Practice Business June 12 by Intelligent Media Solutions

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june 2012

Let the games begin

How the Olympic Games could impact your practice

Keeping schtum

Quick ways to improve patient confidentiality

Fighting fire with fire One practice recovers after an arson attack

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Editor’s letter EXECUTIVE EDITOR www.roylilley.co.uk MANAGING EDITOR julia.dennison@intelligentmedia.co.uk ASSISTANT EDITOR carrie.service@intelligentmedia.co.uk REPORTER george.carey@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER george.petrou@intelligentmedia.co.uk ACCOUNT EXECUTIVE gabriele.zaccaria@intelligentmedia.co.uk PUBLISHER vicki.baloch@intelligentmedia.co.uk DESIGNER sarah.chivers@intelligentmedia.co.uk PRODUCTION/DESIGN peter.hope-parry@intelligentmedia.co.uk CIRCULATION MANAGER natalia.johnston@intelligentmedia.co.uk

Is it possible to plan for the future when you don’t know what it will bring you? PMs do it everyday This month’s Practice Business features a very moving story about a practice that suffered a double tragedy in a short period of time. St Andrew’s Medical Centre in Spennymoor, outside Durham, was victim to an arson attack in 2010, after which the entire practice building burnt down, and then, three days after they moved into a new premises, one of its partners, the leader of the rebuild project, died suddenly. On page 16, practice manager Tracey Martin speaks in detail about what it’s like to have something so tragic happen and how, if ever possible, a practice can look to the future after such a blow. When I spoke to her, she was extremely stoic, though still obviously very shaken months afterwards. I gleaned two things from my conversation with her: one, your team is everything. A surgery building can burn down to the ground, but the practice can survive, by hook or by crook, with its people. This is why Tracey felt that she could recover from a fire, but found it very difficult to move on after the death of one of the doctors – someone she considered a friend. The second thing I learned is that you truly never know what can happen. The fire and sudden death of Dr Sensier came completely out of the blue and were two things the practice did not anticipate. While it’s impossible to anticipate the sudden death of a friend and colleague, a fire is something practices can and should plan for. In her interview, Tracey explains what she would have done in hindsight and urges practices to do now. Speaking of thinking ahead, we have another article in this issue focusing on what practices should do to prepare for the Olympics (p25). While many of you outside of London are probably thinking you won’t be affected, you may want to think again. With the influx of tourists throughout the country, no practice should assume they will be untouched. In the meantime, here’s hoping you make the most of the sunny weather (if the sun is still shining when you read this, that is).

editor

Contents sector 06 news QOF error sees thousands of practices paying money back 08 executive editor comment Recession? Lilley says you ain’t seen nothin’ yet

primary provider 10 12

commissioning news CCGs ramp up the pressure on practices

case study providing with care GP Care provides a successful DVT/Ultrasound service to 100-plus practices in Bristol and the surrounding area

PEOPLE 16 case study fighting fire with fire Spennymoor doctors’ surgery celebrates a fresh start

after a tragic arson attack and death in the practice

MANAGEMENT 22 advice the right move The chairman of the Independent Ambulance Association

discusses the landscape of regulated transport services for patients

25 olympics let the games begin Preparing for the Olympics – how to do it and why it

could impact your practice

28 patients keeping schtum What you can do to vastly improve patient confidentiality on

a budget at your practice

32 clinical medicine for managers This month: Tuberculosis 34 HR in the family way How to organise flexible working hours for employees with

family commitments

Work/life 36 survey variety is the spice of life We survey practice manager readers to find out

the wide variety in their career backgrounds

38 diary Ann Boyle on receptionist duties

sector

QOF error sees thousands of practices paying money back Over £1m is due to be clawed back from GP practices all over the country due to an error in the QMAS QOF calculations that dates back to 2010. PCTs will be taking back up to £800 from thousands of GP surgeries after the Department of Health asked them to “make good” the error to the system, Pulse reports. While most practices affected were overpaid (7,677), 512 were underpaid and will be due some money. The average overpayment per practice is £140 and the average underpayment is £95. At the extreme end, one practice will have to pay back £825 and another will receive a payment of over £1,100. This comes in the wake of the £28m in overdue QOF payments distributed last February. Richard Armstrong, head of the Primary Medical Care Commissioning Development Directorate, commented: “The final adjustments for 2010-11 have now been calculated and PCTs are now required to take action to make the adjustments which are set out in the attached spreadsheet accompanying this letter. “In making these adjustments, the legal advice we have received is clear that PCTs must make good any underpayments to practices and have no discretion around this.” Fast facts He explained that where a GP contractor has been overpaid, • Practices could have to give PCTs have the discretion over whether they reclaim these back as much as £800 payments or not. • £1.1m is the total PCTs have “For example, if the amount of overpayment is less than the been asked to reclaim administrative expense in reclaiming the payment, a PCT may • 7,677 practices were overpaid decide not to reclaim the payment,” he added. • 512 were underpaid and are due The total reclaiming of underpayments to PCTs would be money. £1.1m.

