Spotlight On General Practice

Preparing for the Demands of Clinical Governance and Revalidation

Sally Irvine, Hilary Haman

• Publisher: CRC Press
• Year: 2018
• Print ISBN: 9781138448049
• eBook ISBN: 9781315348018
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

What are the dynamics that shape a primary care team? How can difficult issues be tackled when aiming towards the government's strategies? This book shows how good governance and quality management in general practice can be achieved. It addresses difficult issues, such as power, leadership, interpersonal behavior, confrontation, accountability and handling conflict, and looks at the dynamics of both groups and individuals, and investigates ways of dealing with them. It provides practical solutions, questions to help the reader analyze problems and test their performance, case studies and real examples drawn from the authors' many years experience in diagnostic management consultancy. It is essential reading for all members of the new primary care organizations, especially GPs, practice managers and nurses.

Part 1

Changes to primary healthcare and the role of diagnostic consultancy

1

The past and the present

During the 18 years of our diagnostic consultancy work there have been significant changes in the overall context in which general practice is delivered. That pace of change looks set to continue. In sharing and developing what we have learned from visiting practices over that time, we have been very conscious of the need both to draw from the past and also to set our conclusions and lessons in the present and future context for primary care. This first chapter therefore starts with a brief discussion of that context.

Five principal changes can be summarized as follows:

1. The changing nature of primary care, as general practice and primary care have moved from being the point of entry and referral to the health system, to being major providers of care in their own right.
2. The developing concept of partnership and team-working, with much more emphasis on the non-medical contribution to healthcare delivery as chronic illness and preventative care are managed mainly in the community setting.
3. Structural and political change, as successive govern-ments, the wider public and many in the health professions have started (although not finished) to shift the emphasis in healthcare from a professionally oriented to patient-oriented service.
4. Increased accountability and the application of basic management method to clinical care, through the development of clinical governance, embodying the principles of audit and external peer review against explicit professional standards.
5. The development of the commissioning role in respect of purchase of secondary care, with the management and organisational demands that entails.

Each of these changes is explored below.

The changing nature of primary care

The sort of care the public wants reflects the societal values and priorities current at any given time. In the 1970s and earlier, the emphasis was on secondary and tertiary care – the sexy, glossy and glamorous end of medicine, where miracles occurred. This is no longer so. The public now wants more accessible, ‘user-friendly’ care on its doorstep, as well as good secondary care. Primary care today is seen as the way of organising healthcare better through maintaining patients at home or in the com-munity, where it is appropriate to do so, reflecting current social thinking and demand. General practice, the main provider of primary care, provides major services in early decisions about acute illness, in the care of the chronically sick and preventative medicine. In other words, there has been an important revaluing of the rather ‘messy and un-sexy part of the service’ (Irvine and Irvine, 1996).

In the 1989 White Paper Working for Patients (DoH, 1989), and the New Contract which followed (DoH, 1990), determined (and, for many, misguided) attempts were made to strengthen accountability in general practice and to contain costs, especially of prescribing. At the same time, almost as an afterthought, general practice fund holding was introduced. This greatly extended the influence and power of those practices which took it up, through their ability to purchase secondary care. Arguably, however, the main impact of fund holding was on the practices themselves because of the new organisational and management demands it made. In particular, those at the leading edge used the enhanced practice management requirements to develop their capacity to quantify and monitor their care.

This trend has continued. Today, under a different government and a new NHS Act, the key elements of fund holding have been extended to all practices through the potential of the PCGs, LHGs and LHCs. In addition, there are completely new services such as NHS Direct, the walk-in clinics and nurse practitioner services.

For practices, this steady evolutionary trend points in one direction only. To be effective, indeed to survive, practices have got to get to grips with the key messages that low from our observations over the years.

Partnership and the team

This change of role and position in the hierarchy of healthcare has put enormous demands on general practice and has forced changes in its way of working, particularly in relation to other members of the primary healthcare team. As Huxham (1993) said, ‘Collaborative advantage will be achieved when something unusually creative is produced that no organisation could have produced on its own and when each organisation through collaboration is able to achieve its own objectives better than it could have done alone.’

As a consequence, multidisciplinary working in primary care has received a lot of attention in recent years. As Chapter 4 shows, it is still in transition but the lead role of medicine and the medical profession as the guardians of the nation’s health, both population and individual, is now shared with others. The development of the wide range of skills and professions now involved in the delivery of healthcare has tested doctors in their management role and their attitudes to the development of wider partnerships, not just inside but outside the practice.

