A
nalysis of free-form answers in the postal questionnaires (Tables 9–11).TABLE 9 Contributions made by clinical leaders (expanded list)
Dimension Verbatim response
Knowledge and understanding
Clinical knowledge; local knowledge; knowledge from front line experience; professional knowledge
A more clinically informed view than managers could hope to offer They understand services much better than managers
We understand the bigger picture
Attention to detail: insight into small things that create large obstacles to good clinical care Knowledge of systems and advocate for patients
Position/location in the system
They reflect and understand the realities of the‘front line’ Generalists, wide-ranging
Bring a‘can do’ attitude
Enthusiasm, practicality and prioritisation
Better system overview than acute sector providers have
Able to understand the problems of implementation at ground level Less constrained than managers
A counter voice to finance imperatives They bring the voice of the front line Analytical and decision-
making skills
Evidence based thinking Sensible service design; . . .
Understanding of the evidence and ability to describe what‘good’ looks like Understanding of patient needs
Expertise in care planning; . . . Patient centred, patient focused Outcome focused
Clarity and structure, practical patient focus
Clear evidence-based thinking. Clear understanding of what is needed to maximise the potential for front-line staff to work effectively together in the interest of their patients They have an understanding of resources
Clear insight into the operational implications of challenges to services and service redesign Rapid option appraisal
Relationships and collaboration
Strategic clinical leadership influence and followed by all clinicians and officers Experience and judgment
Patient engagement and member engagement; . . . . . . collaborative instincts
TABLE 10 Major obstacles to clinical leadership
Dimension Verbatim response
Lack of time/practice workload
Not enough GPs; increasingly have to devote time to direct patient care as fellow GPs leave Inability to attend all meetings and planning sessions due to practice commitments Recruitment and dedicated time
No paid time in job plans to do it
Reducing number of clinicians willing to take leadership roles Providers’ financial constraints
The pressure of doing the day job at the same time Pressure from clinical practice
Recruitment difficulties Ageing GP population
TABLE 9 Contributions made by clinical leaders (expanded list) (continued )
Dimension Verbatim response
Challenge and independent views
Their challenges to plans proposed by others Challenge the status quo
Challenge potential inertia of consultant colleagues
Brings healthy dose of challenge and always reminds staff of how it is in reality They influence provider clinicians to understand the need to change
Trust, credibility and status
Important touchpoint with patient/public kudos and trust form the public Momentum of purpose, authenticity, trust
Patient focused, on quality issues and on problems with service Credibility, practical experience and local knowledge
Independent: less wedded to organisations Insight and understanding of realities
Insight to what works/doesn’t work in a clinical sense – a reality check Ensure safety
Communication and influence
Representing patient views; ability to communicate complex issues in plain English; . . . Important in selling to colleagues and patients
Influencing peers to change behaviour
Evidence based mobilisation of clinical public support Communicate the vision to patients
Engagement with clinicians to implement change with credibility Peer to peer discussions and influence
TABLE 10 Major obstacles to clinical leadership (continued )
Dimension Verbatim response
Lack of capability and experience
Poor commissioning support
Lack of project management skills in CCGs
Managing a £1.2 billion budget is beyond the skill of clinicians In a CCG with three localities the default position is competition Lack of understanding of commissioning
No knowledge of how to be a director of a board
There are not many visionary GPs– they struggle to think bigger than a practice Clinicians are not usually organisational leaders and they have not usually been involved previously in major change programmes
Often unclear decision making
Lack of engagement with other professionals
Inability of managers to ask focused questions rather than open-ended questions Managerial manipulation of the status quo
Lack of trust between managers and clinicians Money Finance; there is simply not enough money
Finances, every time we set up pilots without sustainability of funding Misaligning of incentives
Government not matching input to expectation
Constant policy change from centre, not being able to invest our plans in long term initiatives
Lack of influence/lack of autonomy
Gaining approval from NHS England NHSE
The status quo; . . . Agenda driven by managers Over managers
Over secondary care Tiers and tiers of bureaucracy NHSE!
Inexperience of GPs in large organisations. Consultants are much more used to this environment
Management blocking clinical change become of worry of loss of trust income.
