Clinical Directors in evolution
2008 - 2014
Dr Colm Henry
National Lead
Clinical Directors Programme
Wednesday April 2nd 2...
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 outsi...
Post-Griffiths: protestors to participants
• ‘....this involvement by clinicians in
management has to embrace a
contributi...
Outline of role of Clinical Directors in 2008 Contract
• Deploy and manage consultants and resources
• Plan hospital and n...
Clinical Directors in Ireland – 2008-2014
• Hospital-based and Mental Health
• 55 hospital-based
• 18 Mental health direct...
Clinical Directors 2009-2014 – expectation vs.
reality
• Nominal responsibility across all clinical
areas
• Patchy devolut...
‘Upside-down’ accountability
• ‘...I remind you that I do not accept
clinical responsibility for an unsafe
service. I remi...
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-centr...
0
5
10
15
20
25
2011 2013 2015 2017
All ages
65+
1. Demographics: increase in health service cost
pressures due to demogra...
2. Expectations: expensive advances
0
100000
200000
300000
400000
500000
600000
700000
2004 2006 2008
Expenditure
(euro)
E...
2. Expectations – older people
1. Changing attitudes to cardiopulmonary
resuscitation in older people: a 15-year follow-up...
3. Over-centralisation of accountability
4. Cultivation of cynicism
• Opposing targets
• Multiple and contradictory drivers for change
• Organisational practice op...
‘No more heroes’: The future of leadership and
management in the NHS. (The King’s Fund 2013)
‘The NHS needs to move beyond...
Quality and Patient Safety – a long-term race
• National Healthcare Charter
• ‘Your Service Your Say’ – measuring
feedback...
Devolving Leadership – from coal-face up
Group CEO
Chief Clinical
Director
Chief Academic
Officer
Chief Director of
Nursin...
The New Clinical Leader
• ‘Traditionally, medical care has been
based around what doctors do, not
primarily what patients ...
....the last era of
management was about how
much performance we could
extract from people
.....the next is all about how
...
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Colm Henry, National Lead Clinical Director Programme

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Clinical Directors in Evolution

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  • Medicare and MedicareOnce given you cant take backTrue not only for access but also quality
  • Medical committees – Greek chorus, commenting on everything that was happening on stage but not participating in the play Then elected representatives to hospital boards- brought level of disinterested observer to higher level Then cogwheel system of divisions with rotating chairs often based on seniority or somebody’s turnGriffiths started the slow journey from cogwheel to fuller engagement
  • Post-Griffiths – set up clinical directorates replacing cogwheel divisions. Business units with manager and senior nursePrimary care largely bypassedLord Darzi : high quality care for all NHS next stage review final report 2008 –enthusing doctors about being more engaged with leadership while maintaining clinical role (NB)
  • Berwick ‘If clinical frontline staff decide they do not want to make changes then no one outside the healthcare system can be powerful or clever enough to make them do so’
  • Intrinsic – range of lystyles and skills necessary to effect change and, even more importantly, to bring people with themFor variety of reasons, some people struggleLesson of quote is that ALL will deplete in timeFocus on extrinsic features which may accelerate depletion
  • Speak about issues in black firstRe No. 4- mention deskilling and surgeons
  • 150 older people awaiting discharge questioned re CPR 1992 vs 200776% would refuse CPR in 1992 vs 6% in 2007Critical illness 55% vs 0%Terminal illness 37% vs 0%– AVASTIN – explosion of medical performance – JFK Dick Cheyney – Sok PAPERGeorge Burns
  • Is it sustainable to centralise accountability? – Learn nothing and forget nothingIs it evidence-based when more than 80%of adverse events systems rather than individual – yet response of regulators is inverseRefer to upside down and ‘your fault’ letter againAllude to Medical CouncilKevin Stewart –Belfast safety conferenceAllude to presentationGunther Jonitz –President Berlin Chamber of PhysiciansHolistic approach based on organisation of healthcare and systemsBuild network of individuals and organisations focussed on safety
  • Colm Henry, National Lead Clinical Director Programme

    1. 1. Clinical Directors in evolution 2008 - 2014 Dr Colm Henry National Lead Clinical Directors Programme Wednesday April 2nd 2013
    2. 2. Once upon a time… Anatomy Lesson of Dr Tulp, Rembrandt, 1632
    3. 3. National Health Expenditure vs GDP, USA 1960-2005 Centres for Medicare and Medicaid Services, USA
    4. 4. National Health Expenditure,USA, Public vs Private funding
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. 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’
    10. 10. ‘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
    11. 11. A sustainable and realistic model? • ‘the exercise of all power is a process of depletion..’ Henry Kissinger
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 2. Expectations – older people 1. Changing attitudes to cardiopulmonary resuscitation in older people: a 15-year follow-up study P. E. COTTER1, M. SIMON1, C. QUINN1, S. T. O’KEEFFE2 1Portiuncula Hospital, Ballinasloe, Co. Galway, Ireland 2Galway University Hospitals, Galway, Ireland Age 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 Tinetti NEJM February 20th 2014
    16. 16. 3. Over-centralisation of accountability
    17. 17. 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
    18. 18. ‘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
    19. 19. 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/qps Source: Health Information and Quality Authority (2012)
    20. 20. Devolving Leadership – from coal-face up Group CEO Chief Clinical Director Chief Academic Officer Chief Director of Nursing Chief Finance Officer Clinical Director Medicine Chief Operations Officer Clinical Director Peri-operative Clinical Director Diagnostics Clinical Director Women and Children Site Clinical Lead Site Clinical Lead Site Clinical Lead Site Clinical Lead
    21. 21. 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
    22. 22. ....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

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