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Clinical Engagement primary care leading by design

ANational Leadership and Innovation Agency for Healthcare


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


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: [email protected]

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


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:[email protected]

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


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

2



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

4



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.

6



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



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

10



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;


12



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


14



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


16



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.


18



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.


20



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;


22



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.


24



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


26



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.


28



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

30



elements of the planning process have either been too hastily addressed or ignored.

That is to say:

an evidence-based rationale m

Documents

NLIAH ClinicalEng test2 - NHS Wales · of the NHS and draws on the international research ... prescribing practice chronic conditions management, ... based best practice of clinical