Clinical Directors in Evolution

1. Clinical Directors in evolution
2008 - 2014
Dr Colm Henry
National Lead
Clinical Directors Programme
Wednesday April 2nd 2013

2. Once upon a time…
Anatomy Lesson of Dr Tulp, Rembrandt, 1632

3. National Health Expenditure vs GDP, USA 1960-2005
Centres for Medicare and Medicaid Services, USA

4. National Health Expenditure,USA, Public vs Private funding

5. Disappearing autonomy:
The Road to Control
• Clinicians vs. managers
‘Clinical freedom created a political
dimension outside any normal
managerial framework. As quickly as
efficient management reduced long-
established queues, medical
science opened new ones. Clinical
freedom allowed consultants to
make decisions affecting resources,
and consultants had to be
persuaded if they were to make their
clinical demands more modest. A
long and divisive conflict was in
prospect’
Dyson, ‘Griffiths Inquiry, a Personal
Perspective, BMJ, 288, 1984
Science and Charity, Picasso, 1897

6. Post-Griffiths: protestors to participants
• ‘....this involvement by clinicians in
management has to embrace a
contribution both to the strategic and
operational management of a service, in
hospital, in the community, in practice,
and in the commissioning role at district
and central level, rather than doctors
simply seeing themselves as there to
give advice’.
Chantler (1994) How to treat doctors: Role of
Clinicians in Management: Policy and Change in the
NHS
• ‘ we enable doctors to be partners and
leaders alongside manager colleagues..’
Lord Darzi (2008) High Quality Care for All
Dr Gachet, Vincent Van Gogh, 1890

7. Outline of role of Clinical Directors in 2008 Contract
• Deploy and manage consultants and resources
• Plan hospital and network strategy
• Formulate annual service plan
• Align service plan with regional and national priorities
• Monitoring and measuring performance against KPIs
• Audit/governance
• Accreditation
• Risk Management
• Agree and formulate individual consultant practice plans
• Agree and formulate schedules
• Align plans/schedules to local and national priorities
• Grievance and disciplinary
Men of Destiny, Jack Yeats, c1945

8. Clinical Directors in Ireland – 2008-2014
• Hospital-based and Mental Health
• 55 hospital-based
• 18 Mental health directorates
• Roles evolved based on local requirements and
politics
• Aligned to institutions primarily
• Limited regional governance approach until advent of
Hospital Groups
• Reactive vs proactive
• Protestors vs participants
• Tension between doctrine of clinical autonomy and
managerial demands for improved efficiency, cost
control and accountability…’
Escher, Waterfall, 1961

9. Clinical Directors 2009-2014 – expectation vs.
reality
• Nominal responsibility across all clinical
areas
• Patchy devolution of power and authority
• Upside down accountability
• Tension between expectations of managers
and ‘system’ and what can be achieved
• Public face of failure and risk
• Time
• Data – quality and timeliness
• How to change behaviour and deal with
‘outliers’

10. ‘Upside-down’ accountability
• ‘...I remind you that I do not accept
clinical responsibility for an unsafe
service. I remind you that you will
be clinically responsible for adverse
events which occur following your
rostering and staffing decisions’.
• ‘....the Consultant Medical Board
unanimously condemn the decision
of management and the Clinical
Director’....’
• ‘....ethically and professionally, I
cannot comply with your
instructions....’
Scream, Edvard Munch, 1893

11. A sustainable and realistic model?
• ‘the exercise of all power is a
process of depletion..’
Henry Kissinger

12. Extrinsic depletion
1. Demographics
2. Advancing technology and expectations
3. Recruitment of medical staff
4. Over-centralisation of accountability for risk and patient safety
5. Balancing clinical and administrative workloads
6. Succession planning
7. Cultivation of cynicism
8. Compassion fatigue

13. 0
5
10
15
20
25
2011 2013 2015 2017
All ages
65+
1. Demographics: increase in health service cost
pressures due to demographic effects
Source: CSO census of population and provisional DOH data projections to 2017, Based on
cost relativities from the 2012 Ageing Report: European Commission 2012

