doctors and managers

Published: 27/03/2003, Volume II3, No. 5848 Page 28 29 30 31 32 33

Today sees a summit of 100 senior clinicians and managers organised by the NHS Confederation and the royal colleges. It will debate why some managers and doctors find it hard to get along and how a more agreeable relationship can be built. Over the next five pages, HSJ presents examples of managers and medics working together in ways which avoid the destructive tensions which inhibit progress elsewhere in the NHS

Primary care

Tooting walk-in centre

The idea of a walk-in centre in Tooting, south London, was met with unconcealed hostility by many local doctors when first proposed. But three years on, the results are beginning to show.

The nurse-led centre now sees 100 patients a day, 30 per cent of whom would otherwise have gone to accident and emergency. It has also developed a number of patient directives - and perhaps most importantly it is acting as a model for co-operation in other parts of the area.

The transition involved in the latest restructure in south-west London has been amazingly smooth, says professional executive committee chair Dr Tom Coffey - and much of that is a result of trust built up by this project.

'In advance, everyone tends to think everyone else is going to shaft them.

But if you have got to know someone and they really care about patients and about GPs, then things become so much smoother.'

'Our relations with the [St George's Healthcare] trust have also been excellent throughout and that effect rubs off on other projects.'

The genesis of walk-in centres were fraught with tensions, virtually from the day in 1999 when prime minister Tony Blair announced their development.

GPs were angry that the decision had been made without consulting them and it appeared the government were bowing to consumer pressure.

But the concept offered a chance to address a number of local problems. There was concern about the poor access for those with mental health problems, refugees and asylum seekers and high rates of teenage pregnancy. It was also felt that a quarter of those attending A&E departments could be better cared for in primary care.

The fact that 80 per cent of the initial costs would be found by the Department of Health was a further incentive - which helped local organisations to agree to plough£138,000 of their own money into the project over each of its first three years.

The key players in the project were South West London Community Health trust chief executive Helen Walley, St George's Hospital accident and emergency consultant Aiden Gleason, Merton, Sutton and Wandsworth health authority primary care director Steven Evans, and Dr Coffey.

A senior speech therapist was seconded by the trust to implement the business plan and project-manage the opening and running of the centre.

Dr Coffey says: 'The commitment of a senior health professional with excellent project management skills was a key ingredient to the operational success.'

From the start there were problems. The timetable for the project application process was incredibly tight. The team had to agree a service model, find a venue and organise funding within six weeks.

Somehow they managed to meet their deadlines.

A dilapidated Victorian building close to A&E was found and the organisations used money from various sources to support the 20 per cent contribution required for the project to be considered viable.

Three years on, there is no doubt it has been worth it. The centre has received funding for a further three years, and is seeing many patients who would not normally have made contact.

Most of the clients are aged 15-40 and tend to be young, middle class people - the 'usual critics of the health service and the opinion formers', as Dr Coffey puts it - who want quick access for normally selflimiting conditions such as cystitis, conjunctivitis or eczema. It also seems to be getting to grips with the teenage pregnancy problem - the most common drug offered at the centre is emergency contraception.

The centre acts as a training base for local practice nurses and nurse practitioners and provides a model for nurse-led care.

Only a handful of refugees and asylum seekers have attended the centre. It is a similar picture for people with mental health problems.

Inevitably, there has been tension between clinicians and managers along the way.Most focus on anxiety about change and the threat it might pose to their area of work. GPs, for example, were worried that the walk-in centre would undermine the continuity of care. But in fact, says Dr Coffey, they have warmed to the concept because it is clear it is helping them.

'It has acted as quite a good pressure valve.When demands are particularly high in the surgery, That is when the centre is likely to be at its busiest because some patients are being redirected to the centre.

Some did wonder why the money couldn't have been spent on primary care in the first place, but this is a good way of concentrating services.'

But, says Dr Coffey, a lot of the credit for the project's success must go to Ms Walley, who agreed to take a significant financial risk to develop a vision of a new model of care by extending the role of nurses. The fact that she has a nursing background has proved invaluable in tackling potential mistrust and hostility between clinicians and managers.

Dr Coffey adds: 'My previous experience of management had been tainted by a perception of ingrained risk-averse behaviour. This was not the case on this project.'

