Managing Clinicians or Just Filling Shifts ? Dr Mark Reynolds CEO and Medical Director On Call Care Ltd

Context What was Co-ops – undifferentiated local docs filling the rota Commercials – business focussed What is NQRs, contract price Nursing What's coming Contracted outcomes New benchmarks Focus on non elective spend – PCT and PBC Secondary to primary care shift Interpretations and changes to employment status

Clinicians Doctors – OOH traditionally a core competence, so not monitored or managed Nurses- OOH a new role, so monitored and managed Contrast between the monitoring of the two groups

Managing Doctors Risks Fairness Vanishing rota Medical directors time and cost Employment status Tribunals and stress

Managing Doctors Gains Service to patients Service efficiency Best use of public funds Professional development

100 calls Dr Soft – 10 minutes per patient on the phone Dr Perfect – as above Dr Tough – 5 minutes Base consults – 15 minutes each Visits – 45 minutes each 999 £ 500 Admissions £ 2000

Dr Soft % TC > self care = 5 hours 40% Base (including TC) = 16 hrs 40 mins 30% Visit (including TC) = 27 hrs 30 mins 49 hours and 10 minutes doctors £60 =£ % and 5% 12.5K

Dr Tough % TC > self care = 5 hours10 mins 25% Base (including TC) = 8hrs 20 mins 5% Visit (including TC) = 3 hrs 45 mins 17 hours and 15 minutes doctors £60 =£1029 1% and 2% 4.5K

Dr Perfect % TC > self care = 8 hours 20 mins 40% Base (including TC) = 16hrs 40 mins 10% Visit (including TC) = 9 hrs 10 mins 34 hours and 10 minutes doctors £60 =£ % and 3% 7K

Variation from the 100 Dr Soft 49 hours and 10 minutes £2946 cost to provider 12.5 k downstream spontaneous letters of praise, no complaints, reserves required Dr Tough 17 hours and 15 minutes £1029 cost to provider 4.5k downstream one complaint, PEQ niggles, practices grumble, audit concern, staff like him Dr Perfect 34 hours and 10 minutes £ 2046 cost to provider 7k downstream PEQs fine, audit fine

“Management” Implies Sanctions Clinicians need to be “signed up” to monitoring and targets - criteria Need to understand consequences of non compliance Dropped ? Fined ? Coached ?

Who can best judge quality? Patients ? Colleagues ? The next consulting doctor ? It would be fabulous to have feedback from the patients GP But who dares criticise on the record?

What Criteria? Need to be fair, evidence based, reflect quality of care, and recorded Productivity 999, A and E, admissions Triage outcomes Timekeeping Complaints PEQs RCGP scores

Pitfalls Software use Staff preferences Shift types Workload constancy Search accuracy What is “best “ care – who can judge? Reproducibility of RCGP scores

Pragmatism Organisational norms National comparators Top and bottom 5 or 10% Feedback from colleagues and practices?

A Validated Tool? Ask for RCGP assistance? Academic assessment of “quality” BMA / LMC input Independent local assessment? A national consensus would be a great help

Lessons from Nursing NHSD sophisticated individual KPI Coaching Has produced change I imagine an expensive process Can we afford it

But Determining if a clinician is an employee or an independent contactor “Control” who controls; –What work is done –Where the work is done –How the work is done –Who does the work, esp delegate, send replacement or hire more staff The higher the degree of control the more likely an employment relationship exists

Mutuality of Obligation What other jobs, for how many organisations Evidence of commitment – sick pay, holiday arrangements Commitment evidenced by guarantee of work and of service Where mutuality exists there is likely to be an employment relationship

Other Factors Length of relationship Method of payment Own equipment? Degree of financial risk Responsibility for investment and management Opportunity to profit Do they have their own business? Is the worker part and parcel of the others organisation Tax treatment an indication, but not conclusive

Sessional Clinicians Should not have guaranteed shifts Need to bid for work Need to have a variety of shifts Need to have an unpredictability in gaining shifts Then it will be safer to manage them and yet retain their self employed status

Conundrums If you manage Drs Tough and Soft to the norm will it affect organisational outcomes? Price driven contracts favour Dr Toughs Does more management risk self employed status? What is best care? Is genuine clinical governance affordable?