Yesterday, I attended the North West Medical Leadership School event; debating discussing and exploring the recently published white paper ‘Equity and excellence: Liberating the NHS” with some of the North West’s most prominent clinical leaders. Read about their bios in the event manual.
The recent white paper: just another healthcare reform?
After Dr Benjamin Brown’s introduction to the concepts raised in the paper and an orientation of their context in our current socio-economic climate, we broke out into small groups to quiz our esteemed speakers one by one. Check out this brief summary of the paper adapted by Charlotte Simpson, speciality registra in public health in the Mersey deanery.
I had the pleasure of being in a very motivated and passionate group of secondary care clinician’s ranging from foundation stage to specialist registra. After offering my services as a scribe, we began to generate our questions (of which we were allowed 3) for the speakers. Our tables queries included:
1) How will the proposed GP consortium’s be composed and what level of experience/training will it’s members have?
2) How will the paper impact upon the delivery and design of secondary care?
3) What exactly is meant by “no decision about me, without me” and how does it differ from our present patient centred approach?
One by one the speakers came to speak with us and each answered our questions eloquently and with their own spin. We were then asked to present our findings – at which point I requested to put my emerging graphic illustration techniques into practice! Sadly the quality of the drawings was not exactly “da Vinci” or “Rembrandt”, but the messages were effectively conveyed!
North West Medical Leadership School: established to enhance clinician engagement in medical leadership
From our conversation with the rotating speakers we discovered that the proposed GP consortiums (GPC) may be a “relabeling” of the current practice based commission system. The old ingredients will remain: managers (presently seconded from the PCTs) and GP leaders with experience in commissioning. New ingredients in Andrew Langsley’s ideal GPC would include multi-disciplinary staff, secondary care clinicians and greater patient/public engagement. The down sides, or the bad taste in our mouths, was that the lack of a tangible recipe for the construction of these GPCs, the high likelihood of disinterested GPs and the chance that many GPCs may not include the new ingredients meant that there may well be wide descrepancies in the effectiveness and functionality of these GPCs from region to region. Perhaps a new form of the old “post-code” lottery?
In terms of the papers impact upon secondary care the views were mixed. Many GPCs may be experienced enough to know that proper change management to commissioning processes will require buy-in from all stakeholders. This means that they should be proactive in involving secondary care clincians in the design process. The introduction of social enterprise into frontline clinical work and within Foudation Trusts essentially implies that clinical staff may be able to determine the direction of the FT and hence the relationships with the GPC. Some argued it may liberate clinical providers in both sectors to decide on the methods for provision of care to meet the outcomes set by the GPCs. This has the potntial to break organisational boundaries and increase collaboration.
On the otherhand, there is concern that this shift of commissioning power will “shrink” secondary care in a number of ways. The incentive to send patients for secondary care decreases and GPswill look for alternative options. This may lead to creative solutions but runs the risk of deteriorating into poorer quality of care. As the market opens up, comissioing may be directed towards private firms, potentially shifting funds, and eventually quality staff members away from the NHS and into the private sector. To compete in this market the NHS will have to innovate and work hard not to deteriorate into a secondary provider of secondary care.
This conversation led into the discussion of outcome measures. Currently much of our work is assessed on process measures of targets. Many of us would happily lose this system as we have found that rules and numbers have been bent to meet those targets, often at the cost of quality of care. The new system proposes using quality outcome measures for attribution of finances. This in theory sounds fantastic, lets look at results not how we get to results. However concerns were rasied that it would not be the outcomes but how these outcomes are measured that would determine their success. Once again there is a risk of bizarre and unrealistic unpractical measures leading to the bending of rules!
"No decisions about me without me" Improved patient empowerment will need improved opportunities for patient education
Finally, and most importantly we looked at the proposals to further empower the patient to make decisions about their own care. While we all advocate this in theory In practice it will require careful planning and increased support in certain areas and boundaries in others. The new proposals are intended to give the patient more responsibility to manage their healthcare; responsibility in how they use services and responsibility in how they apply prevention in the community. This is all well and good for certain groups of patients, however our group was concerned with some of the outliers. What about the vulnerable, lower socio-economic groups and the elderly who may lack the understanding required to make complex decisions, putting them at risk? What about the super-empowered middle class patient who will demand certain expensive treatments and care plans, despite being shown all evidence to the contrary? What about the indifferent patient who just wants the healthcare profession to tell them what to do? How will we accommodate for these persons? Certainly at least clinic times will have to be extended to accommodate for all the additional education and statistics that will need to be discussed! We would love to have the time to fully educate and empower our patients but firstly it is not a skill that all clinicians have been well-trained in and secondly e do not have time to do the basics in our current system so changes will have to be made to fit all of this in!
From outside our group others raised concern over the diminished role of NICE to merely advisory and worried that this could open doors to ethical dilemas in relation to privatistion and big-pharma marketing. In addition concerns were raised regarding the future of training provision and if this would be deprioritised.
During the closing remarks we were asked to consider some of the following questions:
What are we going to do tomorrow that is different? How will it change our day to day practice? How can we enable patients to manage their own health? How will we take responsibility in implementing this reform in the best possible way for the patients and public?
In her summary Jacky Hayden made an important and pertinent point: There are two ways to implment this white paper:
Competitively or Collaboratvely
As doctors we are constantly taught to be in competition (even this event had a prize for the best small group presentation – which we won!) from medical school and throughout our careers. Can we put this aside, find opportunities and learn to work collaboratively and creatively together? Perhaps that is, as Jacky so aptly said, the only way to make this new reform succeed.
All in all it was a great event, shedding some much needed light on this important paper and it’s potential impact. Most inspiring was the passion and dialogue seen in the room and, as many of the speakers alluded to, the great leadership potential of all those motivated juniors present! If all those present go on to cultivate their drive and interest in clinical leadership then perhaps there is hope for the NHS of the future!