your monthly lowdown on practice management

Practices lose out from PREM1 errors news

june 2012 | practicebusiness.co.uk

Too many GP practices across the UK are losing out on important income because they are not filling in their PREM1 forms accurately, property specialists warn. “Increasingly we are seeing GP practices lose out on notional rent reimbursement because they are not including all of their useable space on the PREM1 forms that they receive from the PCT,” said Chris Johnson, director at GP Surveyors. “This may be due to the fact that doctors and practice managers across the country are going through a very busy time and are rushing to complete their forms, or they’re simply not aware of what they can or can’t include. Given the growing financial pressures on practices, the importance of receiving the correct rent reimbursement is only increasing, says Johnson, “therefore, I would urge all practices to allocate appropriate time and resources to getting the forms right.” PREM1 forms are received by GP practices across the country every three years as the first stage in the rent review process. Practices are asked to write down

all the available space that they plan to claim rent reimbursement for from the PCT. Andrew O’Dowd, another director at GP Surveyors, commented: “The main spaces that we are finding practices to leave out are areas such as lofts and basements that they may use for storage etc. Using these spaces for storage frees up more space for reception areas, treatment rooms or circulation space etc. Therefore it is vital to include it on the PREM1 form to ensure it is all taken into account when the notional rent reimbursement is calculated. O’Dowd is seeing more cases where the PCT representatives are using the details on the PREM1 form to limit what is included in their valuation, causing lost income and delays in rectifying mistakes: “We would advise, instead of trying to note down all the individual spaces available within the premises and running the risk of leaving something out, practices simply write: ‘The whole of the property known as [insert name of GP practice] is used for GMS/PMS purposes’.”

SECTOR | news

clinical news CQC WATCH

PPGs and name badges: two ways to prepare for the CQC

There are a number of ways practices can prepare for CQC registration, which is piloting from July. It has recently been suggested that setting up a patient participation group (PPG) and urging staff to wear name badges are two steps in the right direction. The GPC is urging all GP practices to set up patient participation groups (PPG) in order to comply with CQC registration requirements. Many practices have already begun setting up a PPG as part of the patient participation directed enhanced service. New guidance on preparing for CQC registration, released by the GPC, has said that practices are “likely to be compliant” if they have a patient participation scheme. It also recommends that practices “involve patients in their care”, for example, by establishing patients’ needs, preferences and decisions and providing information about the available care, treatment and support options. Other recommendations include having due regard for the patients’ age, sex, religious persuasion, sexual orientation, racial origin, cultural and linguistic background and any disability they may have. Meanwhile, complying with the part of the guidance that says patients should know the names and job titles of the people who provide their care could be as easy as wearing a name badge. Dr Neil Shaw of Eyre Street Dental Practice in Derbyshire said badging staff members helped to satisfy this outcome for audit.

They said…

“”

“Hospital trusts must put in place arrangements that ensure people cannot exploit the system. However, we need to be careful that we are not putting barriers in place that prevent people from getting access to healthcare. It can be quite challenging. It is too simplistic to call it health tourism. The reality is a lot more complex”

Should childhood vaccines be mandatory? In a debate on bmj.com, Paul Ofﬁt, chief of infectious diseases at the Children’s Hospital of Philadelphia has called for mandatory vaccination in children. He argues that when parents choose not to vaccinate, not only are they making a choice for their own children, they are also making a choice for those with whom their children come into contact. This includes children who are too young to receive vaccines and those who can’t be vaccinated. Vaccinations are mandatory in the US, which didn’t suffer a measles epidemic after claims of a link between the MMR vaccine and autism.

Get the latest news in your inbox Want to be bang-up-to-date on your health sector news? Sign up to the PB Weekly e-newsletter and receive the latest practice manager news and views straight to your inbox. To sign up, email subscriptions@intelligentmedia.co.uk with the subject line “PB Weekly” or visit www. practicebusiness.co.uk.

diary 20-22 June

NHS CONFEDERATION ANNUAL CONFERENCE Manchester Central Convention Complex Conference.NHSConfed.org

Dr Richard Vautrey of the BMA’s GP committee in reaction to news that hospitals are owed as much as £40m from treating foreign nationals

27 June

COMMISSIONING Olympia, London CommissioningShow.co.uk

fact

Five per cent of prescriptions contain errors The General Medical Council has published the results of a study into GP prescribing that found that around one in 20 prescriptions issued to patients contains an error, with one in 550 associated with a severe error. Recommended solutions include a greater role for pharmacists in supporting GPs and better computer systems.

4 July

A PATIENT-CENTERED APPROACH Central Hall, Westminster PublicServiceEvents.co.uk

practicebusiness.co.uk | june 2012

SECTOR | comment

Roy Lilley Roy Lilley is executive editor of Practice Business. He is an independent health and policy analyst, writer and broadcaster and commentator on health and social issues.

No small change

Nicholson Challenge? Ain’t nothin’. Roy Lilley says there will be a lot more money problems to worry about in future

Twenty billion pounds is nothing compared to what the NHS is facing after 2015 june 2012 | practicebusiness.co.uk