Contact Dr Tom Coffey, tom. coffey@gp-h85048. nhs. uk

Neuroscience network

Queen's Medical Centre Nottingham

Over the past 10 years, neuroscience services at Queen's Medical Centre Nottingham, have been subject to a series of inconclusive reviews. So when Trent strategic health authority and Rushcliffe primary care trust began its latest review last year, the omens did not seem good.

Yet within eight months the review has been completed and agreement reached on a wholesystems neurosciences network. So how was this transformation accomplished?

When the project began, there was a great deal of animosity between clinicians, the health authority and the PCT.

A large number of stakeholders were involved in the review across the East Midlands, each with a slightly different agenda.

Trent SHA director of public health Dr Sarah Wilson believes one of the keys to establishing a new relationship was PCT project manager Angela Nisbet, who actually visited the neuroscience departments and agreed that it was desperately in need of development.

At the same time, a shortage of critical care beds meant that braininjured patients were accommodated on general wards, which had knockon effects on elective patients.

In addition, there were indications that some parts of the service were below the standards set out by the Society for British Neurological Surgeons.

Dr Wilson accepts that managers may have been as much at fault as clinicians for previous impasses. A number of doctors had indulged in shroud-waving in the past, and managers tended to react to what they felt was an exaggeration of the problems.

'A battle mentality developed where they were saying 'we need to improve' and we were saying 'We are not convinced'.

'Once those battle lines had been drawn, it became increasingly difficult for either side to extricate themselves.'

Acknowledging that there were deficiencies in the service was the starting point for a new approach. The aim was to provide a safer, more patient-focused service, not about meeting individual ambitions.

A review team was formed by Trent SHA, QMC, East Midlands commissioning consortium and Rushcliffe PCT. Dr Wilson - a doctor turned manager - assumed a strategic role and identified those who were committed to resolving the review and encouraged them to join the team.

Consultant neurosurgeon Barrie White brought the proof and the need to develop neurosciences, as well as an eagerness to work with, rather than challenge, managers to solve the deficiencies.Ms Nisbet examined the situation on the ground and produced evidence of the problems within the service, including lack of resources. Surgical operations director Gavin Boyle put problems into context, based on comparisons with other services, and encouraged a pragmatic approach to achieve realistic improvements.

'I think a lot of it is beginning to get to know and trust the business managers and clinicians you're dealing with, ' says Dr Wilson.

'It is about the personalities accepting they're on the same side and It is not a war between manager and clinicians or between health authority and trust.'

Another important factor was that clinicians played by the same rules as managers. 'One of the things that happened in the past was that you got lots of clinicians making direct approaches to the health authority or doing unplanned developments without telling anybody.

'But there is now a much clearer management structure in the directorate. And thanks to Barrie White, It is a much better clinical planning process.'

The creation of the SHA has also provided the chance to look at the bigger picture.

'There is a bit more of a sense that the SHA is working with and helping trusts and not constantly battling with them, ' says Dr Wilson.

There is still a long way to go, with full redevelopment not expected to be completed for another couple of years. There will always be tensions between medics and managers, Dr Wilson acknowledges, and it remains uncertain whether all clinicians in all the trusts will sign up to the grand plan.

'It is a bit like walking on glass.We have got to be careful.We can't alienate the clinicians in the district general hospitals.'

But at last things are moving forward and it seems most doctors are on board. 'I think we have got a fair amount of commitment to the fact that we'll make this happen now.'

Contact Dr Sarah Wilson, sarah. wilson@tsha. nhs. uk

The modernisation effort

East Sussex Hospitals trust hospital improvement partnership pilot

East Sussex Hospitals trust is one of four pilot sites for the Modernisation Agency's hospital improvement partnership, aimed at achieving and surpassing the quality and access targets for patients outlined in the NHS plan. The full scheme starts in April.

Work is underway in the key areas of accident and emergency access and diagnostic and assessment services.

The trust has commissioned a team to work alongside staff in A&E to see how they could stream patients to improve the flow. Staff were asked how they would manage patients ideally and then management looked to make this happen.

As a result, nurses can not only assess patients when they first come in, but in certain circumstances order their investigations and sign them off. The 'see, treat and complete' approach has helped reduce unnecessary waits and improve patient throughput.

The trust is also looking at staff frustrations in the medical assessment unit, including delays in receiving pathology results and long waits for drugs dispensed by the pharmacy.

The endoscopy department is about to see the introduction of nurse-managed lists and direct access from primary care and radiology, which is in the process of installing a digital imaging system to replace traditional x-ray.

