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New UK direction for delivering patient care: Clinical networks
Despite still being in their early stages of development, clinical networks promise more patient-focused services and represent a unique opportunity for the industry.

Structural reform is one of the solutions that the NHS is particularly fond of to deal with the more effective delivery of healthcare, and clinical networks are no exception to this approach. However, some of the elements that make up networks mark them out as different from other structural changes that have been tried in the past. For example, they cross the traditional boundaries of primary, secondary and tertiary care; they follow the patient pathway more closely than the current institutions of care; and they loosen the attachment to individual institutions, which are sometimes a barrier to change.

What is a network?

Networks have been defined as "linked group of health professionals and organisations from primary, secondary and tertiary care working in a co-ordinated manner, unconstrained by existing professional and existing organisational boundaries to ensure equitable provision of high quality effective services." They may be grouped by function (e.g, pathology, A&E), client group (e.g, children, older people), disease (e.g, cancer, renal or coronary heart disease) or speciality (e.g, vascular surgery, cardiology or intensive care.

In the past, the NHS has solved problems related to the more effective provision of healthcare by either using markets (by commissioning services from external suppliers) or by providing the service themselves internally. Networks offer a different approach, particularly in situations where there are high levels of uncertainty or where there is a requirement to co-ordinate teams and professionals in different locations.

Networks exist throughout life, both at work and in social situations. Many people belong to a large number of informal networks, which tend to be fluid and are based around specific topics or areas of concern. Formal networks, however, are required when relationships need to be continuous and there are agreed rules about the method of working, aims and objectives and standards to be achieved. Networks are also useful when it is necessary for members to surrender sovereignty to achieve a shared goal. Clinical networks are formal groups of clinicians and managers in the NHS that co-ordinate services across a number of institutions and share resources in order to deliver them.

Having a formal network is not without its problems in that the effectiveness of a network is inversely proportional to its formality. In other words, 'imposing' such a structure on healthcare professionals may destroy the trust and co-operation that tends to grow with informal groups. In fact, developing networks requires a lot of skill on behalf of those whose role it is to do this and ensure the time spent on demonstrating the benefits and obtaining quick and early successes is not wasted once the enthusiasm of clinicians is engaged.

What are the benefits?

The main advantage of clinical networks is their capacity to be flexible, robust and to respond rapidly to an external environment that is changing almost constantly. There is nothing like capturing the force of like-minded clinicians to achieve a desired change in services.

Putting together clinicians in a field allows for the sharing of scarce expertise, improving access to care for patients and an improvement in standards of service. Through this process, patients can still expect a high standard of care even though they may be treated far from the specialist centre.

Through a sharing of resources, clinical networks can be a useful mechanism for sustaining small and vulnerable services where the requirements of training or sub-specialisation would otherwise mean the complete closure of local services. For example, a clinical network can provide local training and development opportunities for biomedical scientists in pathology across a number of trusts, which may have difficulty in retaining such staff on an individual organisational basis. Furthermore, there is a greater potential for offering a post to these trainees once they have completed their courses within the network thereby reducing the loss of trained workers from the area.

As a result of increased interaction between different disciplines and organisations, networks provide a great potential for stimulating creativity and innovation that may otherwise not occur. Sharing and developing ideas and practice is not something at which the NHS has historically been very good. Another benefit of networks could be to improve the level of recruitment of patients to large clinical trials by expanding the population base and providing a focus. This is another area in which the NHS has traditionally not been effective.

The more practical aspects of working in a network include the setting of a strategic direction of services that will impact on the decisions made by the component NHS organisations. This would include common goals and tasks around development of the workforce, information technology, joint purchasing of equipment and drugs and a standardisation of clinical practice.

Furthermore, with a great clinical input into networks there is an opportunity for the commissioning of health services to be more clinically oriented than before.

Management of a network

Setting up a network requires much input in terms of understanding the purposes of the process and anticipated outcomes, so it is important that the following key steps are followed:

clarify the purpose - why are we doing this?

identify the members - who is involved?

establish the links - how are we connected?

multiply the leaders - who is responsible for what?

integrate the levels - how are we connected within the hierarchy?

Although clinicians may not be keen on having 'managed' networks, administrative support is required at the very least.

Working in networks will mean that those involved need to develop a different set of skills to ensure the effectiveness of these groups. Such skills include a readiness to trade across various boundaries to gather resources; an ability to see the larger picture, make connections with different groups and broker appropriate partnerships; and diplomatic and listening skills - an ability to persuade, mediate and manage conflict. In addition, facilitation and working with uncertainty will be important skills. These will be new to clinicians who will not necessarily have had to get involved in management processes previously.

Strategic health authorities have an important role in facilitating the development of networks and they have a key responsibility in monitoring their performance.

Measuring success

Clearly, the success or otherwise of clinical networks will depend on whether they deliver more effective services that are patient-focused. But how can this be measured? Generally, networks have defined national policy objectives that will guide their work, for example, CHD networks have the standards of the National Service Framework for coronary heart disease to achieve and the picture is similar for cancer networks.

In addition to improving the process and outcomes of patient care, networks must create a rewarding environment for staff, for example, in terms of training opportunities, better terms and conditions and physical surroundings, such as IT. It is essential that networks demonstrate accountability for their work, as they will be responsible for the spending of public money.

A key measure of success for networks in the future will be whether the members say that they work for the network rather than their individual organisations. Currently, network members are still employed by their particular trust or work in their own general practice. However, as networks mature, these could develop into NHS trusts in their own right.

How should the industry approach clinical networks?

Once again, the industry is faced with the situation of working out who to connect with in terms of key decision-makers and how to engage them. Clearly, networks represent a different structure that does not have a basis in terms of statute such as NHS trusts or strategic health authorities. They are also evolving and fluid organisations that have the potential to develop in a multitude of ways.

In the early stages, which is the level of development many of these structures are at, accountability will appear to outsiders to be vague and decision-making uncertain. However, this situation represents an opportunity for the industry to develop new relationships as these organisations mature. It is probably most helpful to realign working relationships with these partners as they emerge and perhaps begin a dialogue on how their work could be supported. The most obvious approach would be in the area of skills development to help the participants get the most out of the network.

Networks also could potentially provide an opportunity for R&D partnerships, in that larger trials could be set up that would involve a number of centres and an agreed approach to research.

Clinical networks are currently mostly in the early stage of development with many of the participants still finding their feet. However, the drive to work across traditional boundaries presents a great opportunity for the NHS to ensure more clinically oriented and patient-focused services.

Dr Thoreya Swage