In the real world – outside healthcare reorganisation, funding, NICE, pathway design formulary management and all the rest – there’s a worldwide financial meltdown going on. Saving £20bn in the NHS by 2015 is a trifling issue. What happens after 2015 is more interesting. With flat-line funding, four per cent growth in demand (some are now saying six per cent) and an economy bumping along the bottom, savings of £60bn are probably not out of kilter with what will be a difficult reality. The NHS will reorganise, find another word for rationing, and delay treatments in the name of the clinical benefits of watching and waiting. Formularies will be ‘realigned’ and expensive drugs set impossible value-for-money targets. The NHS can cope. It always does. But, what about the patients? What is it like for them to live in austerity Britain? Austerity measures were introduced following the spending review in October 2010. This included £81bn of cuts over four years. In April 2011, claims for benefits on the basis of incapacity for work were transferred to claims for employment and support allowance (ESA). Entitlement was reassessed using the new stricter criteria of the Work Capability Assessment (WCA). The Welfare Reform Act introduces a new Universal Credit that will replace most existing benefits and limits the total amount of benefit a person can claim. As well as these broader plans for welfare reform that will come into effect in 2013, there are changes to working tax credits implemented now. A report on the UK Parliament website estimates the number of households that are expected to no longer be entitled to tax credits as a result of these changes, including over 25,000 households in the central belt of Scotland. I’ve come across a really interesting report called ‘GPs at the Deep End’ (see gla.ac.uk/media/media_232766_en.pdf) and it is well worth getting a cuppabuilder’s and having a read. All the conclusions point towards a greater patient contact with general practice. It starts with the deteriorating mental health of people who are still in work; under increasing stress at own jobs due to cutbacks; taking on extra work/jobs, with resultant impact on family and relationships and experiencing stress of job insecurity At the other end there are those with chronic mental health issues and established physical problems who are ‘deemed fit for work’ and have their benefits cut. They will be struggling to make ends meet, have increasing contact with GPs and psychiatry, increasing antidepressant/antipsychotic use and self-medicating. Financial hardship is manifesting in several ways, but perhaps most striking is the growing number of individuals and families experiencing fuel poverty – the combination of increased costs and falling benefits resulting in a choice between heating and eating. Practices reported cases of an elderly patient going to a friend’s house in order to wash; families relying on relatives to pay for food and cigarettes (unable to stop smoking due to stress); and a mother resorting to prostitution to feed her family. It seems to me, this report reminds us, however bad you think it is now, you ain’t seen nothing yet.

PRIMARY PROVIDER

ccgs RaMP UP The PRessURe on InDIVIDUal gP PRacTIces Clinical commissioning groups are calling for a tougher performance management system for practices as they take control of GP access. This comes as CCGs across the country have been putting pressure on GPs to perform better, Pulse reports. Areas for improvement CCGs have been targeting include referrals, by hitting back at high-referring practices; patient access, by putting patient satisfaction and opening hours under scrutiny; and monitoring practice spend on prescribing. Examples of this pressure include a GP leader from Islington CCG incurring the wrath of LMCs across London by suggesting a “less light-touch” approach to practice ratings across the capital. Meanwhile, CCG leaders in Manchester have

Delivering commissioning in practice

PRACTICE BUSINESS HAS LAUNCHED A NEW COMMISSIONING MAGAZINE

june 2012 | practicebusiness.co.uk

While we will still cover commissioningrelated topics from a primary care provider point of view, practice managers heavily involved in clinical commissioning will want to refer to our new bi-monthly commissioning magazine that launched last month, called Commissioning Success. It will be targeted at decision-makers and participants in commissioning, from board members to commissioning support units and supporting groups. Because of our background in practice management, the magazine will focus on the management and strategy behind effective commissioning, as well as keep readers up to date with all they need to know in terms of news and updates. If you’re interested in receiving a free copy, please email your details to subscriptions@ intelligentmedia.co.uk with the subject line “Commissioning Success”.

been rolling out mystery shoppers to scrutinise GP access in their local practices. Meanwhile, it was revealed that NHS London is already running new indicators on its GP Outcome Standards to tighten scrutiny on practices surrounding care for alcohol misuse, mental illness and care for the dying, as well as a new indicator for the effectiveness of CCG monitoring of GP access.

PRacTIces ‘MUsT noT Be leFT oUT oF ReFoRMs’ The development of clinical commissioning groups (CCGs) is happening without the involvement of many ordinary GPs and their practices, a GP leader has warned. Acknowledging that in some areas of the country the development of CCGs is progressing positively, in his speech at the annual BMA GPs’ conference, chairman Dr Laurence Buckman said there were other areas where commissioning groups are trying to impose “unacceptable” structures. He says GPs should stand up to this: “CCGs are ‘membership organisations’ as we keep on being told, they are our creatures not just another version of the PCTs they replace,” he said. “GPs should be telling them what to do, not the other way round. We were told it was going to be different...the Government needs to make it so.” The BMA was opposed to the Health and Social Care Bill and continues to voice concerns about its roll-out to ensure that implementation is evidence-based.

Diabetes reaches crisis point in UK Diabetes healthcare in England has entered a “state of crisis”. These were the words from Diabetes UK on the release of its ‘State of the Nation’ report last month, which revealed that less than half of people with diabetes are getting the basic minimum care they need. There are some areas where just six per cent of people with the condition are getting regular checks and services, as recommended by the National Institute of Health and Clinical Excellence (NICE). This has led to a rise in rates of diabetes-related complications, including amputation, blindness, kidney failure and stroke, all of which reduce quality of life and can lead to early death. These complications account for around 80% of NHS spend on diabetes and are one of the main reasons that treating diabetes costs about 10% of the entire NHS budget. The report urges the Government to introduce more effective risk-assessment and earlier diagnosis so people can avoid Type 2 diabetes altogether, or at least get the healthcare they need to better manage the condition and avoid complications. It also asks for all people diagnosed with diabetes to have access to educational materials to help self-manage the condition. Wholesale change As well as people not getting the checks they need to manage diabetes, the report reveals that, from diagnosis to managing the complications of the disease, the care approach to diabetes is in need of wholesale change. Barbara Young, chief executive of Diabetes UK, said: “We already know that diabetes in costing the NHS a colossal amount of money, but this report shows how in exchange for this investment we are getting second-rate healthcare that is putting people with diabetes at increased risk of tragic complications and early death.” The report, she says, shows that diabetes healthcare had “drifted into a state of crisis” and presents a “compelling case for change” and a need for a national plan to be put in place.