Director of service development and modernisation Kate Harmond says the key to these developments has been focusing on the patient experience at all times and acting on clinical staff concerns.

'There are a load of people who are so hungry for change. Once they see an opportunity, It is quite frustrating to have to hold them back.

But we need to realise that not everybody is responding at the same pace, ' she says.

But the best argument of all, she believes, is to show that change works. Some specialties have adopted pooled surgical lists where patients are not necessarily referred to a specialist surgeon for a specialist problem. Instead the GP sends a generic referral letter, which is then dealt with by the surgical team as a whole.

'Some firms found that difficult to conceptualise.

But what we tried to do was demonstrate that it worked and the sky didn't fall in.

'Nobody was at risk, patients were operated on safely and there were good clinical outcomes.'

Ideally, managers should not have to tell clinicians and other staff of these benefits - peers should inform each other.

'These are the sorts of dialogues we are trying to set up and support. And some of the results have been quite stunning.'

The biggest achievement so far, she feels, is that doctors and managers have signed up to a common vision of patient-centred care. 'It is about thinking about the patient rather than the logistics of operational management or the parameters of clinical practice.

'We have now got doctors and managers talking the same language and talking about the same outcomes.'

But you also have to be canny about how you proceed. 'I haven't spent time beating on closed doors.

'I work with the people who are very committed to making these changes. But It is amazing how many other people are now desperate to be part of it.'

Contact Kate Harmond, Kate.Harmond@esht. nhs. uk

The cancer network

Surrey, West Sussex and Hampshire cancer network

The Surrey, West Sussex and Hampshire cancer network - which aims to help the health community meet the objectives of the national cancer plan - has been in operation for 18 months.

It has been a tough assignment, says Macmillan lead clinician Professor Hilary Thomas, and at times the core management team has faced a bumpy ride. For instance, they lost credibility when a lengthy process to establish clinical priorities was scuppered by last year's reorganisation of health structures. By this stage, the teams had cut down their 'shopping list' to five top priorities, she says. 'But when they were then told we can't even fund your top priorities, people started to say 'what's the point of all this?'' But gradually the network has become more harmonious and effective, she believes. An important stage in this progress was a leadership day for the clinicians and managers involved in the network, where participants discussed their strengths and weaknesses with great honesty.

The result, says Professor Thomas, is that 'people seem more focused on what they want to do rather than carrying on with more of the same'.

Inevitably tensions arise between different members of the team. This can sometimes be the difference between those who focus on the detail and those who see the bigger picture. But often the source of conflict is money.

The money that has been poured into the cancer collaboratives, for instance, is not always seen as money well spent.

Some clinicians were frustrated that the increase in managers did not seem to be reflected by increases in frontline staff.

Clinicians in the lung tumour group became disillusioned when funding for their data collector, who had been helping audit outcomes for lung cancer, was abruptly stopped because the money had to be transferred to national targets.

'The message is that if you are just focused on government targets and do not look at their clinical utility or relevance, then doctors will not buy into them, ' says Professor Thomas. 'The perception was that managers were there to implement government targets and were not there for the doctors, which was damaging.'

For the same reason, she and her colleagues are critical of the two-week wait for consultation after referral because it has been introduced without reference to other parts of the system.

As a result, cancer patients may see a doctor in two weeks but then have to wait a further six months for radiotherapy.

She believes the tendency to think in silos, encouraged by rivalry between NHS organisations rather than across a managed clinical network and along patient pathways, is gradually breaking down as the network matures.

'The biggest obstacle is not getting together enough. The good manager has an open-door policy while the bad manager doesn't bother to get out there. But It is also up to doctors to work together. The worst thing is the 'us and them' culture.'

She also feels the rapid turnover of management staff is not helpful to their relationship with clinicians. Doctors feel more secure in their job and will often fail to engage with managers because they do not expect them to be around for long.

Contact Professor Hilary Thomas, hilary. thomas@surrey. ac. uk

South London and Maudsley trust

Mental health

Disagreements between medics and managers are almost inevitable on any health project - and the Lambeth early onset project has been no exception.

The project aims to identify and treat local residents, especially younger people, who are experiencing their first or second onset of psychotic illness.

It started off with a community-based team and has since developed a dedicated inpatient unit, an early assessment team and an outreach service working with GPs and others to identify psychosis at the earliest possible stage.

In the four years of its existence, it has successfully developed a comprehensive and focused service, and stayed in touch with a high proportion of service users.

