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Chapter 3 deals with the development and early operation of Clinical Commissioning Groups (CCGs) of GPs. Building upon the context set out in chapter 2, we examine the factors affecting early CCG development, highlighting the complexity of their governance structures, approaches taken to engaging with their members and the development of external relationships with a wide range of new bodies. We found an explicitly ‘bottom up’ approach to policy implementation, with CCGs given considerable lee-way in developing their structures and processes. As a result, the history of previous commissioning structures and arrangements played an important role in the development of each CCG, as did the approach taken by local leaders and by the PCT/ developing NHS England local team. Engagement with local bodies such as Health and Wellbeing Boards and Local Authorities were also significantly affected by local history and geography. We found that the approach taken by NHS England to CCG development, with early freedom to develop as they chose increasingly curtailed by more prescriptive guidance and a complex assurance regime, led to some frustrations for those involved.

Chapter 4 looks at the evidence about clinical engagement in primary care-led commissioning. Extending and strengthening clinical leadership was one of the key elements of the HSCA12. However, this idea was not new, and this chapter reviews the evidence on the role of clinicians in primary care-led commissioning and how this has contributed to the delivery of healthcare services since the early 1990s. It examines the nature of clinical engagement/involvement in the various primary care-led commissioning models that have been introduced into the NHS. Drawing on a review of the literature and our research on Clinical Commissioning Groups the chapter shows how the extent of clinical engagement has varied between the various schemes. GP commissioners have historically been more successful in influencing the work done by GP practices than in making broader changes to services provided by secondary care. The chapter goes on to explore the claims made both by those involved and in official documents about how greater involvement of clinicians in CCGs – and in particular GPs – will enhance commissioning practice. We test this against evidence from our study of CCGs, showing how the engagement and involvement of GPs requires careful attention to detail. Using a realist approach to evaluation, we highlight the contexts and mechanisms associated with successful – and unsuccessful – GP involvement in commissioning.

Within the United Kingdom, general practitioners (GPs) will manage the care of the majority of patients with life-limiting and terminal disease, including those with complex problems requiring specialist palliative care involvement. The consultation is at the heart of general practice and communication skills, underpining the UK General Practitioner Vocational Training Scheme (GPVTS). To attain membership of the Royal College of General Practitioners, trainees are required to undertake learning methods during their training programme as outlined in the RCGP Curriculum, which include video analysis of consultations, random case analysis of a selection of consultations and patients' feedback on consultations using satisfaction questionnaires or tools. This chapter discusses the Cardiff University Post Graduate Course's specialist palliative care education designed to meet the needs of specialists and of GPs with a developing specialist interest, the Cardiff six-point toolkit (listening, reflection, summarising, question style, comfort, language), the use of role play for developing communication skills, and reflective practice/portfolio learning.

This chapter explores the cultural embeddedness of medical expertise in three European countries by confronting medical practitioners with an issue that has yet to be integrated into medical practice—problem gambling. Focus-group interviews were conducted with groups of Finnish, Italian, and Polish general practitioners (GPs). Film clips depicting gambling problems served as the interview stimuli. The study shows that the country-specific approaches to the problems in general, and their welfare culture, shape GPs’ views on problematic gambling. The Finnish GPs tend to replicate the Nordic welfare state’s inclusive, all-embracing system logic and they embrace some typical individual traits in the same culture. The Italian context of the Southern European welfare state regime is articulated in the GPs’ discourse about familial relations. The influence of the church in shaping the concept of addiction is also made evident. The profound changes in Polish society initiated deep changes in the perception of social problems, including their individualization: the Polish physicians thus referred to individual and familial contexts of help provision. These findings question a simple medicalization claim, and point towards a more complex picture, where institutional practices will concretely influence how problems are perceived.

Teamworking is an inevitable part of working within a complex multidisciplinary environment. Thankfully, most interactions with other members of the healthcare team will be positive and constructive. Unfortunately, such happy circumstances do not make for particularly interesting SJT scenarios. The following section is therefore full of colleagues that are angry, rude, dishonest, unprofessional, and even intoxicated. In Raising and Acting on Concerns About Patient Safety (2012), the General Medical Council (GMC) states that ‘all doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organizations in which they work’. The GMC proposes taking the following steps in sequence when you develop serious concerns about a colleague: ● Raise the concern with ‘your manager or an appropriate officer of the organisation . . . such as the consultant in charge of the team, the clinical or medical director’. Alternatively, a foundation doctor may raise their concern with an appropriate person responsible for training such as their Foundation Programme Director. ● Raise the concern with a regulator (such as the GMC), professional body (such as the British Medical Association), or charity (such as Public Concern at Work). This step should be taken if you have exhausted options for raising the concern internally and there is an ‘immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene’. ● Raise the concern publicly. This step should be taken when you have exhausted options for raising the concern internally and have ‘good reason to believe that patients are still at risk of harm’. Your usual duty is to avoid breaching patient confidentiality. This is a highly unusual and significant step to take and is unlikely to be appropriate without first having taken advice from an appropriate organization such as the GMC, BMA, or Public Concern at Work. The questions within this section highlight your ability and willingness to work with team members. You will need to work collaboratively and respectfully within a multi- disciplinary team, as well as provide advice and support to colleagues.