Fast facts n Only 49.8% of people with diabetes are getting the basic minimum care they need n Potentially preventable complications account for around 80% of NHS spend on diabetes n Treating diabetes costs around 10% of the entire NHS budget.

provision | case study

Providing with Care The ﬁrst in a series of case studies focusing on business-minded GPs and practice managers, we look at GP Care, a group of GPs based in Bristol, which set up DVT/ultrasound services on behalf of its 100-plus Bristol and surrounding area practices. POLLY ELLISON ﬁnds out their story

When the NHS called for a secondary to primary care shift and when care-closer-to-home became a focus, several GP groups took up the initiative. One of those was GP Care UK. In 2006, a proactive group of GPs in Bristol joined together to form GP Care, a network of GP practices which, with other professionals, would design, implement and deliver a range of high quality NHS services in a community setting. Eighty-five practices joined in the beginning and other practices in the area followed as it developed. Now the network exceeds 100 and comprises over 650 GPs across the Bristol, South Gloucestershire and North Somerset area with a patient population of around 1,000,000. The group’s aim was to provide appropriate high-quality diagnostic and outpatient care services closer to patients’ homes, june 2012 | practicebusiness.co.uk

making the services more efficient and convenient for patients, while easing capacity within acute hospitals and delivering savings to the NHS. The LMC sponsored the very first meeting that the Bristol GPs had in the start-up of GP Care, then they stepped back and left the organisation to gather its own momentum. In order to get the organisation up and running, each practice was asked to contribute £0.50p per patient to the initiative. The organisation started out originally as a limited liability partnership but this proved administratively burdensome, so it became a limited company. It also became apparent to those involved that in order to establish the necessarily robust clinical and corporate governance infrastructures to support the delivery of high quality clinical care it would be necessary to raise further funds. So, some

provision | case study

•

two years after start up, in 2008, practices were asked to contribute further funding. GP Care raised some £600,000 to set itself up and to safely take it through the inevitable early phase of investing heavily and temporarily running at a loss. GP Care says investing in good services is critical and you can’t be frightened of making initial losses during the start-up phase. The business has built its support infrastructures carefully with patients in mind and, alongside delivering excellent care, has realised some real wins for patients, GPs and commissioners, such as: • delivering cost savings to commissioners ranging from 25%-80% of national tariff • running with an average wait of less than 14 days on all of its services, delivered largely as one-stops wherever possible

not using automated telephone systems – patients and referring GPs always get straight through to talk to a patient/service coordinator and call answering times in 2011/12 averaged at just under eight seconds presenting reports to patients at the end of the appointment and forwarding these to referring GPs within 24 hours.

Initially there needs to be a lot of money and considerable hard work. Now, all companies need CQC registration if they are going to supply regulated activities and have the appropriate clinical governance in place, all of which costs. All the policies and procedures, quarterly audit reviews, reports to commissioners and infrastructure to deal with any complaints and significant incidents – the whole lot has to be in place to meet CQC registration standards. GP Care delivered its first year of profitability in 2010/11, after having incurred planned losses for the previous four years. The organisation now has nine service contracts with NHS commissioners as well as a wide array of new clinical service models in the pipeline and two highly innovative support services to enable easy access to advice and guidance and to support secure transfer of patient records – the future is promising. Another contributing factor to success lies in recruitment. GP Care has recruited and works with highly skilled NHS clinicians, professional managers and highly motivated support staff. Building a comprehensive and robust clinical governance framework GP Care has not only been able to achieve the objective of delivering high quality NHS services closer to patient’s homes, but also to greatly improve the administrative efficiency with which the services are delivered. Chief executive Roger Tweedale believes tackling the issue of poor administration in the NHS, which is so distressing to patients and frustrating to clinicians, and harnessing the clinical expertise that already resides within the NHS has led to significantly improved patient pathways, better clinical care and cost savings for NHS commissioners: “A lot of what we do is not rocket science – the ability to take clinicians out of their normal environment and get them to think differently about non-clinical aspects of a patient pathway has enabled us to unlock ideas and initiatives that others have struggled to deliver.” Clear objectives and realistic targets are also key. At the outset, GP Care was clear that they would only try new services where they could radically improve the patient experience and deliver efficiency savings to the NHS. Another objective was to work, wherever possible, with local NHS clinicians in service delivery, thus supporting the retention of good quality local NHS clinical teams. GP Care now has contractual relationships with multiple local acute trusts and community service providers, as well as the majority of GP practices, who provide the expert clinicians to provide the actual clinical care. As a consequence, GP Care’s services have achieved a high degree of integration with other local NHS care pathways. Tweedale is clear that the objective is to provide patients with high quality care in a convenient and efficient manner and to

