Training

Thoughts on achieving excellence in primary care

Introduction
This was a forum for the development of primary care. Most of the participants were either GPs or PCT representatives.

Points that I picked up
Professor Martin Rowland made the point that internationally primary care has been shown repeatedly to be very cost effective. He had a nice graph showing the inverse relationship between cost/pt and degree of primary orientation. Despite this the NHS has been progressively spending a higher % on hospitals resulting in increasing problems.

There are still huge variations on the services available in particular the number of practice nurses employed.

Conflicts noted were: -
- Resources v. Capacity
- Continuity v. Rapid Access
- Variability of care – Hypertension, Asthma, Diabetes etcTargeting of resources
– New contract 30-40% related to quality markers

Finally the concept of the Patients’ perspective and the maintenance of moral among health care providers.

Professor David Colin-Thome discussed
- the management of organisations,
- the patients’ voice & choice,
- hospital use of resources,
- New technology
- Expert patient
- Local strategic partnership

Organisations will be judged on Quality, The public health, Accountability

Nigel Edwards – NHS confederation spoke about the systems in healthcare.
System failure –
- failure of leadership
- organisational design
- team work – moral
- quality improvement
- positive feedback
- key people
- supportive culture
- partnership between Management & Clinicians

An interesting item was a grid of how one sees oneself:

There were a number of breakout sessions:

Keiran Sweeney – Complexity & Clinical Excellence
This may sound a rather obscure area to think about but I found it quite useful. A lot of the things we deal with in the real world are non linear but much of the health production systems assume that there are linear relationships.

In primary care we are in an open system where we are readily buffeted by the outside world and have to cope with areas of uncertainty and unpredictability.

In a chaotic system there are attractors and self-organising systems, which reflect areas of primary care in particular. It gives a limit to our ability structure programmes except to cover many areas of care. One can set general principles and processes but to push this to the extreme is counterproductive.

- Attractors have shared valued, sense of togetherness and common goals.
- A receptive community does not use force but is receptive, nudges, prune.
- Conflict is endemic within an organisation. The Stacey diagram is one way of looking at this.

- Real organisations are about Values & Culture, Making connections, Continuous learning and Self Organising Teams.
- The NHS is a Complex Adaptive System

Dr David Haslam
David gave us a feel of where the RCGP had come from and was doing in the quality field.

He noted the present themes of: -
- Information Explosion
- Shift between primary and secondary care
- A Quality based contract

The following Quality processes are in place: -
- 1965 MRCGP
- 1989 Fellowship by Assessment
- 1999 Membership by Assessment of Performance
- Practice Quality Award
- Training Practice Accreditation
- 2001 Accredited Professional Development
- Accredited Research Practices
- RCGP Leadership Programme

We have a number of challenges: -
- Capacity to deliver
- Management Support
- Implementation of the new contract
- Variance- Targets
- Safety in Primary care – Clinical Governance
- Methods of coping with rapid change
- Getting better all the time

Not TO you but WITH you
Mr John Hutton gave a useful resume on the state of affairs and answered questions from the floor.

The questions from the floor which he answered well were about such things as the inability of PCTs to make any changes because the funds were already spoken for.

Conclusion
It was a worthwhile meeting that raised some interesting ideas and gave a feel of possible avenues, which the NHS can go down. I feel that the biggest challenge is not which system is picked to run the organisation but how do you support the workers through long-term transition.

I particularly found the concept of the limits of organisational structure and the value of complexity and self organising structures a real insight on the management or lack of it in huge undertakings like the NHS.

The NHS Confederation web site is www.nhsconfed.org