Medical engagement: change or die

More than a year since Robert Francis’s recommendations, and after reports by Don Berwick and Sir Bruce Keogh and the new Care Quality Commission inspection regime, we are still being challenged to demonstrate that health care is first and foremost focused on the needs of the patient. 

At the same time, there has been a call for the most expensive assets in health care – the doctors – to step up and engage in management and leadership. We use the right words when writing about medical engagement but how do we move from rhetoric to reality and more importantly why should doctors embrace this responsibility?

On our Seattle Study tour in April this year, we experienced an intervention that underpinned the drive to put patients first with a new management process, and the resulting culture encouraged more doctors to take the lead on driving quality and innovation. 

The Virginia Mason Institute (VMI) experienced a significant turnaround in 2000, when their CEO, Dr Gary Kaplan, challenged them with a stunningly simple message – ‘Change or die’. He highlighted a problem that will be familiar to many health organisations – espousing patient-centredness while at the same time organising care around the needs of doctors.

VMI chose to embrace a management process, Toyota Production System, (TPS), which was supported by Gary Kaplan’s strong leadership in the drive for the delivery of safe care to be their core objective. Many of the staff we met at VMI outlined the challenges involved in prioritising this objective. ‘We are never there’ is how one executive described it. It was evident that changing the culture at VMI was critical to its success and that motivating doctors to engage in that culture change was a key component. ‘If we were to stop giving attention to and prioritising the system that underpins our culture [TPS] the years of progress made would be lost in months’.

Many doctors in the UK have been influenced by VMI’s journey, as we discovered in our study, published today, of four health care organisations: Northumbria NHS Foundation Trust, Salford Royal, Southern Health and University College London Hospitals NHS Foundation Trust. 

Echoing comments made by doctors at VMI, many of the doctors and executives we spoke to admitted that medical engagement is a ‘work in progress.’ All four organisations suggested that the commitment of their medical workforce is an essential ingredients in creating a culture in which providing high-quality and safe care is the objective. Other components include: creating a collective appreciation of the value that the multi-professional team bring to the delivery of patient care; the active involvement of the patient; financial stability; consistent and resolute leadership at all levels; and a commitment to recruiting and selecting all staff on the basis of their organisational values.

One of the most noteworthy aspects of our discussion with these organisations was their realisation that it was important to value the time that clinicians, alongside non-clinical managers and leaders, give to agreeing ‘how things work around here’ –ie, to the culture. It leads to more commitment and more engagement, which then become the fertile ground on which innovation and improvement with and for patients becomes possible.

As one medical director remarked ‘I think there’s a kind of a particular engagement challenge over the next couple of years and it’s not unique to doctors here. I think probably it’s at least as big for other clinical professionals. It’s engaging people on how challenging their financial pressures are going to be, how innovative we’re going to have to be with our solutions.’

How will we address this challenge? Leaders at a system and organisation level must make the current generation of newly appointed doctors see that stepping up to management and leadership through driving innovation and quality is a valued proposition.

This means accelerating progress on: professionalising medical careers; valuing the time doctors spend on managing, leading change and innovative practice; drawing medical leaders from backgrounds as diverse as those of the patient populations they serve.

We have, in our study, heard from many leaders who systematically make medical engagement a priority because, as our report concludes, ‘it is too important to be left to chance’. What will you do to make it a priority?

This blog is also featured on the British Medical Journal website

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#42277 Sam Majumdar
Consultant Surgeon
NHS TAYSIDE & University of Dundee

Thanks to King's Fund, Vijaya & her fantastic team for arranging the excellent learning event on Medical engagement. The speakers are transformational leaders by their own examples at work. They have shared their vast experience in quality improvement through medical leadership as well as their individual takes on the visits to the centres of excellence in the most concise and poignant way. They have certainly put medical leadership in the context of our work in the NHS. We need to persevere on spreading and sustaining this energetic movement engaging and empowering medical leaders. Time to walk the walk. And keep walking on the never ending path of QI. We want to thrive, not just survive. And certainly not die!
It was certainly worth travelling all the way to London from this far north in Dundee.

#42281 Carolyn Johnston
Consultant anaesthetist
St Georges Healthcare NHS Trust

A very interesting report and lots for us all to absorb and emulate.

I am particularly interested in the 'cohabitation' of quality improvement and leadership. I am an alumnus of NHS London's Darzi fellow scheme; motivated to take a year out of clinical work to learn improvement skills, I studiously avoided calling myself a leader for 12 months and I'm sure I'm not the only one who feels uncomfortable with the title.

Working on an improvement project encourages development of so many important leadership skills (I'm sure I don't need to list). You come out of that work with new skills, new multi professional relationships with managers and other healthcare professionals, and crucially new confidence: in this process, you have become a leader. I can see the same phenomenon now in my role as a consultant co ordinating our foundation year doctors quality improvement programme.

A desire to improve quality of care is by far the most commonly cited reason to enter leadership roles. It creates engagement, as you demonstrated in the study tour and Medical engagement case reports.

I would encourage anyone seeking to promote leadership or develop leaders to promote and develop their improvers, and your leaders will be created in the process.

#42286 Vijaya Nath
Assistant Director
The King's Fund

Sam, thank you for taking the time to travel from Dundee and give of your effort and time to contribute to our Medical engagement day. Thank you also for reminding the audience of how participating in Quality Improvement engages Drs . all 4 countries of the UK's NHS can learn from each other we will continue to look for ways to collaborate.