The clinical leadership is often sessional– lack of continuality, e.g. Mon, Thurs and Fri but not every day
Therefore decisions move on at pace without clinical leadership input External factors which overrule us
Meddling by non-clinical led organisations such as NHSE and local authorities
TABLE 10 Major obstacles to clinical leadership (continued )
Dimension Verbatim response
Diversity of goals Different views of what services should look like Be clear about the rationale/case for change Pre-conceived ideas of what should happen Politics and the political cycle
I have to question redesign as a concept: I would expect providers to drive service redesign (though with some collaboration with commissioners)
NHS England’s relentless drive to increase expectation without expanding resource Attempting complete redesign rather than frequent small steps
Conflict of interests among GP as care providers Pressure to bail-out hospitals
Fragmented system with diverse goals
Too many providers; . . . Too complex a system to unravel
Failure of the acute hospital to deliver on promised service transformation
Failure of county council to engage as no incentive to work outside their government targets NHS structures and organisational boundaries
Historic provider/commissioner conflict System disintegration
Too many meetings
Influence of NHS Improvement and acute providers in maintaining their power Leadership failings Lack of willingness to accept leadership role in convincing peers to change rather than
simply reflecting existing willingness
Lack of belief that they can make a difference Lack of interest
Lack of engagement from some members
GPs have other interests and few incentives to change
Not enough GP’s interested in leadership to spread the workload
Demands of clinical time result in lack of proper engagement by secondary clinicians Lack of commitment
TABLE 11 Best examples of clinical leadership
Type of leadership Examples of types of leadership
System leadership Vanguard projects Development of ACO
Early development of place-based care
Stopping the local health economy from collapsing completely Raising awareness and prevention of health equalities Built a vision for transformation
Service redesign Changes to MSK services
Procuring an excellent MSK service which has reduced secondary care use and operations Community MSK services/physiotherapy
Mental health redesign/talking therapies Redesign of urgent care
Primary care commissioning Pathway redesign
Redesign of frail and elderly services New models of primary care developing A new pathway for diabetics
Community Respiratory Service
Diabetic services– taken five separate providers and commissioned as whole programme budget– outcomes were below average now above national average
Value-based commissioning for diabetes
Out of hospital teams to lessen pressure on acute admissions New co-ordination centre
Focus on self-care Integration:
cross-boundary working
Developing an integrated community service across health and social care New models of care
A new integrated care team
‘Better Together Programme’, strategic alliance and new primary care strategy IT [information technology] sharing patient records with acute trust
Joint planning with primary and secondary care services
Multidisciplinary Team (MTD) working across traditional boundaries Commissioning integrated neighbourhood teams
Re-shaping of maternity and paediatric services across NW [north-west] London Organisational
development/softer skills impacts
Motivating an over-burdened workforce
We have a well-developed plan for closing the financial gap Built good working relationships across the system
Starting to implement AQP [any qualified provider] Engagement
Built good working relationships
Stimulate positive discussions about the future Patient relations and customer service excellence
TABLE 11 Best examples of clinical leadership (continued )
Type of leadership Examples of types of leadership
CCG scope and nature of activities
Co-commissioning of primary care GP practices appraisal
Financial balance
Excellent engagement with all CCG practices
Established four neighbourhoods within the CCG and support them to work for themselves in shaping neighbourhood-level innovations
Development of neighbourhood teams that are almost MCPs
Implementation of referral support website to improve communication and dissemination of projects and services to clinicians
Holding the secondary care provider to account Supporting GP federation and GPs
An improved understanding of services
Clinical leaders standing up and leading public consultations Our last public consultation was successful
Quality initiatives Referral management processes put into place Improved elective referrals
The‘Way to Well-Being’ project: provision of patient mentors and coaches Prevention
Impact on secondary care
Building relationships with hospital provider with a clear clinical focus Reduction in mortality in local providers
Utilising Right Care/Commissioning for Value
Working relationships with the acute hospital are more constructive then they have been for up to 10 years
Partnership work with‘Keogh’ trust to raise standards of care for local community Primary care
improvements
Weekend GP opening GP practices working together GP access
18 practices doing 7 day GP services with others keen to join Making primary care an exciting and attractive area of work Better management of long term conditions by practices GP hubs and integrated care teams in the hubs Locality– integrated hubs operational
Financial package to prevent practice closures A supportive practice programme
Achieving GP federations
GP quality contract– good uptake and engagement by practices Social prescribing
Primary care-extended access
Identifying‘carers’ champions’ in all practices investing in community navigators’ who can signpost access to voluntary/local authority support services
Multi-disciplinary teams delivering home first, hospital care at home Designing a blue print for primary care