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CVD risk calculations error

Following a statement issued by the MHRA, an investigation has been launched into how a digital calculator (QRISK2) used by GPs to assess the potential risk of cardiovascular disease, has resulted in incorrect risk estimation scores being calculated. The SystemOne’s version of the QRISK2 calculator is used in more than 2,500 practices across the country and it is now thought that incorrect scores could have been determined for potentially hundreds of thousands of patients, dating as far back as 2009.

The MHRA confirmed that it was only the interaction between QRisk2 and SystemOne that have caused the alert and this must be reiterated to patients when concerns are being raised. Having said that, this is a major system error, one that could potentially result in a loss of confidence in the tool and one that could create a lot of additional work to already excessive GP workloads.

The risk to patients can vary and includes:

– Thousands of patients may have been prescribed statins when they are not indicated.

– Patients who should not be on statins may suffer unnecessary side effects from being on them.

– Patients may choose to stop their statins because of a loss of confidence in the decision making process. This may cause cholesterol to return to dangerously high levels in just a few weeks.

– The risk of a cardiovascular event from not being on a statin, when in actual fact one should have been commenced.

The numbers of patients affected by use of the tool are thought to be low because this is a tool to aid to clinical decision making. Therefore, the hope is that only a small number of patients will require changes to their CVD management plan. If only one patient is affected by a software system error this, however is one patient too many. GPs and the company that manufactures the SystemOne software system, TTP, are therefore working frantically to enable practices to identify patients to ensure that they receive accurate risk estimation scores and treatment where necessary is altered accordingly.

TTP have temporarily, but only recently suspended the use of their tool until the glitches within the system have been identified. The MHRA are working closely with the company to get to the root cause of the problem. One thing is certain, it is going to take a lot of time and reassurance from TTP before many GPs find confidence in this particular brand of the tool, especially in the face of so many other competitors whose end product is much more reliable. In the meantime GPs are advised that if it is necessary to use an algorithm to assess a patients risk then QRISK2 is available at www.qrisk.org

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Leadership I – GPs as Leaders, what’s your style?

The evidence for strong leadership at every level of the healthcare system has never been more compelling with research proving that good leadership skills can have a positive impact on effective team working, the health and wellbeing of team members, quality of care, patient experience and patient outcomes. During recent years huge amounts of money have been invested in leadership development across the whole spectrum of the NHS aimed not only at those who manage services but with particular focus towards clinicians.

GPs have an intrinsic leadership role within health and social care services and therefore are essential in the effective delivery, running and future delivery of these services. Both ‘The NHS Five Year Forward’ and ‘General Practice: Forward View’ recognise how significant this role is and therefore it is essential for GPs and others within Primary Care to embark on leadership development programmes. Development within Primary Care should now begin to match pace and scale of colleagues within Secondary Care who are much further along the road in relation to the importance placed on leadership development.

Indeed much can be gained from developing GPs as leaders in as much as it enables resilience, adaptability and collaboration in the face of the difficult working conditions that are faced daily. With services being delivered through more interconnected and interdependent organisations in order to nurture, develop and maintain these relationships, collaborative and transformational leadership skills are required, as health care moves across traditional boundaries.

The reality is that the people in the system know it the best and therefore it is essential for them to get involved and lead the way. The reality for GPs however, are that full clinics, numerous home visits, unnecessary workloads, staff shortages and extreme demands on the service result in very limited non-patient facing work being completed. In a system that has no time it seems incredibly ill conceived that the very people who need time, energy and resource spent on them to develop them as leaders cannot be released because this will leave no one else to do the work. How will we ever get the best out of GPs, get them to think differently and enable them to use their skills and their knowledge to get the best out of people, services and the most from their patients without running them into the ground?

Recognising how difficult it is to get time away from work to focus on leadership development, this is the first of a series of blogs on the topic. In this first series you are asked to consider;

  • Which leadership style you most closely associate with?
  • Which leadership style do you use in your daily work life?
  • Which leadership style is your dominant preference?

Leadership styles describe a person’s habitual behaviour when confronted with any number of managerial situations. They can be influenced by personality, values, preference, culture, team/organisational culture, the response of others and behaviours learned from others such as mentors or colleagues. The concept of leadership styles is based on work by psychologists Litwin and Stringer at Harvard University. Each of these styles has pros and cons when being used, especially if the behaviours that arise have damaging effects towards patients or colleagues. No single style is effective in all situations but rather leaders need to ensure they’re able to adapt to different situations with different styles to get the most out of people and not just a quick win.

 

Leadership style and definition

These styles are effective when….

