The Role of Clinical Leadership in Service Transformation

1
The Role of Clinical Leadership in Service
Transformation

• Dr Richard J Reece
• Consultant Rheumatologist
• Calderdale and Huddersfield NHS Foundation Trust

2
Structure of My Presentation

• Me and My Leadership Behaviour
• My pathway through service redesign
• ISIP and how it is effecting change for me
• My reflections
• Engaging more clinicians

3
LEA Introduction

• Leadership Effectiveness Analysis defines the
  leadership role in terms of
• 22 behaviour characteristics
• Grouped into 6 sets
• Individuals are evaluated by
• 1 boss
• 5 peers
• 5 direct reports
• Forced choice response and scaled ratings
• Feedback provides an individualised behaviour
  profile
• Framework for self development

4
Lea Behaviour Sets

• Creating a Vision
• Traditional
• Innovative
• Technical
• Self
• Strategic
• Developing Followers
• Persuasive
• Outgoing
• Excitement
• Restraint
• Implementing the Vision
• Structuring
• Tactical
• Communication
• Delegation

• Following Through
• Control
• Feedback
• Achieving Results
• Management Focus
• Dominant
• Production
• Team Playing
• Cooperation
• Consensual
• Authority
• Empathy

5
My LEA Profile High Scores

• Creating a Vision
• Traditional
• Innovative
• Technical
• Self
• Strategic
• Developing Followers
• Persuasive
• Outgoing
• Excitement
• Restraint
• Implementing the Vision
• Structuring
• Tactical
• Communication
• Delegation

• Following Through
• Control
• Feedback
• Achieving Results
• Management Focus
• Dominant
• Production
• Team Playing
• Cooperation
• Consensual
• Authority
• Empathy

6
My LEA Profile Low Scores

• Creating a Vision
• Traditional
• Innovative
• Technical
• Self
• Strategic
• Developing Followers
• Persuasive
• Outgoing
• Excitement
• Restraint
• Implementing the Vision
• Structuring
• Tactical
• Communication
• Delegation

• Following Through
• Control
• Feedback
• Achieving Results
• Management Focus
• Dominant
• Production
• Team Playing
• Cooperation
• Consensual
• Authority
• Empathy

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Rheumatology is a Success!

• Established Inter-disciplinary Team
• Effective working practices
• Short waiting times (2-4 weeks for routine)
• New to f/u ratio 3.0 1
• Low levels of complaints / critical incidents
• Good relationships with colleagues
• Adopting NICE guidance
• gt140 patients on anti-TNF drugs / COX-2 NSAID
  prescribing
• Out-patient clinics in Huddersfield
• Day case and in-patient services in Leeds

8
But look at it a different way

• Small team and large clinical workload
• 2000 Rheumatoid arthritis patients
• 350 Psoriatic arthritis/Ankylosing spondylitis
  patients
• 200 Connective tissue disease patients
• Current working practice
• Poorly structured non inter-disciplinary annual
  reviews
• Not delivering evidence-based care consistently
• No patient education programme / poor self-care
• Clinical boundaries with Primary Care
  inconsistent
• Clinical governance at Huddersfield/Leeds
  interface

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An Eventful Journey to Date?

• New Shared Care Prescribing Protocols - 2000
• Patient Journey Mapping Day Nov 2001
• Capacity and Demand Metrics mid-2002
• ESP Physiotherapist in OPD Jan 2001
• Imaging and pathology request protocols
• Increased Specialist Nurses 2002/04
• Foundation of Clinical Network - 2005
• Independent Nurse Prescribing 2006
• Ongoing PDSA cycles throughout

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New Patient Waiting Times
11
New Patient Referral Rates
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What are we trying to achieve?

• Comprehensive annual inter-disciplinary clinical
  assessments of all RA patients in community based
  setting
• GPs invited to participate in above
• GP opportunity improve knowledge and skills in RA
  management
• Transfer of Tertiary Services to LHC
• Educational and Self-Care Support Strategy for RA
  patients and Carers

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Projected Benefits

• Delivering on 18 week targets / OHOCOS
• Reduced hospital out-patient attendances
• Improved
• Self-care
• Lines of Communication
• Clinical Governance
• Working Lives
• Informatics
• Reduced direct / indirect costs
• Redefined Clinical Roles

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DH LTC Pilot Site Status Too

• 1 site selected from across UK
• 2 sites in dermatology previously commissioned
• Report to Long Term Conditions Team at DH by July
  2008
• Review and modernise all of rheumatology services
• For new patients
• For existing chronic disease patients
• Kirklees side first, Calderdale to follow
• 115,000 to assist in delivery

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What is Pilot Site Status About?

