Clinical Networks Part 3: Clinical Engagement vs. Clinical Endorsement

This is the last of three blogs describing why and how we decided to reform existing Clinical Networks in NHS Wales. They are personal reflections on the process I undertook with a number of colleagues, listed as authors in our final paper. I am also grateful to Professor Sally Lewis, former National Clinical Director for Value Based Healthcare (VBHC) in Wales for several years’-worth of idea sharing and formative conversation which informed this work.

This final part will look to the future and the opportunities and threats to National Clinical Networks. I’ll talk about clinical leadership, clinical engagement vs clinical endorsement and the balance between having ‘teeth’ and exercising a stronger guiding hand.

You can read part one here and part two here.

A tale of two products

I’m going to begin with a couple of stories which I learned a great deal from.

We got this at the shops: make it work

A few years ago, when I was an Assistant Medical Director, my main portfolio was ‘Digital and IT’. One of the Executives asked to meet with me. They explained that they’d recently attended a technology conference and had procured a product which they hoped would help manage front-door winter pressures. Because the product involved ‘an app’, it was seen as digital, and therefore in my remit.

I did a quick and dirty evaluation of the product and concluded that it wasn’t really a ‘digital project’, but was rather a transformational project which could, if adopted, significantly change established workflows for patient referrals. No biggie as far as I was concerned – I was less interested in digital per se, and more interested in its use as a Trojan Horse for transformation, so was happy to own it.

Unfortunately, as with most ‘apps’, it required a baseline level of infrastructure to operate smoothly, and we lacked this. I also felt that the claims being made by the vendor for its effectiveness and potential help with winter pressures were unrealistic – again not unusual for an ‘app’ being promoted.

On reporting this back to the Executive, essentially the message was ‘we’ve already bought it, so we need you to get your clinical colleagues to start using it’. It’s important to add this was a message delivered without threat or warning, it was simply factual, and also reflected the culture. That culture could be characterised as senior managers making a decision, and clinical leaders then being asked to socialise that decision in their community and make the best of it.

I did my best, as did many colleagues, but very predictably, it failed at the first technological hurdle (lack of infrastructure), and my attempts to encourage and cajole teams to overlook these shortcomings and adopt the product were largely ignored. Spreadsheets of ‘roll-out’ were full of Red and Amber, with very little Green. It was binned.

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We’ve been given a free offer; can we make it work?

About three years later, another Executive asked to meet me. They had received a letter from the Government, explaining that a product (it includes an app!) had been ‘nationally procured’, and was expected to assist with front door pressures. The decision to procure had been made very quickly at policy level (pandemic pressures). The letter was really of an ‘offer you can’t refuse’ type. I was asked whether I thought we should take the free offer or not.

This time I was given time to engage with a number of clinical colleagues (we had established a Clinical Informatics Forum), and with digital and managerial colleagues. We could see how the product could be strategically aligned, and we could re-allocate existing personnel to work on this project given its strategic importance. This included bolstering a still inadequate technical infrastructure which the app-based solution required.

The focus was then on engaging clinical teams, discussing how the product may support transformational changes in workflow that were aligned to what everyone had agreed was strategically important. There were no spreadsheets with RAG ratings, and the process was treated as an iterative and opportunistic implementation, not a roll out. There was constant dialogue between clinical teams and the project team which allowed us to change and adapt our approach as we progressed.

A number of teams embraced the product and managed to use it alongside a suite of other products to significantly change workflows. It was being used more widely in our organisation that any other in Wales.

The product was, of course, exactly the same one we’d tried to use 3 years previously.

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The main difference over those 3 years was what I came to characterise as endorsement vs engagement.

In story one the clinical community were being ‘told’ of a fait accompli, and there was an expectation it would work if only we would use it. My role was to, in effect, endorse a decision I’d had no part in, and this would serve to lend it credibility among the clinical community.

Second time round, the clinical community was being ‘asked’, and was then being ‘listened to’. This, I think, most of us would characterise as ‘engagement’.

My organisation had learned from previous experiences (such as story one), that clinical engagement was important. We had a Chief Executive who firmly believed in clinical engagement and did not look for or want ‘endorsement’ – indeed if the CEO had not welcomed a bit of push-back, I’d have been dispensed with. It went further though. The CEO had encouraged me, (a clinician), to be ‘joined at the hip’ with the Director of Digital (a manager). We functioned as a single unit, and it meant every decision was clinically informed, but also realistic and achievable. That relationship helped ensure there was a much more collaborative approach across traditional managerial/technical/clinical borders, and there was less of a feeling of ‘being done to’. I’m not claiming it was perfect – many of the fundamental problems of lack of resource remained - but it made them slightly less difficult to mitigate.

Clinical Engagement vs. Clinical Endorsement

The National Clinical Framework in Wales is predicated on the idea that clinical engagement is the key to taking forward the strategic intent in A Healthier Wales, and systematising Value Based Health Care.

I’ve observed a few signifiers in recent years which indicate either an engagement or endorsement culture. These are opinions not objective facts. But they are opinions born of experience.

Structural

Managerial and Clinical Leadership: It’s a form of marriage.

