Clinical Directors in evolution2008 - 2014

Dr Colm HenryNational Lead

Clinical Directors Programme Wednesday April 2nd 2013

Once upon a time…

Anatomy Lesson of Dr Tulp, Rembrandt, 1632

National Health Expenditure vs GDP, USA 1960-2005

Centres for Medicare and Medicaid Services, USA

National Health Expenditure,USA, Public vs Private funding

Disappearing autonomy: The Road to Control

• Clinicians vs. managers

‘Clinical freedom created a political dimension outside any normal managerial framework. As quickly as efficient management reduced long-established queues, medical science opened new ones. Clinical freedom allowed consultants to make decisions affecting resources, and consultants had to be persuaded if they were to make their clinical demands more modest. A long and divisive conflict was in prospect’

Dyson, ‘Griffiths Inquiry, a Personal Perspective, BMJ, 288, 1984

Science and Charity, Picasso, 1897

Post-Griffiths: protestors to participants

• ‘....this involvement by clinicians in management has to embrace a contribution both to the strategic and operational management of a service, in hospital, in the community, in practice, and in the commissioning role at district and central level, rather than doctors simply seeing themselves as there to give advice’.Chantler (1994) How to treat doctors: Role of Clinicians in Management: Policy and Change in the NHS

• ‘ we enable doctors to be partners and leaders alongside manager colleagues..’

Lord Darzi (2008) High Quality Care for All

Dr Gachet, Vincent Van Gogh, 1890

Outline of role of Clinical Directors in 2008 Contract

• Deploy and manage consultants and resources

• Plan hospital and network strategy

• Formulate annual service plan

• Align service plan with regional and national priorities

• Monitoring and measuring performance against KPIs

• Audit/governance

• Accreditation

• Risk Management

• Agree and formulate individual consultant practice plans

• Agree and formulate schedules

• Align plans/schedules to local and national priorities

• Grievance and disciplinary

Men of Destiny, Jack Yeats, c1945

Clinical Directors in Ireland – 2008-2014

• Hospital-based and Mental Health• 55 hospital-based• 18 Mental health directorates• Roles evolved based on local requirements and

politics

• Aligned to institutions primarily

• Limited regional governance approach until advent of Hospital Groups

• Reactive vs proactive

• Protestors vs participants

• Tension between doctrine of clinical autonomy and managerial demands for improved efficiency, cost control and accountability…’ Escher, Waterfall, 1961

Clinical Directors 2009-2014 – expectation vs. reality

• Nominal responsibility across all clinical areas

• Patchy devolution of power and authority

• Upside down accountability

• Tension between expectations of managers and ‘system’ and what can be achieved

• Public face of failure and risk

• Time

• Data – quality and timeliness

• How to change behaviour and deal with ‘outliers’

‘Upside-down’ accountability

• ‘...I remind you that I do not accept clinical responsibility for an unsafe service. I remind you that you will be clinically responsible for adverse events which occur following your rostering and staffing decisions’.

• ‘....the Consultant Medical Board unanimously condemn the decision of management and the Clinical Director’....’

• ‘....ethically and professionally, I cannot comply with your instructions....’

Scream, Edvard Munch, 1893

A sustainable and realistic model?

• ‘the exercise of all power is a

process of depletion..’

Henry Kissinger

Extrinsic depletion

1. Demographics

2. Advancing technology and expectations

3. Recruitment of medical staff

4. Over-centralisation of accountability for risk and patient safety

5. Balancing clinical and administrative workloads

6. Succession planning

7. Cultivation of cynicism

8. Compassion fatigue

0

5

10

15

20

25

2011 2013 2015 2017

All ages

65+

1. Demographics: increase in health service cost pressures due to demographic effects

Source: CSO census of population and provisional DOH data projections to 2017, Based on cost relativities from the 2012 Ageing Report: European Commission 2012

2. Expectations: expensive advances

0

100000

200000

300000

400000

500000

600000

700000

2004 2006 2008

Expenditure(euro)

Expenditure on Bevacizumab, Mercy University Hospital, 2004-2009

2. Expectations – older people

1. Changing attitudes to cardiopulmonaryresuscitation in older people: a 15-year follow-upstudyP. E. COTTER1, M. SIMON1, C. QUINN1, S. T. O’KEEFFE21Portiuncula Hospital, Ballinasloe, Co. Galway, Ireland2Galway University Hospitals, Galway, IrelandAge and Ageing Advance Access published January 26, 2009

2. The Hospital-Dependent Patient‘Medicine has yet to acknowledge the ethical and practical predicament of having created a population of incurable, fragile, but not yet terminally ill patients without concurrently developing a healthcare system that can meet their needs’Reuben and TinettiNEJM February 20th 2014

3. Over-centralisation of accountability

4. Cultivation of cynicism

• Opposing targets

• Multiple and contradictory drivers for change

• Organisational practice opposed to statements– ‘An institutional culture that ascribed more weight to positive information about the service than to information…causing concern’

– ‘culture of self-promotion rather than critical analysis and openness’

• ‘Hitting the target but missing the point’

• Regulatory pressures– There is appreciable evidence that the NHS is over-administered as a result of extensive, overlapping and

duplicating demands from both regulator and performance managers. There has not been a substantive review of the information demands placed on the service and its providers for many years. A review leading to a rationalisation of those demands is essential.

• ‘Incorrect priorities’– The Mid Staffordshire tragedy and wider quality defects in the NHS seem traceable in part to a loss of focus

by at least some leaders on both excellent patient care and continual improvement as primary aims of the NHS (or to a misinterpretation by providers of the intent of leaders). In some organisations, in the place of the prime directive, “the needs of the patient come first”, goals of (a) hitting targets and (b) reducing costs have taken centre stage. A Promise to Learn; a Commitment to Act; Improving the Safety of Patients in England. Don Berwick and National Advisory Gro p on Patient Safety in England. 2013

‘No more heroes’: The future of leadership and management in the NHS. (The King’s Fund 2013)

‘The NHS needs to move beyond the outdated model of heroic leadership to recognise the value of leadership that is shared, distributed and adaptive. In the new model, leaders must focus on systems of care and not just institutions and on engaging staff and followers in delivering results. At a time of huge transition and challenge, leaders at all levels and from all backgrounds have a responsibility to ensure that the core purpose of the NHS – to delivery high-quality patient care and outcomes – is at the heart of what they do’.

Sir John Lavery, London Hospital, c 1918

Quality and Patient Safety – a long-term race

• National Healthcare Charter

• ‘Your Service Your Say’ – measuring feedback

• National Consent Policy

• National Open Disclosure Policy

• Clinical Governance

• Clinical Audit Guidelines

• Defining Quality in Healthcare

• Developing Clinical Leadership

• Developing Quality Improvement expertise

• www.hse.ie/go/qpsSource: Health Information and

Quality Authority (2012)

Devolving Leadership – from coal-face up

The New Clinical Leader

• ‘Traditionally, medical care has been

based around what doctors do, not primarily what patients need. The new generation of clinical leaders will…..first and foremost want to make a difference for good in the lives of the patients they care for. They will focus on efficiency, reduction of waste and better value…. …..’

• The New Clinical Leader, Kim Oates, Journal of Paediatrics and Child Health, 2012

Hospital in Arles, Van Gogh, 1889

....the last era of management was about how much performance we could extract from people .....the next is all about how much humanity we can inspire

Dov Seidman

The Doctor, Luke Fildes, 1891

Clinical leadership and compassion