A highly successful cross NHS programme has shown how clinicians and managers can harmoniously work together, share Professor Marion Bain and others

Team

Within the NHS there is often a tension between taking forward initiatives that are primarily focused on delivering against financial requirements and efficiency savings – as defined by chief executives and general managers – but which to be successful, and safe – need to be clinically owned and clinically led. What is it that needs to happen to achieve effective joint working to realise agreed common goals?

Some insights into this come from the NHS Scotland Effective Prescribing Programme which has delivered some £12m of savings over its first year, and is regarded as a highly successful cross NHS programme by the NHS Board chief executives and the Scottish government.

The NHS Scotland Effective Prescribing Programme has delivered some £12m of savings over its first year.

The programme has managed to combine a focus on both improving quality of care for patients and reducing costs – and has achieved a high level of buy in from the clinical community and NHS managers.

Projects within the programme include shifting prescribing to equally effective but cheaper biosimilar medicines, agreeing upon “consensus statements” for treating conditions which allow for more consistent care and more effective procurement, and reducing excessive steroid prescribing for respiratory conditions which results in safer patient care as well as lower drug costs.

Success factors

So, what are some of the success factors that have helped to achieve this? Fundamental to this has been genuine clinical leadership. The NHS Scotland Medical Directors and Directors of Pharmacy took ownership of the work from the onset, supported by the Scottish government.

Clinical leaders working on government policy worked together with clinical leaders involved in service delivery. The role and approach of the chief executives of the NHS boards has also been key.

They gave a clear commission to the Scottish Association of Medical Directors to undertake this work, and they have a keen and ongoing interest in its progress. They were clear that the task involved achieving savings, but they gave the clinical group the freedom to lead and set the agenda.

This allowed a focus on both quality of care and cost savings to be pursued – and thus facilitated ownership by clinical leaders and support from frontline clinicians.

Clinical leaders working on government policy worked together with clinical leaders involved in service delivery. The role and approach of the chief executives of the NHS boards has also been key.

Another essential success factor is a much more practical one. Delivery within the programme has been reliant on high quality dedicated programme support. This has allowed the clinical leaders and clinicians to focus on where they can provide the most value, to use their time effectively, and to feel supported in delivery.

Lastly, the ongoing positive feedback from the chief executives, and from the Scottish government (including ongoing funding support following on from their provision of start up funding costs) has undoubtedly contributed to the ongoing involvement and commitment of the clinical community.

Challenges

The programme has inevitably had to work through challenges. Constant aligning of the different perspectives of the various stakeholders has been required – between the different constituencies and between national and local perspectives.

As the programme progresses, more challenging projects are being addressed, which have greater risks, as well as bigger potential benefits associated with them. Acknowledging that differences exist between the different partners involved, being open and transparent, and being committed to working together is essential in allowing these to be resolved.

Availability of data to both inform and agree on areas for intervention and to track progress was a practical challenge

This in turn continues to be heavily dependent on strong clinical leadership and a constant focus on the desired outcomes. Availability of data to both inform and agree on areas for intervention and to track progress was a practical challenge and has required alternative sources of data to be found, including some new data collection.

A further challenge has been balancing where the savings are attributed, and who should benefit from them proved an aspect of early debate. Ensuring transparency, and agreeing an approach which gives local ownership and some direct benefit of a proportion of the savings locally has been essential.

It is not always easy to align the different perspectives and priorities of different groups within the NHS but to achieve the significant changes that are currently needed, it is essential that we can work effectively together to provide quality care for patients that is sustainable and affordable.

The work of the NHS Scotland Effective Prescribing Programme gives us some useful insights into how to achieve this.