The leadership of clinical networks requires both. A relationship where there is mutual respect between the managerial and clinical lead is essential. That means daily conversations, no secrets, complete trust. A united front is important – but only of it is arrived at by compromise and consensus. I’m not talking about the united front that is a pretence, wallpapering over the cracks. Give and take will be necessary, and that sends an important message to others in the network. Networks are all about arriving at a consensus view: if the leadership duo cannot reach consensus, then they have no hope in fostering it among their colleagues.

One line-managing the other can’t really work in my opinion. It is much better to have separate lines of accountability – one clinical, one ‘management’.  

Clinical Reference Groups (CRG)

This is nuanced. CRGs are described in the National Clinical Networks ecosystem as an ‘engine room’ from which the leadership group can consolidate ideas and reach consensus. But the leadership group has clinicians as a significant part of its make up.

But I have encountered the term CRG used as a mechanism for sidelining the clinical voice and providing cover for ‘clinical endorsement’. A group of managers in one room as the leadership group and clinicians in another as a CRG is not clinical engagement. For many of my clinical colleagues the term CRG has been debased over the years because of the experience of being sidelined.

Nor can the corollary work. A group dominated by clinicians, or with only token managers present is not really doing ‘clinical engagement’. I’ve found those rooms particularly difficult to be in. They have sometimes been self-pitying or angry echo-chambers, and occasionally versions of the Jeremy Kyle show.

The Token Clinician

And adding a token clinician to the leadership group is usually just a signifier of and endorsement approach – those clinicians often lost the respect of their colleagues quite rapidly. The thing about clinical engagement vs clinical endorsement is that although I’m struggling to describe them, most clinicians ‘on the ground’ recognise the difference intuitively and behave accordingly.

Clinical Leadership vs. Clinical Hubris

The clinical community have much to develop to ensure Clinical Networks can truly foster meaningful clinical engagement.

Entitled demanders.

Clinicians participating in Networks, and especially those leading them must avoid slipping into the ‘I’m a doctor and I want my sausages’ mode. The clinical perspective is important, but it is not the only one. There are wider system pressures, health outcome determinants and other clinical areas which may be blind spots for any given clinician. A degree of humility is required.

Lobbying

Related to the entitled demander behaviour is a tendency to develop lobbying behaviours. This, likewise, will work against meaningful clinical engagement. The role of the National Networks is to provide the clinical part of stewardship to the whole health service – they need to be mindful of finite resource and their place in a much wider system. There are other arenas in which to lobby for a cause, but not within a ‘Central Guiding Hand’ function.

Groupthink

The National Networks are deliberately designed to be broad churches to try and avoid groupthink. This requires careful and skilful leadership, as arriving at consensus is more difficult. The leadership must ensure that they have a diverse range of opinion, and that their Networks are as diverse as our workforce and communities. The Clinical voice will be less likely to be regarded seriously if it is only reflecting a narrow range of views, and particular segments of whole-system patient pathways.

Even worse than groupthink is one-person think. I've experienced too much of the Brian Clough approach to resolving disputes over the years.

I realise that’s all been a bit negative, but I think it’s important to call some of these things out. I believe all described above are surmountable, especially with leaders who are supported to show the way.

Guiding hand vs. Clunking Fist

As I mentioned in one of the earlier blogs, a major complaint and perceived failing of the legacy Clinical Networks was their lack of power – ‘no teeth’.

This is one of the most contentious areas and will probably always remain so. It’s deceptively simple to imagine that in a Learning Health and Care System, the ‘National Clinical Networks’ can become a data and knowledge-based design authority, describing the best ways of doing things. The reality is that there are relatively few clinical situations where there is compelling evidence that one particular method or treatment produces clearly better outcomes than others, so for the most part it is appropriate that the function is that of a guiding hand.

The governance arrangements between the Government, the NHS Executive and the Health Boards is still being worked through. The Health Boards have a high degree of autonomy and are held to account for the care they deliver in their own population footprint. I believe that should be maintained.

But where there are nationally agreed evidence-guided and data supported pathways, there are mechanisms by which Health Boards can be encouraged, helped and if necessary compelled to implement them. It will be for the government and NHS Executive leadership to decide whether to allow those teeth to develop. The Networks will inform the process. It is not for them to possess the teeth, but it would also be unwise to ignore their guidance.  

Clinical Networks: Success vs. Failure

The National Clinical Networks remain at an early stage in their development. They had a prolonged gestation, a challenging delivery, a stormy neonatal course, and have not really yet achieved their developmental milestones. But they can definitely catch up to where they should be with the right support.

The direction of travel remains positive. To maintain this, Clinical Leadership must be supported, valued and developed. That doesn’t mean getting everyone to buy a copy of ‘Compassionate Leadership’ or go on an expensive course – it means ensuring that those appointed into leadership roles believe in working to a National Clinical Framework, believe in the value of National Clinical Networks, and above all are committed to the Value Based Healthcare approach described in A Healthier Wales. It also means that Clinical Engagement, not clinical endorsement becomes the default way of working.

I hope that the colleagues I’ve left behind who are taking the networks forward will be given the Political and political support to start making a material difference to the services provided for the Welsh population.