reconfi guring the NHS.
3. England & Wales: Different Perspectives
28
Clinical Engagement primary care leading by design
29National Leadership and Innovation Agency for Healthcare
4. Theoretical Perspectives application to Engagement
4.1 The literature review indicates that GPs have been subjected to substantial forms of
change over recent decades to do with policy developments, information technology,
contractual changes, continuous professional development requirements and
management issues. They have also been encouraged to move from traditional
reactive and individualised care to a more proactive and population based approach
to primary care, to involve other agencies within the community; and to recognise the
actual and potential value of business and management skills. The characteristics of
the group have also changed and in response to more fl exible working arrangements
now include more part-time GPs, salaried GPs, more women in the workforce and
more of those who want to develop specialist areas of practice. They have also been
bombarded by the media with regard to the potential collapse of the NHS and by
Journals reporting innovations and use of privately funded initiatives, as well as some
abject failures to obtain a successful contract with a primary care organisation.
4.2 The rapid pace and breadth of change within the NHS means it is hardly surprising
that amongst a survey of senior professionals exploring culture within the NHS
comments such as we all need a siege mentality; we all have to be super human;
only do something if there is money in it; its change for change sake have been
found (Cullen et al 2000). A small (27 GPs in the sample) but recent study supports
the notion of divergence within primary care by highlighting possible sources of
tension that appear to be creeping in to practitioner relationships, where rank and fi le
GPs indicated their perception of an elite stratum developing amongst their colleagues
those who become involved in policy formulation for instance.
4.3 The engagement of clinicians is of great importance, and has recently been
emphasised again this time by The Royal College of Physicians (2007) who
have stated that Doctors have a neglected role in health service management and
leadership. They feel dangerously disengaged, alienated and depressed by the
rhetoric of Connecting for Health and the instability evident in continuous policy
change the re-engagement of the health professions in policy strategy is critical for
the restoration of order in the NHS (Horton et al 2007).
4.4 Yet there appears to be little or no reliable evidence in the literature of detailed
mechanisms for the engagement process itself, between GPs and commissioning
organisations, although overcoming resistance to change must underpin all future
developments within primary care.
4.5 But it seems reasonable to infer from the literature reviewed, that:
providing fi nancial incentives
allowing GPs the freedom to compare the advantages/disadvantages of options and
participate in decision-making are key components, as well as
ensuring there are clear benefi ts for patients and/or for the practice can all lead to
better engagement of GPs.
4.6 There is plenty of research based evidence of GPs being involved in clinical trials
and the literature also shows, from the number wanting to be involved in aspects
of research and development, that they are interested in practice development. A
number of new models of primary care provision have been suggested and put into
practice by the clinicians themselves, and a commitment to joint working has received
support in a recent Joint Statement from the Royal College of Physicians and the
Royal College of General Practitioners (RCGP 2006) where it is suggested that
balanced clinical partnerships should be explored to develop new ways of working
and commissioning evidence of a desire from professional bodies that they want to
participate in shaping the future of the NHS.
4.7 Implementing new scientifi cally based fi ndings is not always problematic or slow to
change practice the published fi ndings from randomised control trials concerned
with the treatment of acute otitis media in children for example, which showed no
signifi cant difference between surgical intervention and a conservative approach
comprising waiting and medication, was suffi cient to halt the former within a short
period of time. Although the evidence based road to best practice is now well
established in the work of NICE and in the ever enlarging database of the Cochrane
Library, research indicates that while clinicians want to have a scientifi c basis to
support their decision-making, there are diffi culties in accessing such data bases as
these (Guyatt et al 2000; Tomlin et al 1999). It should also be accepted that for the
purposes of wider engagement a signifi cant proportion of day to day clinical actions
and decisions, there is no good scientifi c evidence available and that professional
experience determines best practice (Naylor 1995). For example, where the best
patient care involves a complex set of arrangements and processes and includes
a variety of care providers, teamwork, clearly defi ned roles and responsibilities and
effective communication systems will be more important than the separate procedures
carried out by individuals refl ecting the signifi cance of integrated provision or total
quality management (Berwick 1998).
4.8 Introducing organisational change in a multi-disciplinary context is a considerably
more complex business than the introduction of guidelines, or the modifi cation of
prescribing in the face of NICE guidelines (Elwyn & Hocking 2000). In the context
of maximising all available resources, promoting teamwork has become particularly
relevant, both in the UK and USA (Crabtree et al 1998; Elwyn 1998) but has often not
been adequately addressed in intervention programmes, suggesting that essential
4. Theorectical Perspectives - application to Engagement
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Clinical Engagement primary care leading by design
31National Leadership and Innovation Agency for Healthcare
elements of the planning process have either been too hastily addressed or ignored.
That is to say:
an evidence-based rationale m