Teams without Walls: enabling partnerships between generalists and specialists
Abstract
This one-day conference for senior clinicians and NHS managers was a partnership between the King's Fund, Royal College of Physicians (RCP) and Royal College of General Practitioners (RCGP). It explored clinical partnerships and integrated care by examining how to develop constructive and workable relationships between generalists and specialists that harness clinical skills, support professional practice and deliver excellent care to patients.
Professor Sir Bruce Keogh, NHS Medical Director, delivered the keynote address in which he reminded delegates of the drivers to policy reform: medical and information increasing technological advance, changed societal attitudes and demands for safety and quality, on a background of economic and political influences. The NHS is now in the third and final stage of policy reform, ‘transformational change’, in which strategic health authorities (SHAs) will have independence to drive service change at a local level for the benefits of patients. The change will be clinically driven, evidence based and locally led.
John Clark, Director of Medical Leadership at the NHS Institute for Innovation and Improvement, acknowledged that most service change was driven by doctors and that the NHS hierarchical structures distanced front line clinicians and did not involve junior doctors. A ‘medical leadership competency framework’ has been developed to inform medical training curricula and assist in personal development and career planning. A medical engagement scale would score organisational performance and create a culture of clinical involvement through benchmarking across organisations. His final plea was to nurture talent not frustrate it and for leadership and engagement to become ingrained, not a fad.
Mike Pearson gave a clear description of the problems behind measuring quality and success. Standards depend on the perspective, purchasers want maximum cost benefit, patients want to feel better, providers need to meet targets and physicians practice professional values. Variability exists in all audits so data must not be misinterpreted and used punitively. National audits, specifically the Myocardial Infarction National Audit Project, had resulted in significant service improvement. Clinicians are inherently competitive and like to see their own benchmarked performance data presented in an understandable format.
Massoud Fouladi spoke on integrated governance as medical director of Circle, a partnership of clinicians and business managers. Integrated governance has four components – financial, corporate, IT and clinical – and he spoke of four levels of integrated care:
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1. integrated care pathways for single conditions
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2. integrated practice units for clusters of medical conditions
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3. provider organisation integration (specialty specific teams and networks, primary care integration between general practitioners (GPs), community services and social care, vertical integration between hospitals and community service, US models of independent physician association)
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4. system integration between payer and provider, Health Maintenance Organisation (HMO) model.
Integration needs more than simple co-location. Its governance is independent of care setting and medical leadership should be secured by giving responsibility at a board level.
John Dean spoke jointly with James Mountford of McKinseys concerning Bolton's community-based specialist diabetes service and how this could be adapted to other long-term conditions. They concluded that clinical integration brings improved outcomes and experience for patients and staff, requires strong clinical leadership and good relations between clinicians and managers.
Discussion highlighted the need for multiprofessional learning in team-working skills and future clinicians need training for this new integrated environment.
Three parallel sessions followed. The joint RCP/RCGP/Royal College of Paediatrics and Child Health and NHS Alliance Teams without Walls publication was presented followed by an open discussion highlighting the value of clinical networks. The role of the primary care trusts and in particular the role of the chairman of the professional executive committee in the clinical direction of commissioning alongside SHA medical advisors was discussed. Those who have experienced service redesign endorsed the Teams without Walls concept.
Deborah Colvin discussed quality assurance and integrating services and Sushema Saksena described her case study on medical leadership in the delivery of a district general hospital liver service. A final panel discussion was chaired by Steve Field. Panelists discussed the need for training to match service needs. PCTs needed help with local service accreditation. GPs with special interests received particular attention since there is concern around local sustainability of the role and cost effectiveness. Panelists were clear that GPs with a special interest should not replicate the specialist but that they should be an interface between specialist and generalist care. Other forms of role substitution, especially nurse prescribing, were also discussed.
Conference programme
Footnotes
This conference was held at the King's Fund on 11 June 2008 and was jointly organised by the Royal College of Physicians, the King's Fund and the Royal College of General Practitioners
- © 2009 Royal College of Physicians
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