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Follow the leader

Back from a fact-finding trip to the US, our diarist muses on how clinical leadership can really shake everything – and everyone – up.

The story so far: Dr Peter Weaving is a GP and locality lead for Cumbria PCT, which is launching two ambitious integrated care pilots and – like all PCTs – is facing lean times. As a former chair of a large consortium he can often see both sides of a argument…

The earthquake struck at 04.15. The swaying hotel woke me. ‘Gosh, it's windy,' I thought, looking out at the motionless trees. The news next morning was wall-to-wall coverage of a small earthquake (only 4.4 on the Richter scale) centred a few miles south of where we were in Pasadena. A large crack in the freeway was the only damage.

The ground was also shaking in Washington where President Obama was trying to push through his health services reforms. The TV's earthquake news stories were punctuated with slick adverts showing sad, middle-class people telling their partners they had been made redundant as their companies were unable to afford the new healthcare costs imposed by the impending changes.

I was visiting Kaiser Permanente in Southern California with an educational party under the guidance of Chris Ham, then professor of health policy and management at the University of Birmingham. We visited Kaiser, a holistic health maintenance organisation providing totally integrated care covering everything from brain surgery to blood-pressure control. Then some of us travelled to San Francisco to meet its opposition, Hill Physicians, and its boss Steve McDermott, alleged instigator of QOF and our purchaser-provider split. But more of Steve and his legacy another time.

What was striking about these very different organisations was their belief in, and implantation of, clinician leadership. Clinical leaders were present in a formal way at every level. Virtually all carried a clinical workload. Docs are the most difficult group to lead, let alone performance-manage, and there is a natural antipathy between docs and managers that seems to start somewhere between sixth form and graduation. Docs feel it is not only their right but their duty to do as much as possible for their patients. The responsibility for the resource implications of those actions lies with the manager – whose duty is to provide the resources and not to question the manner in which they are spent.

What we saw with Kaiser was the application of formalised peer pressure backed with the adage ‘If you can't measure it, you can't improve it'. As a practising doc, your clinical leader would be armed with accurate, timely data about your clinical behaviour, your patients' perceptions and your use of resources. Think of it as your own personal QOF being run at monthly intervals. Where we diverge further from the US model is that the challenge about performance comes not from your faceless PCT but someone who works alongside you and probably sees the same patients as you. So there is nowhere to hide.

Their culture completely supports consistent performance management in this way. The talk is of slaying the three giants of waste, variation and inefficiency to maintain quality services in a financially challenged future.

And that's the docs talking.

Follow the leader