14. 2. Expectations: expensive advances
0
100000
200000
300000
400000
500000
600000
700000
2004 2006 2008
Expenditure
(euro)
Expenditure on Bevacizumab, Mercy University Hospital, 2004-2009

15. 2. Expectations – older people
1. Changing attitudes to cardiopulmonary
resuscitation in older people: a 15-year follow-up
study
P. E. COTTER1, M. SIMON1, C. QUINN1, S. T. O’KEEFFE2
1Portiuncula Hospital, Ballinasloe, Co. Galway, Ireland
2Galway University Hospitals, Galway, Ireland
Age and Ageing Advance Access published January 26, 2009
2. The Hospital-Dependent Patient
‘Medicine has yet to acknowledge the ethical and practical predicament of
having created a population of incurable, fragile, but not yet terminally ill
patients without concurrently developing a healthcare system that can meet
their needs’
Reuben and Tinetti
NEJM February 20th 2014

16. 3. Over-centralisation of accountability

17. 4. Cultivation of cynicism
• Opposing targets
• Multiple and contradictory drivers for change
• Organisational practice opposed to statements
– ‘An institutional culture that ascribed more weight to positive information about the service than to information…causing concern’
– ‘culture of self-promotion rather than critical analysis and openness’
• ‘Hitting the target but missing the point’
• Regulatory pressures
– There is appreciable evidence that the NHS is over-administered as a result of extensive, overlapping and
duplicating demands from both regulator and performance managers. There has not been a substantive
review of the information demands placed on the service and its providers for many years. A review leading
to a rationalisation of those demands is essential.
• ‘Incorrect priorities’
– The Mid Staffordshire tragedy and wider quality defects in the NHS seem traceable in part to a loss of focus
by at least some leaders on both excellent patient care and continual improvement as primary aims of the
NHS (or to a misinterpretation by providers of the intent of leaders). In some organisations, in the place of
the prime directive, “the needs of the patient come first”, goals of (a) hitting targets and (b) reducing
costs have taken centre stage.
A Promise to Learn; a Commitment to Act; Improving the Safety of Patients in England. Don Berwick and
National Advisory Gro p on Patient Safety in England. 2013

18. ‘No more heroes’: The future of leadership and
management in the NHS. (The King’s Fund 2013)
‘The NHS needs to move beyond
the outdated model of heroic
leadership to recognise the value
of leadership that is shared,
distributed and adaptive. In the
new model, leaders must focus on
systems of care and not just
institutions and on engaging staff
and followers in delivering results.
At a time of huge transition and
challenge, leaders at all levels and
from all backgrounds have a
responsibility to ensure that the
core purpose of the NHS – to
delivery high-quality patient care
and outcomes – is at the heart of
what they do’.
Sir John Lavery, London Hospital, c 1918

19. Quality and Patient Safety – a long-term race
• National Healthcare Charter
• ‘Your Service Your Say’ – measuring
feedback
• National Consent Policy
• National Open Disclosure Policy
• Clinical Governance
• Clinical Audit Guidelines
• Defining Quality in Healthcare
• Developing Clinical Leadership
• Developing Quality Improvement expertise
• www.hse.ie/go/qps
Source: Health Information and
Quality Authority (2012)

20. Devolving Leadership – from coal-face up
Group CEO
Chief Clinical
Director
Chief Academic
Officer
Chief Director of
Nursing
Chief Finance
Officer
Clinical Director
Medicine
Chief Operations
Officer
Clinical Director
Peri-operative
Clinical Director
Diagnostics
Clinical Director
Women and Children
Site Clinical Lead Site Clinical Lead Site Clinical Lead Site Clinical Lead

21. The New Clinical Leader
• ‘Traditionally, medical care has been
based around what doctors do, not
primarily what patients need. The new
generation of clinical leaders will…..first
and foremost want to make a difference
for good in the lives of the patients they
care for. They will focus on efficiency,
reduction of waste and better value….
…..’
• The New Clinical Leader, Kim Oates,
Journal of Paediatrics and Child Health,
2012
Hospital in Arles, Van Gogh, 1889

22. ....the last era of
management was about how
much performance we could
extract from people
.....the next is all about how
much humanity we can
inspire
Dov Seidman
The Doctor, Luke Fildes, 1891
Clinical leadership and compassion