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The Matrix – CORPORATE STRUCTURE

Corporate Structure usually represents the line management of organisations Note that the Executive Team (four groups) have considerable concern as to the percep-tion of the organisation to the outside world, including local press, patient groups and issues surrounding complaints. The press advisor and legal affairs are key voices with regards the Chief Executive. Since April 1999, the CE was not only responsible for finance, but is now responsible for the quality of both patient care and the staff who are delivering it. Given that most CEs are not trained practitioners of any sort, the responsibility and accountability can only be delivered through clinical gover-nance. Of all the Executive Directors, the Medical Director and the Director of Operations are the two who have a significant impact on the role and performance of clinical staff and sup-port services. The Director of Nursing is one of the most far-reaching and diverse roles and will be a key target for stages of nurse prescribing, nurse consultants and nurse education. However, as is often the case, these individu-als are almost exclusively out of reach to most representatives from the Pharma industry. The Director of Finance (DOF) has become one of the most commanding and dictating positions within the Trust. Directives on cost containment or budget reduction will have compulsory attainment. No argument. No dis-cussion. Directors of HR are interesting targets for the industry as most NHS Trusts & PCTs have staffing difficulties and Pharma companies, whilst realising this, have not yet been able to crack this problem. There are some fantastic examples, however, of collaborative working within pockets of the Trust. General Managers for the various Directorates (Medicine, Surgery, Woman and Children’s Services) have become very impor-tant with regard to interface logistics between the Executive Directors, their Trust Performance Targets and the patients on the wards who require care within the budget available from the DOF. Indeed, recently, one or two drugs and ther-apeutics decisions have been blocked or deferred by General Managers who hold sig-nificant budgetary power and can, to a certain extent, dictate commissioning resources for problematic drug use/costs. Director of Pharmacy holds many keys though these individuals have varying accessi-bility to the Pharma Industry. More important-ly, pharmacy staff working under this remit (formulary pharmacists, directorate pharma-cists and medical / drug information pharma-cists) have significant influence over medicines use within the hospital and subse-quent primary care interface. Pharmacists will be covered in further issues of the Matrix. Other Support Services such as Dieticians, Physiotherapists, Microbiologists will be tar-gets for those therapeutic areas in which they are directly or indirectly involved. Note some support services are now under PCT auspice for example, diabetes nurses and dieticians. NHS Trusts have many Boards & Committees as can be seen by the diagram Philosophically, they allow staff and man-agers who often do not have any line respon-sibility to each other to come together in some forum as dictated by the title of that Board. Operationally, they allow decisions to be made which often cross departments and multi-disciplinary staffing grades. These Boards and committees will either be advisory or policy making. It is not always clear which type a given group is! The CMB is a very important Board and acts as a filter to major decisions that may affect the Trust. Some therapeutic decisions may need to go, ‘through’ CMB although even this is varied and may not be clear to what extent the CMB, ‘need to know’. Modernisation Review Group do have all the NSF groups reporting progress along with Cancer Unit Steering Group. As the Government becomes more focused on per-formance than just audit, this will be a very important group. Remember that CHI (Commission of Health Improvement) are changing their role over this next year from an, ‘audit’ role to an, ‘inspection’ role. Their teeth have become larger and sharper and issues around cost, quality and performance will become more focussed than they have ever been before. This is both good and bad news for Pharma Companies. Whilst Drugs and Therapeutics Committees will become, ‘even more focused’ on evaluating new drugs, more and more groups will have an impact that will need con-sideration. Case Study A Trust comprising of three hospitals where a mixed variety of products were used for thrombo-embolic disease (DVT, PE, unstable angina) should see a concerted effort made to standardise practice across the hospitals. For historical reasons different heparins were being used for similar conditions. During this process a variety of Pharma Companies made contact with various individuals – but who were the key players? The review was Pharmacy led – but the lead consultants across three Directorates were crucial. Orthopaedics, General Surgery, Medicine and Obstetrics and Gynaecology and Cardiology. In each case, various companies targeted certain individuals but it became apparent that not one single representative had been able to see all the relevant clinical staff. Orthopaedic surgeons are never keen to use heparins – in fact to pursue the process Clinical Risk Management and Clinical Audit were both called upon to increase pressure and move issues in the right direction. Non of the Pharma companies had thought about this. Where does clinical evaluation for risk assessment in surgery occur? The answer lies very much in whether patients are blue-lighted in or whether they are elective. Patient access and consideration of where patients are eval-uated (as much as how they are evaluated) was key to producing well placed guidance on completion. Again, staff involved with clerking or ward staff involved in assessing risk were targeted by one company only and it helped them significantly. Post Grad Med Centre was key to meetings being held by individual directorates. Only one company was able to influence support at Directorate meetings so as to be at the right place at the right time. The Finance Director watched this process very closely. Significant financial data was provided throughout the process. As Haematology is key to the whole process, and there were significant issues addressing three sites and cross-political borders, only one company was able to bring some of these influences together in a short but very effective forum Medical education for nurses was addressed by all companies but most only one or two deliv-ered on promise. Some nursing staff reported favourable discussions regarding this to pharmacy. The creation of ward charts, protocols and lamin-ations was crucial in supporting the process. Clinical project sub-committee was key to aiding the audit process which actually helped the Trust achieve some of its audit targets – something which inevitably helps the CE of the Trust look favourably on those involved. Pharma companies should bear issues like this in mind. We all have targets to reach. In the context of the Matrix, do any of your targets match ours? If you don’t know – find out! Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare Trust, PCG Formulary Advisor to Primary Care, Executive Board Member of the National Obesity Forum, the Pharmacist Representative of the Diabetes Local Services Action Group and if that isn’t enough Omar is a National UK Speaker.

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