practicebusiness.co.uk | june 2012

provision | case study

ensure that they feel they are receiving “one service” from the NHS. As such, integration is key and constructive relationships with primary, secondary and community care providers are essential. “There is clear potential to bring a lot of services out of the acute sector and re-provide them closer to home, not only making them more patient friendly but also freeing up capacity in secondary care to deal with the urgent/complex/life-threatening cases, which is what those teams are excellent at. By continuing to use established local NHS clinicians it becomes a transfer of volume rather than a loss of volume for other local NHS organisations which is important – after all, we are all NHS patients in the area and it is in our interest that the strength and depth of local clinical teams are retained.” Tweedale says it is important to look at what your strengths are and recognise the strengths of local NHS organisations with whom you work – “don’t try to re-provide things that are already working well for patients,” he says. “You also need to be realistic as to how many new service opportunities you can run with at any one time.” Initially GP Care identified a long list of ideas for service redesign from their GP membership, but carefully prioritised them according to potential to improve patient pathways and deliver cost savings, and focused on three niche services. GP Care also offers a select range of private patient services, delivered by GPs, GPSIs and hospital clinicians from practice premises. The group is also supporting GP practices with back office functions, such as HR, payroll etc. This idea came about when the company needed its own HR and payroll support, as Tweedale explains: “We weren’t big enough to recruit an HR or payroll manager so we outsourced it. Once we had selected a provider and they had demonstrated excellent service we negotiated with them to offer their services to 100 GP practices for a discounted package. We got a 30% discount in some cases and so gave 20% back to the GPs and kept 10% to generate a bit of net income for GP Care.” Chairman Dr Phil Yates is optimistic about GP Care’s future: “We are a GP-owned and led organisation, and starting a provider company has enabled us to generate more significant change to patient care locally than other initiatives that GPs have been involved with. We are flexible, responsive and innovative and have managed to work with local teams of NHS clinicians to deliver changes that others have been unable to deliver.” GP provider companies have a great future. GPs are in a position of having a national network of contacts in all sorts of areas and this is a hugely powerful situation to be in, providing you are doing it in the patients’ best interests. GP ownership of provider companies does however give rise to a potential conflict of interest that sits alongside the many others that already reside within the health sector and these conflicts have to be acknowledged and managed carefully. As long as commissioners have sound rationale for any decision regarding patient care and value for money and have run a fair and transparent process, then there is nothing to stop them having a healthy dialogue with june 2012 | practicebusiness.co.uk

Taking clinicians out of their normal environment and getting them to think differently about non-clinical aspects of a patient pathway has enabled us to unlock ideas and initiatives

GP provider companies as they do have with acute providers and community service teams. Tweedale explains: “There is an absolute requirement to split commissioning from providing from the public probity point of view so if you have not got an organisation that is clearly a provider or a commissioner, life will be complicated for you!” GP provider companies have to be careful about being seen as trying to line their own pockets but so long as they are providing the best services, there is no reason they shouldn’t win the contracts. It is important not to fragment services between multiple providers, so companies can keep care within their locality, with local GPs providing a day time service, then the integration for patients is brilliant. It also makes good clinical sense.

one-to-ones with the people making a difference

people

St Andrews Medical Centre, in Spennymoor, outside Durham, has had a fresh start with a new premises after a fire left the last building in ruins. Tragedy struck again when the partner driving the project died suddenly. Julia Dennison speaks to practice manager Tracey Martin about the experience

The phoenix of Spennymoor

june 2012 | practicebusiness.co.uk

people | case study

unpredictable, but on the other hand, she realises you never know what life will bring you – so you’ve got to make the most of it.

St Andrews Medical Centre’s new premises after its old building was destroyed in a fire

St Andrews Medical Centre in Spennymoor, outside Durham, is the GP practice equivalent of a phoenix rising from the flames – in a very literal way. The well-established community surgery was forced to start afresh after a devastating fire left it in ruins in March 2010. Tragedy struck again when a partner, who was the life force behind the renovation project, died suddenly three days after moving into the new premises. Practice manager Tracey Martin was left reeling; and when I speak to her two years later, she still is, but has been left with a new outlook on life. On one hand, she has learned that when running a GP practice, you can never be too prepared for the

Fire strikes It was a Saturday evening in March when Martin got a phone call. The senior receptionist’s son, who worked in the ASDA next door to the surgery, had noticed two children playing with matches in the car park. Martin was not too worried when she decided to head over to see what was going on. “My colleague said: ‘Do you want me to come with you?’ I said: ‘Oh no, it’ll be fine; I’ll just pop up and see what’s going on,’ thinking it would be nothing,” she remembers. But as soon as her car pulled out onto the main road she could see the flames, and realised very quickly it was far from nothing. Indeed, an eight- and nine-year-old had set a bin on fire, which had very quickly spread and by the time she got there, the whole practice was engulfed in flames. The fire brigade followed her into the car park. “They said almost immediately that I’d lost the building,” she recounts. She felt a sense of shock at first. “You just think it can’t be possible. At that point I’d been there 18 years, and when you think of all the work you’ve done...” Only a couple of decades old, the building was far from the end of its life, and would have had many more years’ use in it, particularly as the practice had undertaken a lot of work on it, including two extensions. Martin immediately went into practical mode, addressing everything that needed seeing to on a step-by-step priority basis. At that point she didn’t even have any of her GPs’ phone numbers on her mobile: “It wasn’t something I’d thought of doing.” Luckily, the nearest one lived a mile away, so she drove to his house and from there he notified the other GPs. At one point on the day she went home to contact the PCT, since Martin knew the practice wouldn’t have a building to see its patients. She then made sure the telephone line was switched over to the local urgent care centre, which ran the out-of-hours service, and informed them to expect a lot of calls. The one thing she didn’t have to worry about is notifying the practice’s 10,000 registered patients. “We didn’t have to get in touch with our patients – the patients could see the flames! It was a very big fire and a lot of the patients were sitting there watching it,” Martin remembers. Those who didn’t see the fire certainly heard about it in the local news. It was very much the talk of the town.

