Consultants Based Care the future? Royal College of Surgeons 7 th May 2009 Dr Jonathan Fielden FRCP FRCA Chairman Central Consultants and Specialists Committee.

Consultants Based Consultants Based CareCare

the future?the future?Royal College of SurgeonsRoyal College of Surgeons

77thth May 2009 May 2009

Dr Jonathan Fielden FRCP FRCADr Jonathan Fielden FRCP FRCA

Chairman Central Consultants and Specialists CommitteeChairman Central Consultants and Specialists Committee

Director Medical Education and Development Director Medical Education and Development

Royal Berkshire Hospital ReadingRoyal Berkshire Hospital Reading

Consultant based careConsultant based care

Right patient, right person, right Right patient, right person, right time, right nowtime, right now

Stafford never again, Bristol Stafford never again, Bristol never againnever again

There are many methods for predicting the There are many methods for predicting the future. For example, you can read future. For example, you can read horoscopes, tea leaves, tarot cards, or horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods crystal balls. Collectively, these methods are known asare known as

““nutty methods.”nutty methods.”

Scott Adams (1957-), The Dilbert FutureScott Adams (1957-), The Dilbert Future

Or you can put well-researched facts into Or you can put well-researched facts into sophisticated computer models, more sophisticated computer models, more commonly referred to ascommonly referred to as

““a complete waste of time.”a complete waste of time.”

Scott Adams (1957-), The Dilbert FutureScott Adams (1957-), The Dilbert Future

… a consultant delivered service …… a consultant delivered service …

The NHS Plan – 2000The NHS Plan – 2000

The consultant’s roleThe consultant’s role

Consultant ledConsultant led

The consultant’s roleThe consultant’s role

Consultant based Consultant based serviceservice

DefinitionDefinition Consultants lead the teams Consultants lead the teams

delivering all care, are involved in delivering all care, are involved in all major decisions and deliver all major decisions and deliver treatment to patients appropriate treatment to patients appropriate to their level of skills and trainingto their level of skills and training

http://www.bma.org.uk/ap.nsf/Content/Consultantexpansion0408

Consultant based careConsultant based carethe continuum of quality the continuum of quality

carecare

Out-patients

Community teams

Multi-Disciplinary teams

Emergency life-threatening

surgery

Elective lists

Departmental and trust leadership

Education

Departmental and trust management

“Consultants actively involved in all

appropriate aspects of patient treatment”

Final Recommendation Final Recommendation 55

There needs to be a There needs to be a common shared understanding of the roles of all common shared understanding of the roles of all doctors doctors in the contemporary healthcare team that takes due account of public in the contemporary healthcare team that takes due account of public expectations. Given the interdependency of the professional constituents of the expectations. Given the interdependency of the professional constituents of the contemporary multiprofessional healthcare team we suggest a contemporary multiprofessional healthcare team we suggest a similar analysis similar analysis extends to other healthcare professional groupingsextends to other healthcare professional groupings. . Clarity of the doctors role must Clarity of the doctors role must extend to the service contribution of the doctor in training, doctors currently extend to the service contribution of the doctor in training, doctors currently contributing as locums, staff grades and associate specialists, the CCT holder, the GP contributing as locums, staff grades and associate specialists, the CCT holder, the GP and the consultant. Such issues needs to be urgently considered by key stakeholders. and the consultant. Such issues needs to be urgently considered by key stakeholders. Notwithstanding the need to keep such a key issue under constant review, Notwithstanding the need to keep such a key issue under constant review, stakeholders should seek to reach public consensus before the end of 2008, so stakeholders should seek to reach public consensus before the end of 2008, so important is the issue for current NHS reform.important is the issue for current NHS reform.

Education and training need to support the development of the redefined roles for Education and training need to support the development of the redefined roles for each professional grouping and provide the necessary educational foundations to each professional grouping and provide the necessary educational foundations to enable them to practise safely and effectively, and to enable them to practise safely and effectively, and to aspire to enhanced aspire to enhanced rolesroles..

CCSC developing view CCSC developing view of the Role of the of the Role of the consultantconsultant

'Primarily as clinicians 'Primarily as clinicians predominantly predominantly involved in the involved in the delivery of expert clinicaldelivery of expert clinical care usually within a team, including the care usually within a team, including the ability to recognise ability to recognise and manage the and manage the more complex end more complex end of the specialty spectrum. of the specialty spectrum. also involved in running also involved in running departments, managerial decisions, departments, managerial decisions, teaching, training, researching, developing teaching, training, researching, developing local services; being involved in local services; being involved in the wider management and the wider management and leadership of the organisations they leadership of the organisations they work in, and the NHS generally. work in, and the NHS generally.