These styles are least effective when…

Directive:

“Do it the way I tell you”

Effective when the primary objective is immediate compliance

– Applied to relatively straight forward tasks

– Used in crisis situations

– Deviations from compliance will result in serious problems

– All else has failed with problem employees

– Applied to complex tasks

– Used over extended periods with self-motivated employees

– Used with individual specialists or talented people who are expected to be creative

Visionary:

“This is where we are going and why”

Effective when the primary objective is providing long-term direction or vision

– A new vision or clear direction and standards are needed (e.g. in times of change)

– A manager is perceived to be the “expert”

– New employees depend on the manager for active guidance

– The manager does not develop employees

– The manager is not seen as credible or if used with experienced employees who are themselves knowledgeable

– Trying to promote self-managed teams

Affiliative:

“It’s important we all get on”

Effective when the primary objective is creating harmony

 

 

– Used as part of a repertoire that includes Visionary, Participative or Coaching styles

– Tasks are routine and performance adequate

– Giving personal help

– Getting conflicting groups/ individuals to work in harmony

– Employees’ performance is inadequate and negative performance feedback is required

– The situation requires direction and control

– Employees are task focused

 

Participative:

“What do you think”

Effective when the primary objective is building commitment and generating new ideas

 

 

– Employees are competent

– Employees possess critical information

– Employees have clear ideas about the best approach to take

– Visionary style has already been used to create and champion a clear overall direction for the team

– There is a crisis, and there is no time to hold meetings

– Employees are incompetent, lack crucial information, or need close supervision

 

 

 

Pacesetting:

“This is the way to do it”

Effective when the primary objective is accomplishing tasks to a high standard of excellence

 

 

– Employees are highly motivated, competent, know their jobs, and need little direction

– Managing “individual contributors”

– Quick results are required

-Developing employees who are similar to the manager

– The manager cannot do all the work personally, and needs to increase delegation- Employees need direction,

– Employees need direction, development and co-ordination

 

 

Coaching:

“Here is an opportunity to practice”

Effective when the primary objective is the long term professional development of others

– Employees acknowledge discrepancy between their current level of performance and where they would like to be

– Employees are motivated to take initiative, be innovative, and seek professional development

– The manager lacks expertise –

– Employees require much direction and feedback- There is a crisis

– There is a crisis

 

(The Hay Group, 2015)

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GP Forward View – improvement on the horizon or more broken promises?

In recent months, GP Leaders along with the Government have been working tirelessly to ensure that a new strategic direction for the future of Primary Care is realised. This has come in the wake of what appears to be an endless release of new or changed policies, reform, documents and promises of investment to improve the current state.

The challenge of overhauling the system to efficiently meet the increasingly co-morbid health needs of the UK population is extremely complex. Even more so when one considers that quality care and patient and staff experience are the core values driving the work-streams. Its success is dependent upon lots of diverse microsystems (GP surgeries), working collectively and cohesively in the best interests of patients, colleagues and national health. Many GPs out there do think reform is possible, despite seeming like an unsurmountable task at this stage, and of the recent literature reviewed a lot of the successes are aimed at ensuring that;

  • Primary Care is sustainable for the local populations for which they serve and that the health needs of the local population reflect what the GP surgery can offer without one size to fit all.
  • The role of the GP is one that appeals to the future medics of tomorrow, but at the same time proves attractive enough to entice back those who have left the profession.
  • GPs are given time to spend some of their professional working lives freed up from only patient facing activities so that they can provide leadership on improvement, strategy and service development.
  • Workloads don’t cripple the system that they are so desperately needed to support, by ensuring that work that can be completed by another suitably trained professional is completed by that professional. It doesn’t have to remain the role of the GP, just because ‘that is the way that it has always been done in the past’.
  • GPs are nurtured and develop the necessary skills required to be able to manage and adapt to the future landscape of an ever changing NHS.

Many GPs have their own ideas on what the root cause of the problems within primary care are, what actions are necessary so that improvement occurs and what change is required in order to ensure sustainability. ‘General Practice: Forward View’ (NHS England, 2016) is the latest document released outlining change, investment and reform. It seeks to address rising workload pressures and growing patient concerns about access.

To summarise ‘General Practice: Forward View’ focuses on improvement in the following areas:

On investment: by 2020/21 recurrent funding to increase by an estimated £2.4 billion a year, decisively growing the share of spend on general practice services, and coupled with a ‘turnaround’ package of a further £500 million. There will be investment in staff, technology, GP premises, and action will be taken concerning indemnity and growing red tape.

On workforce: attempts will be made to try to double the growth rate in GPs, through new incentives for training, recruitment, retention and return to practice. During the last 10 years there has only been a net increase of around 5,000 full time GPs, however the aim will be to achieve a further 5,000 net in just the next five years. In addition, the aim will be to recruit and train 3,000 new fully funded practice based mental health therapists, an extra 1,500 co-funded practice clinical pharmacists, and nationally funded support for practice nurses, physician assistants, practice managers and receptionists.

On workload: there will be a new practice resilience programme to support struggling practices, changes to streamline the CQC inspection regime, support for GPs suffering from burnout and stress, leadership and management development for GPs, legal limits on administrative burdens at the hospital/GP interface, and action to cut demand on general practice.

On infrastructure: there will be new rules to allow up to 100% reimbursement of premises developments, direct practice investment tech to support better online tools and appointments. Consultations and workload management systems along with better record sharing to support team work across practices.

On care redesign: there will be support for individual practices and for federations and super-partnerships. There will be direct funding for improved in hours and out of hours access, including clinical hubs and reformed urgent care; and a new voluntary contract supporting integrated primary and community health services.

This is a substantial investment and strategy for reform. It represents a significant amount of support and should add a large amount of resilience in to a system that has been under resourced for the last decade. It is aimed as a five year piece of work and within that time period it will be important that the system continues to learn and respond to changes in circumstance, national health and government.

Will this represent the solution to the complex challenge of solving the primary care system crisis?