Fact box Practice: St Andrews Medical Centre Patients: 10,000 Partners: Five Practice manager: Tracey Martin Time in role: 18 years practicebusiness.co.uk | june 2012

people | case study

After that, she arranged a meeting with the police the same evening, while the fire continued to burn away. “The police knew who the culprits were and they were concerned about a community backlash – vigilantes and that kind of thing,” she says. While revenge rarely comes to anything good, Martin does speak well of the positive support she had from the public, who felt aggrieved at losing their local GP practice. once the fire was put out, Martin couldn’t bring herself to look at what remained. When she eventually did, there was little left: “There were rooms there where i didn’t even know what they were. There was nothing left. The plaster had burned off the walls; you were down to brick. There was no paint, nothing. it was completely unrecognisable.” A stOP-GAP sOLUtiON After taking care of the immediate issues, the practice team, PCT and police met at one of the partners’ home to discuss what they were going to do on Monday (the fire having happened Saturday evening). “We had nowhere to work from and we didn’t have a thing left – we didn’t have paper, a pen, a Post-it, nothing. We were just the people,” she remembers. The PCT offered a nearby office building as temporary accommodation for the practice’s admin team, while the GPs could see patients at a nearby health centre. “So we went from 16 consulting rooms to three overnight,” Martin continues. The practice made do. The PCT supplied computers and Martin and the GPs used their own money to buy office supplies, since the chequebooks had all burned. “We didn’t have a practice credit card – we never had one – we’d paid for everything by cheque or cash,” says Martin. “So we had to just use our own money for the time being.” She praises the practice and PCT teams alike, both of which worked through the weekend to make sure the surgery was in working order for the week ahead. Another positive was that the practice stored its back-up data tapes off site at another practice, and still had access to those. So it was up and running that following Monday – though the phone company was not as helpful and the phone lines weren’t up and running until the Wednesday. The practice continued working across the two sites, which was not an ideal set-up, and in June they moved into a portable office building on the car park of the PCT’s health centre where the GPs were holding clinics. “The portable building was actually very nice inside; you didn’t feel like you were in june 2012 | practicebusiness.co.uk

one and we were glad to be together again,” remembers Martin. “But we were just so cramped for space and it was a bit of a struggle.” They operated from this temporary accommodation, which was covered by the insurance company, for the next 17 months while they undertook the onerous task of rebuilding the practice building. NeW BUiLDiNG sAMe FOUNDAtiONs Plans to rebuild the practice were in place from the day of the fire, but seeing it through was not without its hurdles. The PCT at first urged the practice to build a Darzi-type health centre instead, that the whole town could use, but they soon changed their mind when the July 2010 whitepaper signalled their eventual demise. “it was all very difficult because we just wanted a building,” Martin says, “but all the red tape you have to get through to get to that point is really tiring. every time you cheer because you think you’ve got something sorted, something happens and you’re back to square one again.” Thanks in part to a £1.75m loan from lloyds TSB and support from an architecture firm the practice had used before, work on the new building was eventually underway. “We looked at a lot of different plans,” remembers Martin. “We felt that if we were going to have to start again, maybe we could make a more functional and flexible building than we had.” There was a lot of discussion internally and a few differences of opinion between partners about what this new building would look like. in the end, they decided on a two-storey building, comprising patient rooms and clinics on both floors, a common room, boardroom for staff meetings, admin office and a pharmacy. once this was decided, finally, 18 months after the fire, a new practice was built on the old building’s foundation. They managed to keep most of their 10,000 patients throughout the transition

PICTURED: Practice manager Tracey Martin (middle) with Malcolm Swan and Joanna Clough of Lloyds TSB Commercial, which loaned the surgery money for the new building

A lot of practices think all they need is a fireproof safe, but that is absolutely no use to you when your building is falling around your ears and you’re walking on hot ashes

people | case study

period, which speaks volumes of the practice’s strong bond with its population and it seemed that soon everything would go back to normal. But this was far from the case. trAGeDY strikes AGAiN Three days after the practice took possession of the new building, Dr Alan Sensier, the driving force behind the surgery’s reconstruction and partner for nearly 25 years, died suddenly from a brain haemorrhage. “We opened a Monday morning and we were really pleased because we had anticipated all sorts of hitches with iT and the telephones, but none of that happened – it went very smoothly,” Martin remembers. “He was absolutely thrilled with it. He kept coming along to my office and saying: ‘isn’t this lovely?’ That afternoon, i went to get him because there was a bit of a problem with the lift and he knew how to fix it and he collapsed there and then.” His untimely death left the practice in pieces again. A fire where no one was hurt, however devastating, was something the practice felt it could cope with. in fact, losing the building made Martin and her colleagues realise that the most important part of any GP practice is its people. But when the person who kept the team going forward was gone, it was very hard to move forward. “We wouldn’t be here now if it wasn’t for him,” says Martin of Dr Sensier. “He led the project; he was instrumental in getting the finance, the architects – he was the key to it all and he worked absolutely tirelessly to get it finished.” PiCkiNG UP tHe PieCes When i speak to Martin nine months after Dr Sensier’s death, the practice is still healing, but feeling quietly optimistic about the future. A new partner, who trained under Dr Sensier, has just been brought on board and they are settling into the new premises. Martin’s advice to practices is to check their insurance policy to ensure it’s exactly what they think it should be. “We tend to renew insurance policies year after year, and not really think about them, and ours was not what we thought it was in many ways,” she says. one of the main problems was the practice only had a one-year indemnity, which meant the insurance only covered the costs of temporary accommodation for a year, which was six months too short in the end and the practice had to pay for the portable building for that period at the cost of many thousands of pounds a month. She also urges practices to keep their back-up tapes off site. “We would not have been able to see june 2012 | practicebusiness.co.uk