#42287 Vijaya Nath
Assistant Director
The King's Fund

Carolyn ditto and you role model the result that the system can benefit from if emerging leadership is nurtured and you are now being that transition for others. Promoting 'improvers' promotes engagement and leadership as you have stated and demonstrated . Thank you for taking time to read the report and comment.

#42289 Jessie Cunnett
Patient and Public Involvement Solutions

It is a good idea to make sure the patient is seen as at least a third of the solution. Managers, clinicians and patients. The full picture and response will not be visible without all essential partners taking equal responsibility for any changes or leadership challenges. Also are doctors the most expensive assett in the NHS or is it patients?

#42290 Dr Umesh Prabhu
Medical Director
Wrightington, Wigan and Leigh FT

For effective medical engagement medical leaders are the key. Good medical leaders who are visible, approachable, who listen, engage their clinicians are the key to the success of NHS. It is equally important to have good relation with Primary care, CCGs and social services.

#42292 Vijaya Nath
Assistant Director
The King's Fund

re : Jessie without patients this work would have no meaning . Focusing on Medical Engagement is entirely so that patient experience and care can be improved. Drs at all levels and in all settings / disciplines primary, secondary, mental health, public health have the 1 to 1 interactions with patients , engaging Drs and all clinicians & non clinical staff in driving improvements critical if patients are to be put first. The 'assets' costs referred to in the paper are to do with the Medical workforce and the investments made in developing this cohort vs what they are able to repay through their clinical and we argue their continued engagement .Thank you for taking the time to post this comment vital to us making progress together.

#42293 Vijaya Nath
Assistant Director
The King's Fund

Umesh, thank you for continuing to remind us that great medical engagement is a key ingredient in developing present and future services , and most importantly that this is also needed at the Primary Care level .

#42298 Andy Watts
GP Partner
Goodwood Court Medical Centre

Engagement as medical leaders is going to challenge us all to re-vision the sense of Value that drove the formation of the NHS in the post-war era; to discover anew our unwritten Contract with patients/ carers/ 'friends & families' - all within purely Market-driven and focused provision. Health and social care boundaries are being challenged and re-moulded by Personal Budgets / explicit Rationing / the complexity of frailty/ a new sense of assertion by patients empowered by knowledge (variably evidenced) from the internet/ a re-written Social Charter where patient is able to voice and discuss and question us directly. This is an exciting -a challenging -an invigorating time.
How we respond to this challenge of Engagement within Medicine/ growing confidence in our Colleagues (such as Nurses & Therapists) who have bust through our complacent medical monopolies and sheboliths - this will be a purifying fire in my view. Like steel (which softens, warps & bends initially with heat - but then tempers to become hardened and tougher as the level of heat rises) we need to really demonstrate our worth in the new multi-directional 'fires' of new realities in health & prevention - new disease patterns- failure of established treatments such as antibiotics- and a generation of consumers (that we too are part of) in richer/developed countries that just will not tolerate failure - ageing - physical & mental degradation 'with grace & tolerance' but will rail against those. Demands will grow not lessen and we have to work with these forces. Like toughened steel we will need to withstand the searing heat!
Kings Fund leadership programmes (such as the Strategic Med Director programme I experienced 4 years ago) are facing these issues - developing the leaders of the future - and challenging policy makers to face longer-term issues and not just being tempted by the 'quick fix' / 'prod & poke'
mentality that Prof Chris Ham asserts has been the mainstay in the past.
Other key bodies - The Nuffield Trust - NHS Confed - Queens Nursing institute
- The Medical Colleges - RCN - are making their presence felt too. In my view, only together can we build a stronger 'heat proofed' and resilient Health Service. Together we need to build stronger Patient Voice organisations and a multidisciplinary environments that bring Social Care & Workers into the new world and deep-rooted/ lateral -thinking Managerial professionals.
In my own backyard of Primary Care/ General Practice we need to rebuild a service that is in many ways 'broken' and in desperate need of new impetus and focus.. No more can we expect to be rescued by successive governments- we need to rediscover our very purpose - integrate - Manage Care - Invent - Research - Educate. in fact, we probably need to sow seeds of our own dissolution and put patients in control of the health & social care Agenda - take responsibiliy - decide their own fate - deal with their own destiny.
Medical Engagement may in fact be the Nemesis we feared and Ivan Illich (and more recently Kennedy) predicted, but surely that is the only way forward as the gains of Technology increasingly deliver less and less 'bangs per buck'
and we need to assure a truly Value-Driven NHS system for the 21st Century and beyond!

#42299 Abid Hussain
Clinical Lead
Public Health England

This is a very interesting and well written report. It is heartening to see that the experiences and ideas of those in front line specialities are still transferable to specialities like pathology. Engagement is a key part of any clinical improvement programme. I was particularly motivated by the thought that leadership is an essential part of all of the employees role across the whole organisation. At the end of the day, we are here to improve patient care, which in the climate of fiscal responsibility we should not loose sight of.

#42300 Vijaya Nath
Assistant Director
The King's Fund

We need to encourage and develop many more clinicians to step up to leadership roles . the Scientific communities especially disciplines like Pathology attract many who have an eye and a capacity for leading quality improvement .We are all more alike than different and professions allied to medicine have a significant part to play . Thank you for your feedback , carry on being curious and stay engaged.

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