Invited Service Reviews

Management

Frequently the ISR is requested long after the concerns are first raised which should have been dealt with locally and much earlier. Weak management of clinical teams and concerns about clinical competency are common. There appears to be a reluctance to engage with such issues perhaps because of the perceived medical hierarchy. A failure by trusts to follow due process in matters of competency and discipline has been surprising. They may have recognised long-term problems with the working practices of consultants, nurses and others and yet there has been little engagement with HR. If poor practice is identified then employers are responsible for taking action in line with their staff policies.

Another common theme is the variable quality of many clinical directors some of whom appear to have accepted the post with reluctance and have not been supported with adequate training in the necessary skills or given protected time to carry out the job to a satisfactory standard. Many of the trusts provided extra salary for these clinical management roles but expect clinical responsibilities to remain as before. Clinical directors have a difficult job and not all are suited to the task. It was seen that many remained in post for too long without senior review and with no attention to succession planning. Unsatisfactory working relationships with clinical teams were frequently observed with evidence of bullying and insufficient management expertise. Trusts need to invest more at this level of clinical management; clinical directors are an important resource and need effective development. In many instances there was obvious lack of communication between the clinical directors and their senior colleagues on the board and thus little meaningful involvement with strategic planning even when this impacted on their directorate. A disturbing lack of engagement and planning with commissioners and primary care was evident in many of the reviews. This has to improve if service providers are to work together for the benefit of patient care.

Consultant job plans and appraisals

The job plan is a standard part of the consultant contract. The plans were, however, often unclear and sometimes it was impossible to identify all the paid sessions and even where consultants were working throughout the week. This also applied to on-call responsibilities and many examples of excessive payments, and where paid activities far exceeded the national average (11) or what was appropriate for the hours claimed, were found. This reflects poor management and requires urgent attention by HR managers, something which the ISRs regularly recommend.

Annual appraisals were not always carried out and were often inadequate which suggests a need for more training for medical directors and others. Too often they had been left to inexperienced clinical directors, sometimes with no understanding of the specialty if it was not their own. Occasionally the appraisals were arranged by a non-clinical manager which is not appropriate. There were particular difficulties in achieving a meaningful appraisal where consultants were employed in smaller departments and especially primary care trusts (PCTs). There are increasing numbers of physicians who now work as a single specialist for a PCT. They require more support from colleagues to facilitate good working practices and allow joint clinical audit and professional development. Problems of this nature were observed in specialties such as genitourinary medicine and dermatology when they were managed in the community.

Clinical outcome data

A persistent lack of good outcomes data for most specialties, with the exception of cardiology, was noted. Publication of SMRs for different trusts by Dr Foster has increased public interest in outcome measures. Despite this, and the long history of clinical audit of medical patients that began with reviews of hospital deaths, only a minority of the visited trusts held regular multiprofessional mortality and morbidity (M+M) reviews. These are essential since clinical management in many specialties, particularly acute medicine, involves initial assessment by one team and transfer to others which makes follow up difficult for the admitting team with little opportunity to learn from diagnostic (frequent) and other errors.

It was often suggested that M+M reviews should be established and the results shared with the trust board at several ISRs. This advice was invariably well received and should be included as part of all consultant job plans (non-clinical activities). Trusts recognise the need for robust systems to collect and analyse outcome data, essential for improving patient safety, and yet few do so.

Patient consultation and commissioning

Unfortunately only a minority of the reviewed services provided evidence that the views of consumers were actively sought. While records of patient complaint investigations were seen there were few examples of structured engagement with local patient organisations which might influence clinical services and contribute to commissioning. There was a general lack of joint planning between secondary care trusts, the PCTs and commissioners even where services had been moved from secondary to primary providers. The lack of patient participation detracted from service developments and contributed to the demotivation of clinical teams and their managers.