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Co-Management – The Partnership

Monday, March 1st, 1999
Lorrima Cranstoun, Manager, and Dr Rasiah Yuvarajan, Clinical Co-ordinator, Mental Health Services for Older People, Mental Health Services, Auckland Healthcare, New Zealand



Introduction

Over the past two decades New Zealand has experienced major swings in the way in which power and control has been exercised within the public health sector. In the late 1980s and early 1990s, New Zealand’s move from a clinically dominated health service leadership to a more general management structure was strongly influenced by developments within the UK, as was the subsequent move to managed competition with a strong commercial bias.

Now that “competition” and “making a profit” are being replaced with “collaboration” and “business-like practice”, the opportunity is being taken to restore clinical management to its place alongside business management. New Zealand, in the late 1990s, is introducing partnership, or co-management, as a way of obtaining a new synergy through affirming the need for shared leadership and accountability.

This paper is presented in two parts. It starts with an historical overview of the development of clinical management within the UK over the past two decades and the lessons learned from this. It then describes a New Zealand designed approach to co-management currently being implemented within Auckland Healthcare Mental Health Services for Older People. While the terminology used in the UK and New Zealand differs, there are underlying common concepts and parallel themes in both the implementation processes and the identified critical success factors.



Co-Management: A UK Perspective

The last two decades in the UK National Health Service (NHS) possibly represent a time of the most dramatic change since the service was founded. A variety of policy statements, guidance documents and structural and operational reforms have brought strong pressures to bear on the traditionally defined clinical management. Increasingly, there are changes in the roles of doctors, nurses, other health professionals and general managers in decision-making on resource use in the NHS. The Patients’ Charter, purchasing initiatives to link to “local voices” and the general movement towards quality improvement provide openings to involve patients and the public in these decisions.

A series of key events in the UK health sector management have led to a clinical management team approach.

The 1983 Griffith’s NHS Management Inquiry was instrumental in the introduction of a more managerial culture in the NHS and has lead to strong investment in the development of general management in subsequent years. The Inquiry concluded that there was a need to involve clinicians more closely in the management process, consistent with clinical freedom and accepting the management responsibility, which goes with clinical freedom.

Management budgeting was one of the clinical management initiatives recommended by Griffiths.

The Resource Management Initiative was subsequently launched in 1986, to take forward the aims underpinning management budgeting in a new way. The overall aim of the programme was to help clinicians and other managers make better-informed judgements about how the resources they control can be used to produce measurable improvements in patient care.

The Cumberlege Reports of 1986 undertook a review of community nursing in England and raised serious questions about the role of nurses in the clinical field and in the management of community health services. Devolved nurse management within the community team, the creation of clinical nurse specialists and clinical nurse managers, and the involvement of nurses within clinical management teams were significant changes, enhancing clinical input to management functions.

Project 2000, first introduced in 1989, is now being phased in across the UK and will have a profound effect on the future of nursing. It aims to bring about a substantial change in nursing care through the development of empowered, assertive and autonomous professionals who will be much better able to empower patients and develop the nursing profession.

The National Health Service and Community Care Act 1990 separated the commissioning and delivery functions of the health service. Commissioning agencies became responsible for the health of their local populations. They were charged with assessing local health needs and purchasing a pattern of services that met those needs from the NHS, private sector, charitable trust and voluntary sectors. For providers, the split has removed what many saw as irksome layers of bureaucracy but it has also had the effect of reducing communication and, in some instances, increasing competition between providing organisations, particularly as they assume trust status.

Trust status has had a major effect as health care provider organisations have become increasingly decentralised and relatively more autonomous. It has resulted in the strengthening of unit management with the acquisition of specialist expertise and skills. The new Trust Boards and Unit Management Boards now have to concern themselves with strategy in the market and with managing ‘outward’ to manage relationships with a number of external organisations as well as managing ‘downward’ within their own organisation.

With the introduction of the internal market, a contracting mechanism has become the basic mode of interaction between purchasers and providers. This has driven the rapid development of activity and costing information systems, which have taken precedence over systems generating clinical information. GP fund-holding has also had an effect, particularly outside major metropolitan areas where numbers of fund-holders are higher. Fund-holders have started to contract “packages of care” with local providers.

In addition to GP fund-holding, UK government policy is supporting shifts in the balance of resource allocation from secondary care to community, mental health and primary care. These trends have had significant effects on the size, nature and organisation of acute and community units, and they affect the way that clinical/co-management is practised throughout the service as models are developed for “seamless care” across traditional service boundaries. Some units are beginning to experiment with new approaches to clinical/co-management to address these concerns.

In reviewing the complex environment in which clinical/co-management has developed in the UK, and the factors that will continue to shape it in the 1990s, the following three broad ongoing themes are evident:

  1. a commitment to decentralised clinical management
  2. a move away from the notion of “one right structure”
  3. a multidisciplinary team approach.