• This wider service transformation is running in
  parallel and over a longer time frame
• Encompass all rheumatology conditions
• New and Existing patients
• Implementation of MSK Framework
• Financial support for
• Project manager
• Rheumatology software procurement
• Patient education programme and website
  development
• Facilitation of meetings and events

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Benefits of ISIP Involvement

• Relationship Manager from ISIP
• Understanding Project Management
• Communications Strategy
• Stakeholder and Commissioner Engagement
• Governance Structure
• Public-Patient Involvement
• RTC helps give structure
• Improvement Leaders Guides
• Constant Time Pressure
• Fortnightly diaries on Networks website
• Delivery by September 2007

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Communications Strategy

• Trust News and Press Releases
• Monthly Updates at Directorate Boards
• Intranet site
• Website
• Rheumatology Clinical Network
• Communication cascade across PCTs via practice
  managers
• Specialist Society / College newsletters

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Where do Patients Feature?

• Patient Centred Service Transformation
• Establish a Patient Forum in partnership with
  ARMA?
• RA patient focus group NRAS facilitated
• To give input to and review ISI Plan
• To trial new interdisciplinary clinics
• To benefit from enhanced patient education and
  website development

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Overview of ICP for RA
Diagnosis of RA confirmed by Consultant
Rheumatologist / Known RA Patient Referred/Moves
Into Area
Patient (Re-) referred to Specialist Service

• Inter-disciplinary MOT Clinic Attendance
• patient problem list disease activity
  assessment
• physiotherapy, OT, dietetic, podiatry and
  appliance requirements patient knowledge/coping
  strategies
• physical examination and biometrics update
  of medical history
• functional status, quality of life, work
  instability and benefits drug therapy
  requirements

Treatment Plan and Desired Outcomes Defined and
Agreed With Patient and Carers
Patient Education Programme and Self-Help Groups
Tertiary Care Services
Clinical Research Programme
Referral to Other services
Therapy Services Input
Assessed to be in Clinical Remission
Shared Care DMARD and biologic therapies
(according to agreed protocols)
YES
NO
Clinical Remission Maintained for 2 Years
Patient / Carer/ Other Contacts Rheumatology
per Issued Guidance
Defined Outcomes Achieved
YES
NO
Discharged from Secondary Care
Rheumatology MDT Informed and Appropriate Action
Taken
YES
NO
Moves away / chooses alternative provider / Dies
Subsequent Periodic Inter-disciplinary MOT
Clinic Attendance
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Wider Local Impact

• Rheumatology linked into LTC strategy
• Business case for day-case repatriation
• Opportunity to integrate this with dermatology
  gastroenterology, oncology and haematology
• Identifying space locally to accommodate
• Application to Health Foundation for 150,000
  from Co-Creating Health to develop local
  patient self management programme

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My Personal Reflections

• Managers and Clinicians one NHS divided by a
  common language ?

22
Roadmap for Transformational Change
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Managers Engaging with Clinicians

• Managers read HSJ and DH documents
• Managers dont ask the right questions
• Managers dont understand the clinical service
  (target driven)
• Managers and clinicians have different agendas
• Managers approach the wrong clinicians
• Managers dont give positive feedback

24
Clinicians Engaging with Managers

• Clinicians read clinical journals
• Clinicians are not asked what could be improved
• Clinicians dont (want to) see benefits of change
  (no incentives?)
• Clinicians dont know who to engage
• Clinicians dont trust managers
• Clinicians want to own changes to practice

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Roadmap Phase 1
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Dissemination of Results

• If successful our service transformation could be
  applicable
• To other specialty services within long-term
  conditions programme locally
• Across other rheumatology services
• Widely across NHS
• Action Learning and Mentoring
• Do One and Share
• Map of Medicine

27
Concluding Remarks

• Formal assessment of my leadership behaviour
  suggests good fit with service transformation
• Our current work with ISIP and DH is a natural
  progression of a process underway since 1998
• Im looking forward to the next challenge
  winning over more clinicians to service redesign

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