It is planning to pass on its lessons to other boroughs covered by the trust.

There have been some problems along the way. The trust initially underestimated how much staff time would be needed to help patients suffering from first-onset psychosis and there is still a shortfall in this area.

South London and Maudsley trust chief executive Stuart Bell believes the key is acknowledging that conflicts between doctors and managers are almost inevitable and it is important to get areas of disagreement out in the open.

But he acknowledges that it takes patience to understand the factors shaping others' point of view.

He believes the project has also helped participants see the bigger picture.

'Historically, you have a real tension between the practitioner focused on the specific patient and the manager concerned about the more general patient group. This has helped develop an understanding of the wider agenda.'

The development of early intervention services is a specific target of the mental health national service framework.

But South London and Maudsley trust's main motivation has been a shared belief this was the right thing to do, says Mr Bell.

The fact the project has been subject to careful evaluation and analysis throughout also enables managers and clinicians to take an informed view on the merits and realism of national targets.

Contact Stuart Bell via jean. oliver@slam. nhs. uk

Castle Point and Rochford primary

Primary care care trust

Faced with a shortage of GPs and increased dissatisfaction among those in post, Castle Point and Rochford primary care trust, based in Rayleigh, Essex, hopes to reform its primary care service.

The decision to take action came in October 2002 when the trust already had five vacancies among its 77 GPs and faced the prospect of almost half of its doctors retiring within the next 10 years.

It met senior GPs to hear their concerns and to find out how long they planned to stay in the NHS.

Director of primary care Liz McGranahan says the most striking finding from the meeting was the degree of stress most practitioners felt they were under.

They complained of increased paperwork, heightened patient expectations, difficulties in obtaining locums and shortages of staff.

As a result, the trust has drawn up a programme - partly financed by a£30,000 grant from the Essex workforce development confederation - to redesign primary care in such a way that GP capacity is freed up and the skills of other staff are better employed.

One suggestion, for instance, is to relieve one senior GP in each practice of some of their day-to-day work which would then allow other GPs to use their expertise and knowledge as a sounding board.

The new model will be piloted in three large practices. It is hoped the lessons learnt can then be rolled out to other practices within the trust.

These are still early days, says Ms McGranahan, but she is delighted by the degree of common ground between GPs and the trust. 'I think the biggest achievement so far is that the initiative has come from GPs.

We have picked it up and developed it and then gone back to GPs. Three practices have said they're willing to have a go.'

She does not underestimate the problems ahead. 'We are talking about transformational change, not tinkering around the edges. Even where the team is positive, they may be positive in different ways. The GPs may say they're happy to look at skill mix but how does that affect the nurse practitioner? It is going to be a tricky business.'

Staff shortages will also make it difficult to implement change.And there is the danger that initial expectations may be disappointed, with the project throwing up issues that cannot be tackled because they are too difficult or the resources are not there. But the initial response has been positive - and the trust is determined to make the most of that.

Contact Liz McGranahan, Liz.McGranahan@cpr-pct. nhs. uk

Emergency care

Berkshire emergency services collaborative

Managers know they can lose their jobs if they fail to hit targets, whereas clinicians know they will not. So when it came to a review of emergency services delivery, Royal Berkshire and Battle trust, Reading, was keen to adopt a collaborative approach to emphasise joint objectives.

A project board was established covering all key stakeholders:

Newbury and Community, Reading and Wokingham PCTs, Wokingham district council, Reading borough council, the acute trust, GPs, consultants and NHS management.Project groups looked at accident and emergency majors, A&E minors, emergency medical and emergency surgical admissions.The groups had joint leads with clinical issues largely tackled by clinicians and organisational matters by managers.

So far, the project has been successful. It has reduced waiting times for minor injuries from 2.5 hours to one hour or less.Consultant in anaesthesia and intensive care medicine Dr Jonathan Fielden believes the main reason for the success is their clear joint agenda and an agreed focus on patient needs.

'The key issue is maintaining joint goals and objectives, ' he says.This has been easier because the objectives to reduce waits and improve the service are patientfocused, so fit well with clinical needs.The team has also worked to maintain this common focus 'rather than drift into political agendas'.

Any tensions have been largely related to finance, Dr Fielden says.

'But this has mainly been an issue for managers as they are more accountable for financing.'Problems have been resolved through better communication and refocusing on the real issue: how to improve service to patients.

Contact Dr Jonathan Fielden, jonathan. fielden@rbbh-tr. nhs. uk