patients properly had we not done that,” she says. “A lot of practices think they don’t need to if they keep them in a fireproof safe, but that is absolutely no use to you when you can’t get on site, your building is falling around your ears and you’re walking on hot ashes.” When all is said and done, Martin acknowledges how lucky she is with her team. “our staff have been absolutely unbelievable,” she says. “They have worked under circumstances that nobody could have ever foreseen and they’ve done it without a moan or a complaint. They’ve really got on and rolled their sleeves up. i cannot praise them highly enough.” indeed, the whole experience has brought the practice closer together. “But it is very difficult,” Martin adds. “not the fire – we could have got over that by now and put it behind us – but the loss of Dr Sensier.”

Before: St Andrews Medical Centre after the fire;. After: inside the new premises

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McKinsey’s 20091 report to the previous government identified changes in drug spending could deliver 10 to 15 per cent of the overall savings and indicated this might be achieved by reducing variation in prescribing practice and increasing the use of generics over branded products. In 2011 The King’s Fund ‘The quality of GP prescribing’2 report highlighted the need to address variation in prescribing practice variation and encourage adherence to best practice. Earlier in 2012 the GMC PRACtICe3 study into the prevalence and causes of prescribing errors in UK general practice revealed prescription drug errors for one in six people, with the elderly and young being almost twice as likely to experience an error. Bruce Guthrie’s recently published study in The Lancet4 found that the number of morbidities and the proportion of people with multimorbidity increased substantially with age so that by age 50 years, half of the population had at least one morbidity, and by age 65 years most were multi-morbid with physical and mental health comorbidities. In 2011 First Databank (FDB™) undertook extensive independent research to drill deeper into the current suite of clinical decision support available to understand: • why GPs reject the clinical decision support alerts available, • why GPs don’t always adhere to best practice, and • what extra support is required to assist the new CCGs and their component GP practices to achieve their saving targets? The research showed that currently available technology and tools did not specifically address the issue of deviation from best practice and most importantly none were clinically sensitive at a patient level – making recommendations without reference to current ‘problem’ and comorbidities or polypharmacy issues.

FDB has developed its new Medicines Optimisation solution specifically to help CCGs and GP practices manage their medications budgets and improve patient outcomes through better quality prescribing and adherence to best practice guidelines such as NICE. FDB’s Medicines Optimisation at the point of prescribing helps GPs and patients by providing

sales@fdbhealth.com References 1. ‘Achieving World Class Productivity in the NHS 2009/10 – 2013/14: Detailing the Size of the Opportunity’, McKinsey & Co, March 2009. 2. The Kings Fund – ‘The Quality of GP Prescribing’ A study by Dr Martin Duerden, Professor David Millson, Professor Anthony Avery and Dr Sharon Smart, 2009 3. ’Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a cross-sectional study’ Karen Barnett, Stewart W Mercer, Michael

•

patient specific drug recommendations (with polypharmacy and comorbidities taken into account), • timely, evidence based best practice (prompts to follow relevant guidelines, with links to source documents), and • price comparisons for the drugs that are safe, in line with best practice for a specific patient. FDB’s Medicines Optimisation analytics provides a current view on prescribing behaviour across CCGs providing access to: •

population level analytics, which can be drilled down into the individual patient record to allow interventions, • best practice guidance – reducing prescribing variations, and • the information required to build condition specific formularies. These tools will free up Medicines Management team time for direct clinical care or local initiatives. The next generation of medicines related active clinical decision support is here now, complemented by unique patient level analytics capabilities. For more details on FDB’s Medicines Optimisation solutions email sales@fdbhealth.com or visit fdbhealth.co.uk

fdbhealth.co.uk Norbury, Graham Watt, Sally Wyke, Bruce Guthrie www.thelancet.com Published online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2 4. ‘Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study’, May 2012 Professor Tony Avery1, Professor Nick Barber2, Dr. Maisoon Ghaleb3, Professor Bryony Dean Franklin2,4, Dr. Sarah Armstrong5, Dr. Sarah Crowe1, Professor Soraya Dhillon3, Dr. Anette Freyer6, Dr Rachel Howard7, Dr. Cinzia Pezzolesi3, Mr. Brian Serumaga1, Glen Swanwick8, Olanrewaju Talabi1

management

Reforms, challenge and opportunity for independent ambulances. Rob Ashford, chairman of the Independent Ambulance Association, discusses the landscape of regulated transport services for patients

A good move june 2012 | practicebusiness.co.uk

After a long and politically charged debate by both Houses of Parliament and the medical profession, the Coalition Government’s reform of the NHS is now set in the statute books and what lies ahead is the most comprehensive change programme that the public health service has undergone since it was established nearly 60 years ago. How the NHS will end up in the future remains unclear but what is certain is the continuation of the political and professional resistance. And according to Bob Hudson, who is a professor in the school of applied social sciences at University of Durham, there is a final form of resistance that has probably yet to be articulated – it could be terminated resistance. He says: “The changes have been sold as a radical dose of decentralisation – local GPs to become commissioners of healthcare, local HealthWatch bodies to look after patient interests, local foundation trusts with greater freedoms and new roles for local government through health and wellbeing boards. “In reality these measures are meant to be of much less significance than the centralising powers of the NHS Commissioning Board and the new roles for Monitor in setting up a market in healthcare, but in the right circumstances they could be the entree for local resistance to market encroachment.” In the background will be the well documented concerns that the reforms are yet another step towards the privatisation of the NHS. This is an

management | patient transport

argument that will be difficult to counter because the reforms, with their opportunities for increased focus on patient choice and outcome related measures of performance may well open up the market even further and improve the independent sector’s chances of winning work.