The development of group practice followed the 1966 Doctors’ Charter as the first formalization of the concept of partnership in healthcare – partnership between doctors. That soon extended with the attachment of district nurses and health visitors, and extended again with the arrival of practice nurses and the other health professionals with primary care responsibilities. Fund holding accelerated the rising position of managers in practice as significant members and, frequently, architects of the primary healthcare team. Full team working on practice development plans and inter-professional training has become commonplace. Case Study B in Chapter 8 shows how this can be done.

The concept of partnership and the statutory duty now imposed on healthcare trusts and authorities to seek and exercise partnership across boundaries are the latest in a series of changes in concepts of professional hierarchy (DoH, 2000). Doctors now have to be able to work effectively within wider organisations, such as PCGs, LHGs and LHCCs, and allied institutions, local councils and authorities, voluntary and charitable bodies, user and career groups as well as the private sector. For instance, there are some areas where trusts responsible for mental health services and social services departments have found sufficient common ground and means of resolving the thorny problem of different funding streams to enable multidisciplinary and multi-agency teams to be formed. In some cases, for example, a community psychiatric nurse is accountable to a social worker (Northumberland Health Authority, 1999).

Structural and organisational reorientation

Alongside the changing nature of team-based care has been the change in emphasis from a professional to a patient-oriented service. This change in cultural orientation is not complete. That is why today we see some practices that regard the patient as the starting point for service while others still see the professional service as the primary driver. At a practical level this can result in important differences, for example in attitudes to patients, the way that complaints are handled or whether patient views are sought on practice services and performance, and so on.

In this changing climate, themes are developing around:

• more user-friendly care
• easier access largely through electronic technology developments
• wider range of healthcare delivered in or through the primary setting
• more emphasis on prevention
• increased multidisciplinary workforce
• greater use of professions other than doctors in independent settings
• greater integration with social care and social services
• more emphasis on cross-boundary working between primary and secondary care, especially in the management of chronic illness.

These structural and organisational changes in primary care mean that it is already – consciously or not – at the forefront of the government’s modernisation agenda. The developments reflect, and will further reveal, issues and tensions that have been underlying the organisation and development of general practices since group practice became common. They can be summarised as:

• the capacity of primary care to deliver the expanded range of responsibilities and services
• the demand for efficient and provably efficacious services against the value of holistic and traditional family doctoring
• the conflict between uniformly and centrally driven high quality with the need for local flexibility and innovation
• the loss of the personal touch as more remote means of communications and support are offered
• the balance between vocational service and the modern values of private and family life.

These are difficult tensions to manage. They are exacerbated by the pressure created by other factors discussed below.

Most commentators see the government’s White Paper The New NHS (DoH, 1997) as evolutionary rather than revolutionary. Many of the organisational and institutional changes we have described are intended to force changes in professional behaviour. Example 4 illustrates this.

Example 4

Basketball Surgery had been a first-wave fundholding practice. The six partners were enthusiastic supporters of the concepts involved in quality improvement and saw fundholding as a means of ensuring that patients obtained the best secondary care available through the placing of contracts by the practice. When fundholding was abandoned, the same partners saw PCGs, and the future PCTs, as an opportunity to further develop their potential to constrain and monitor the secondary care that the PCG, and through it the health authority, was commissioning for their patients. They saw the new developments as further enabling them in their advocacy and commissioning role.

Increased accountability and the development of clinical governance

Largely as a result of the development of teaching practices, the principles of external peer review against explicit professional standards have long been embodied in the culture of a substantial element of general practice. Teaching GPs were ahead of the government and the NHS in exploring the use of audit and quality assurance in the teaching practice setting.

The problem is that these basic principles of standard setting and monitoring were never extended to all general practices, either by the profession itself or by the NHS. This is now changing fast. The public demand for greater accountability, especially of professional performance, has brought performance assessment and quality assurance high on the professional and managerial agenda. At the time of writing clinical governance is being implemented and the GMC’s revalidation plans, embracing audit and appraisal against explicit standards, are out for consultation. Chapter 6 explores this in the context of the underlying issues we have revealed through diagnostic consultancy.

Closing the gap between the extremes of variation in general practice needs a general change in both professional and institutional culture, with more emphasis on openness, a willingness to confront error and learn from it, and the adoption of the culture of quality improvement rather than blame. This substantial change implies an equally substantial programme of education, re-skilling and investment in the data and other systems which have to become part of the quality agenda. This is what clinical governance should be all about.

Quality is at the core a...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• About the authors
• Introduction
• Part 1: Changes to primary healthcare and the role of diagnostic consultancy
• Part 2: Underlying issues
• Part 3: Case studies
• Part 4: The future
• References
• Appendix A: What is diagnostic consultancy?
• Appendix B: Practice strengths
• Appendix C: Management tips
• Index