A consensus statement issued in 1995 by the British Association of Medical Managers, the British Medical Association, the Institute of Health Service Management and the Royal College of Nursing, identifies the following as characteristics supporting effective clinical/co-management:

  • appointment and role clarification of the Medical Director
  • appointment and role clarification of the Director of Nursing
  • operational support at all tiers of clinical/co-management
  • improved communication
  • quality (TQM, quality improvement measures, etc)
  • participatory contracting process (at unit level)
  • improvements in training and development
  • the team approach.

There are three different levels of management within a provider organisation that must co-operate to deliver effective clinical management: the trust board; the unit management board (or executive operational decision-making body) and; the clinical management/co-management teams.

Clinical/co-management involves a much broader concept and a much wider range of tasks than incorporating medical decision-making alone and so must involve more than doctors. The token inclusion of a clinical member on a team has been replaced by clinicians playing fuller roles as team members.

The heart of the concept of clinical management is the clinical management team. This team leads the clinical groups, which, together, are the engines that do the work of the provider organisation.

The work of the clinical management team is inherently multidisciplinary and interdisciplinary. For the work and the team to be effective, both must emphasise respect for the contribution of different team members to patient care and the management of clinical resources.

Within a strategic framework, clinical management teams at the unit level must have devolved to them the requisite resources and the authority to manage those resources effectively. The philosophy in unit management should align with that of the governing board(s), which in turn must support unit management.

The primary goal of clinical/co-management is the continual improvement of patient care. All activity within the provider organisation must be driven by the need to prevent illness in the first instance, and then to diagnose, treat and care for patients effectively and efficiently. Clinical management influences the orientation towards quality in the organisation and delivery of patient-oriented care, which has the potential to fundamentally change the way the service operates.

It is especially important to sustain the principle of commitment to quality patient care when a unit comes under financial pressures. The history and timing of the introduction of clinical management, the impetus for it and the overall quality of unit management into which it was introduced have all been significant influences on development.



Co-Management From a New Zealand Perspective

The motivation for active commitment to a partnership approach by the Clinical Co-ordinator and Service Manager within Auckland Healthcare’s Mental Health Services for Older People comes from a number of sources. The Clinical Co-ordinator’s experience is largely UK-based. The Manager’s experience and motivation has come from:

  • An "enlightened" health service experience in the 1980s in which the Medical Superintendent included the Hospital Manager as a member of the Clinical Advisory Group. Together, that team, discovered innovative solutions through bringing together clinical and "business" thinking (though the term "business" was not used at the time)
  • A role as purchaser of health services which highlighted fragmented direction, disempowered systems and poor service delivery where clinicians were excluded from purchaser/provider service development, contracting and monitoring processes
  • A study tour to North America which demonstrated that recognised best-practice mental health service systems had three common characteristics:
    • consumer/family focus
    • mature leadership (management and clinicians working together), recognising their interdependence
    • high staff morale.
  • The "recovery" orientation in mental health, where principles of respect, equality and inclusion at the consumer interface must be mirrored within the service leadership system. Healthy outcomes are achieved through people working in healthy environments, where people’s different abilities are valued and respected.

Shared accountability is the principle underlying a co-management approach. This shared accountability is based on bringing together both clinical and management perspectives, and on the strengths of the individuals who have these roles. It is recognised that some managers have previously worked as professionals within a clinical team, and that some clinicians have both business experience and qualifications.

Some of the clinical issues that a co-management approach is intended to address include:

  • restoring clinical consideration for resource allocation decisions (dollars, human resources, facilities, access)
  • using the care plan and clinical pathways as a means of managing resource utilisation
  • selecting evidence-based cost-effective treatment options
  • utilising an “opportunity costs” approach when rationing decisions are needed
  • assisting with linking ethical and economic considerations
  • ensuring continuous improvement in quality through monitoring and audit
  • bringing a multidisciplinary team perspective to the business of health.

Some of the business issues include:

  • ensuring efficiency gains are never viewed in isolation from overall effectiveness
  • emphasising the business is health and the investment is in health outcomes (including quality of life/well-being) – means and ends must not be confused
  • sharing risks with safety and support
  • jointly championing flexibility to use resources creatively – looking for pilots, getting in early and keeping at the cutting edge of change
  • encouraging an entrepreneurial approach to bring up new innovative programmes quickly.

Although these appear to be service issues, separating them out for conceptual purposes is somewhat artificial and should not cloud the fact they are issues of interdependence. This reinforces the need for commitment to a partnership approach, and recognition that services will only deliver the required benefits through a shared approach.

Within Auckland Healthcare Mental Health Services for Older People, the approach to co-management and the processes used to achieve it are at a relatively early developmental stage.

As outlined above, the approach to co-management has been built on experience of US- and UK-based approaches and on previous experience in New Zealand. A partnership approach is being taken which involves the senior clinical team member and the Service Manager.


Establishing and Managing the Partnership
The initial meeting of the Manager and Clinical Co-ordinator was the start of a "testing out" process. It was used to identify where the Manager and Clinical Co-ordinator had come from and what they valued. The meeting was also used to share ideas about future directions. The commitment to working in partnership was based on a agreement that both parties related well at a human level as well as a professional level and had enough in common to commit to working collegially.