Academic

CanMEDSCanMEDS

Professional Communicator

Colla

bora

tor

Manage

r

Sch

ola

r

Health Advocate

Medical

Expert

Management

Teaching

Research

Clinical

Leadership

Specialty DoctorSpecialty Doctor

AssessmentAssessment

Consultant

Nor does a new specialist grade and contract

need to be negotiated

Consultant

Academic

CanMEDSCanMEDS

Professional Communicator

Colla

bora

tor

Manage

r

Sch

ola

r

Health Advocate

Medical

Expert

Management

Teaching

Research

Clinical

Leadership

Picker insitutePicker insitute

What patients wantWhat patients want

Consultant based careConsultant based care the the implicationsimplications (focused) consultant expansion(focused) consultant expansion Changes in the way we workChanges in the way we work More hands onMore hands on More presenceMore presence Right first timeRight first time Service and quality built on Service and quality built on

consultantsconsultants

0

20,000

40,000

60,000

80,000

100,000

120,000

WTE le

vel o

f doct

ors

Consultant (WTE) GP (WTE) Training (WTE) SAS (WTE)

130,000

150,000

170,000

190,000

210,000

WTE le

vel o

f doc

tors

Projected Supply (WTE) 1.5% constrained supply (WTE) Demand - Solid Progress (WTE)

Demand - Slow Uptake (WTE) Demand - Fully Engaged (WTE)

National Audit Office – National Audit Office – April 2007April 2007

© Institute for Fiscal Studies © Institute for Fiscal Studies

Public spending Public spending squeezedsqueezed

-2

-1

0

1

2

3

4

5

6

7

89

6–

97

97

–9

8

98

–9

9

99

–0

0

00

–0

1

01

–0

2

02

–0

3

03

–0

4

04

–0

5

05

–0

6

06

–0

7

07

–0

8

08

–0

9

09

–1

0

10

–1

1

11

–1

2

12

–1

3

13

–1

4

14

–1

5

15

–1

6

Financial year

Pe

rce

nta

ge

re

al i

ncr

ea

se

30

32

34

36

38

40

42

44

46

48

50

Pe

rce

nta

ge

of

na

tion

al i

nco

me

Real increase, LH axis

Level, RH axis

What is Productivity?What is Productivity? a a cultureculture in which everyone continually strives to in which everyone continually strives to

make better use of all the available make better use of all the available resourcesresources– an ongoing an ongoing processprocess to ensure the effort is effective and to ensure the effort is effective and

efficientefficient

– sustaining sustaining performanceperformance, , responseresponse, , reliabilityreliability, , qualityquality - - all the factors involved in managing resources.all the factors involved in managing resources.

the concept of capital productivity is rejectedthe concept of capital productivity is rejected

– replaced with the concept of replaced with the concept of valuevalue

Karl Marx - Labour Theory of Value

Do we Deliver Value?Do we Deliver Value? Evidence of quality-Evidence of quality-

– NCEPODNCEPOD– RCP academyRCP academy– BMJBMJ

Daily practice – informationDaily practice – information Local role in proving the value –PbR?Local role in proving the value –PbR? Much comes back to 2 aspects Much comes back to 2 aspects

leadership and SPAsleadership and SPAs

Academic

CanMEDSCanMEDS

Professional Communicator

Colla

bora

tor

Manage

r

Sch

ola

r

Health Advocate

Medical

Expert

Management

Teaching

Research

Clinical

Leadership

Performance Performance managementmanagement

Revalidation

Talent managementTalent management

Revalidation

2000 2002 2004 2006 2008 2010 2012

Some keyoutcomes

•key illnesses•throughput•capacity

•health priorities•waiting times•financial stability

•quality, safety•patient experience•18 weeks•credibility

•health & well-being• equity•joined up care

Self-sustaining Health

Transforming care system

ReconfiguringService Delivery

Financial Stabilisation

Growth, Expansion & Delivering the ‘Basics’

Targets &Performance Management

SHA/PCT/TrustsChoice & ProvidersCommissioningConnecting for Health‘REFORM’

Journey

Local Capability & Self-improvementBreakthrough & Innovation

Social MovementsCo-creation

Centre’s‘LEADERSHIP’