Regular meetings thereafter were used to share information, knowledge and expertise. Both parties felt free to question the other when unclear or when heading for apparent disagreement, and to ultimately analyse issues in terms of "problems" not people.

For the relationship to grow, both parties need to know what they agree on, and be aware of where they don’t agree and find ways to negotiate win/win solutions. This is the ongoing challenge – to act with courage and integrity.

The need to work together is regularly reaffirmed. The management partnership will “survive and succeed” through collaboration. In addition to using a collaborative approach, the commitment to partnership is explicitly communicated within the service. There is also effort to actively reflect this shared responsibility within service/team settings, ranging from staff interchanges, to team meetings and planning days.


Making the Partnership Work
In a service that is not used to this partnership approach and which has its own history, mistrust and unease still exist. The partnership team’s belief is that they must “walk the talk” and model a more open and co-operative communication. The partnership members question each other, seek clarification, voice a range of views and discover ways forward. Through this approach, the aim is to open staff to broader perspectives, options and choices, and to promote more lateral ways of viewing challenges and seeking creative solutions. Good communication, frequent, easy and flowing in all directions, is crucial.

This broadening of perspective within the service in turn reflects on consumers and family and ultimately on purchasers and other providers.

It is acknowledged that it will take time to build trust, mutual confidence and openness. Both partnership members are very action oriented and eager for development opportunities. It is therefore essential to start where people are at, to have patience, to not seek "quick fixes", and to be prepared to take people along for the long haul. There is a need to be clear as to the strategic direction and, as a service, to celebrate progress as each building block is put in place.

It is only as service "wins" are achieved, that confidence will build. It is important to regularly reflect on what is being achieved by the partnership team members independently and together. Gains are identified and there is continual analysis and feedback on what is working and what is not. This regular reflection and evaluation is essential at both a personal and a professional level.

Finally, the partnership team members share a systemic perspective. This ranges from the micro aspect of the consumers, with their biopsychosocial needs, through to the service itself, to the networks that the service interfaces with and on to the macro of the wider community and the political environment. There is a awareness of the "ripple on effect" that decisions have and of the need to constantly link "private concerns and public issues". Influence is sought at all levels in order to achieve the best outcomes for consumers.

These approaches, to outline but a few, are being progressively applied to the Auckland Healthcare Core Accountabilities of strategic, professional and operational leadership, quality improvement and financial budget and volumes management. The intention is to complete the Core Accountabilities position statement by June 1999, which will document relative accountabilities of the co-management team members. This will be the first milestone of an ongoing journey of involvement in dynamic processes open to regular review, especially in the face of ongoing change.


Measuring Success
The crucial issue is in knowing if the partnership approach is succeeding and what the critical factors are in determining whether this approach is making a positive difference. Underlying these issues are questions relating to whether the combined creative strengths of the partnership members are being fully applied and whether the partnership members are becoming better at harnessing the synergy that comes through such a partnership.

The anticipated critical success factors are being grouped under three headings, which can be aligned with the Auckland Healthcare corporate framework. If the partnership is contributing to excellence it should make a difference for

  1. consumers
  2. the service
  3. the organisation.

Consumers of the service should be more satisfied because:

  • they too will be participating within the partnership
  • best practice clinical pathways will be clearly communicated
  • functional requirements related to their illness will be met
  • their rights and whole needs as a person will be recognised and they will be treated with dignity, respect and equality
  • the agreed outcomes will be delivered.

The service will be enhanced through:

  • staff feeling valued and the overall morale improved
  • "empowered staff" offering better service delivery
  • positive feedback from customers reinforcing staff effort.

The organisation will be recognised for its leadership in:

  • promoting a learning organisation
  • achieving financial viability
  • providing cost-effective care.

Within each service, the business planning and performance appraisal processes can be used to set achievable objectives which will contribute to and demonstrate these success factors. These processes will succeed to the extent there is ownership of the vision of ’Excellence in Service Delivery Through Partnership’ across all levels within the organisation.



Conclusion

The approach to co-management at Auckland Healthcare Mental Health Services for Older People is at a developmental stage. Both partnership members have agreed that form should follow function, and so the focus is on "practising" the partnership rather than rushing to document the shared accountabilities.

The partnership approach between the Service Manager and Clinical Co-ordinator differs from the team-based UK approach where nursing staff are frequently included in a tripartite management approach. Health services in New Zealand have US and UK models of co-management on which to base local approaches to clinical involvement in health service management. As has occurred with Auckland Healthcare Mental Health Services for Older People, the approach can be tailored to service requirements and available resources.

The goals of co-management include improvements from the perspective of consumers, the service, and the organisation. However, a broader aim is to extend the concept of collaboration beyond these groups to other providers and to funders. Co-management at Auckland Healthcare Mental Health Services for Older People is seen as a microcosm of collaboration in general and the intention is that the principles of partnership, openness, joint decision-making and co-operation extend into all relationships within and beyond the service.
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