Journey

Technical LeadershipAdaptive Leadership

Target setter +Performance manager +

Delivery leader

Regulator +National Standards +

System leader

‘SERVICE’ Journey

‘‘Starter for 10’ view of the journeyStarter for 10’ view of the journey

Better quality

Better patient experience

Better value for money

Reduced inequality

Money following the patients, rewarding the best and most efficient providers, giving others the incentive to improve

TRANSACTIONAL REFORM

More choice and a much stronger voice for

patients

DEMAND-SIDE REFORM

More diverse providers, with more freedom to innovate and improve

services

SUPPLY-SIDE REFORM

A framework of system management, regulation

and decision making which guarantees safety

and quality, fairness, equity and value for

moneySYSTEM MANAGEMENT AND

REGULATION

•Payment by Results •Developments in PbR eg normative pricing

•Quality bonus/discount scheme in model contract

•Other incentives in secondary care eg CGST

•QOF•Frequency and type of clinical & patient experience information

•Benchmarking and audit•Empowering clinical teams•Lean thinking & reliability science

•Provider support eg NIII, CGST•Voluntary accreditation•Workforce development•Professional education/CPD•New providers, eg IS, 3rd sector

•Service reconfiguration

•Patient choice•Information for choice•Commissioning esp PBC & pathway redesign

•Quality requirements in contracts

•NICE guidance + NSFs providing advice for commissioners

•Licensing against core standards of safety and quality

•Clinical failure regime•Performance assessment of providers and commissioners

•Organisational assessment•Professional regulation•Clinical networks across commissioners and providers

Some potential mechanisms to promote Some potential mechanisms to promote quality improvement…quality improvement…

Key purposes

• NQB Quality Report

• Regional quality measures

• Services from Quality Observatory

• Clinical Team quality measure and dashboards

Example product

• Provider quality account

Nati

on

al

Reg

ion

al

Local

Team

• Improvement against national priorities

• Accountability to taxpayers

• International benchmarking• Improvement in quality within the region and progress against the regional vision

• Enable benchmarking

• Service improvement• Board accountability • Provider benchmarking

• Service improvement • Team benchmarking for

improvement

Sources of evidence-based indicators include Royal Colleges, specialist societies, NHS Information Centre, universities, commercial sector

Local clinical ownership of indicators

Co-p

rod

ucti

on

at

all levels

of

the s

yste

m

Subsidiarity

Embedding quality

Successful Successful organisationsorganisations Customer focusedCustomer focused Have visionHave vision Align their vision with their (senior) staffAlign their vision with their (senior) staff

– Value and develop in partnershipValue and develop in partnership– Have/develop inspirational leadershipHave/develop inspirational leadership

Forecast and adaptForecast and adapt– Learn, innovate and improveLearn, innovate and improve

Know their “market”Know their “market” Put quality results as their goalPut quality results as their goal

Successful Successful organisationsorganisations PatientPatient focused focused Have visionHave vision Align their vision with their Align their vision with their consultantconsultant staff staff

– Value and develop in partnershipValue and develop in partnership– Have/develop inspirational leadershipHave/develop inspirational leadership

Forecast and adaptForecast and adapt– Learn, innovate and improveLearn, innovate and improve

Know their “market”Know their “market” Put quality results as their goalPut quality results as their goal

Reward for doing so?Reward for doing so?Individual Individual

ConsultantConsultant Improved patient careImproved patient care Work-life balanceWork-life balance Career developmentCareer development Excellence awardsExcellence awards Pay progressionPay progression Adapting to the changing Adapting to the changing

environment – CCTHenvironment – CCTH PerformancePerformance

Reward for doing so?Reward for doing so?Consultant bodyConsultant body

Maintaining the “Brand” Maintaining the “Brand” consultantconsultant– Marketing the brandMarketing the brand

Product, Place, Promotion and PriceProduct, Place, Promotion and Price Competition, new entrants, customers, Competition, new entrants, customers,

suppliers, substitutessuppliers, substitutes

Advancing the serviceAdvancing the service Changing the paradigmChanging the paradigm

Consultant based careConsultant based carethe continuum of quality the continuum of quality

carecare

Out-patients

Community teams

Multi-Disciplinary teams

Emergency life-threatening

surgery

Elective lists

Departmental and trust leadership

Education

Departmental and trust management

“Consultants actively involved in all appropriate

aspects of patient treatment “

QuestionsQuestions

[email protected]