The introduction of CQC registration helped change the sector’s perception because it gave us equal billing with the NHS ambulance service in that we are both now regulated under the same terms and conditions This view is supported, at least in theory, by the move to give Monitor increased powers as an economic regulator of the industry, with the tools to aid the development of a level playing field for those involved in health services provision. The emergency healthcare landscape presents the independence ambulance sector with both a challenge and an opportunity and was one of the key factors in the decision to establish at the beginning of this year the Independent Ambulance Association (IAA) as a not-for-profit membership organisation for companies

registered by the Government’s Care Quality Commission. The sector’s need for its own trade association has been confirmed by the surge in membership applications and so far we have accepted more than 30 companies, big and small, into the organisation. Our sector plays an important 24/7 role in providing highly efficient patient transport services for the young and old and also working in support of many NHS trusts. Yet for far too long its contribution to the nation’s healthcare has not been fully recognised by the policy makers, evidenced by the previous distinct lack of engagement with independent sector providers when considering or engaging its service redesign/reform. Success in reversing that state of affairs by further professionalising the independent sector is at the heart of all IAA policies. The introduction of registration by the Government’s Care Quality Commission in April 2011 was a help in changing the sector’s perception because it gave us equal billing with the NHS ambulance service in that we are both now regulated under the same terms and conditions. In order to meet the challenge of the new reforms, the IAA will work closely with the CQC as well as other third parties from both the public and private healthcare communities, to upgrade the professional qualifications demanded of independent ambulance providers. The commercial rewards for all independent providers of healthcare services are clear to be seen now but will take time to materialise. It will be a long haul and the IAA will be advising member companies, if they haven’t done so already, to start learning now how to market to the new NHS. They will also need to be innovative and think laterally about collaboration with the NHS in joint ventures and the like if they are to realise to the full the opportunities that the reforms present. Under the new regime, competition for contracts will be even tougher with more NHS trusts joining the bidding wars and the customer will inevitably demand more service and resources, for less money. In this era of change, ambulance companies have the potential for commercial success but will need to substantially up their game – improving their services, investing in training, resources and new technologies – in order to be competitive. Those which respond in this way will survive and prosper – others which decide otherwise will probably fall by the wayside, or be acquired by others with greater vision of the opportunity which lies ahead. practicebusiness.co.uk | june 2012

management | olympics focus

Olympic

preparations The influx of spectators this summer for the Olympic Games is a potential banana skin for any unprepared practices. George Carey reveals the problems practices could face and how they can be avoided The anticipated disruption to transport caused by the millions of people who will descend on London this summer for the Olympic Games has been well documented, often with a degree of pessimism that only this great nation could muster. There is also a substantial burden which could be placed on our hospitals and primary care facilities. Practices in all areas, but especially those close to Olympic venues in the London area, need to ensure they are aware of the administrative and financial consequences of this potential extra work. The NHS estimates that the amount of visitors likely to use the service is low and should constitute within five per cent of normal workloads. It is estimated that the increase in activity should be no more than that experienced during

a mild winter. Problems could arise, though, from the increased pressure on road networks and public transport. Planning is the best way to avoid problems caused by transport issues and a travel plan document is an excellent way to inform staff on the dangers and possible remedies. Going through alternative forms of transport and differing routes with members of staff can save valuable time and money in the event of problems during the games. Staff absenteeism is another area that could cause issues during this time and it is particularly important to check on scheduled holidays during

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practicebusiness.co.uk | june 2012

management | olympics focus

the summer months, to ensure that there is adequate cover in place. It may also be worth looking into temporary staffing to ensure that existing staff are not over-worked in the unexpected event of a vastly increased workload. The majority of visitors, regardless of their country of origin, will encounter fairly typical problems, such as: chest infections, muscular strains and mislaid medicines. Some issues may arise from patients’ eligibility for free health care. People who might need treatment during the games will fit into one of three categories: UK residents, those from countries with reciprocal health service arrangements and visitors from further afield. The 2004 GMS contract has simplified the previous problems involved in defining and claiming for specific patients travelling within the UK, depending on how long they are staying in the area. Funding for temporary residents and for providing immediately necessary treatment is now included in the global sum for GMS practices and in the PMS baseline. One difficulty can arise with UK citizens, mainly expatriates, who are not ‘ordinarily resident’ here. If such patients are not resident, then they are probably not covered by the NHS and may need to be treated as private patients. Receipts should be provided for fees paid to allow these patients to claim some of their treatment costs from their travel insurance. Countries where there is no reciprocal arrangement – generally outside Europe and the Commonwealth – are not entitled to NHS treatment. They should be treated as private patients and consequently, may be charged appropriately. Alternatively, it may be more appropriate to direct them towards a walk-in centre or accident and emergency centre.

Over the years, one of the biggest problems relating to visitors from countries with reciprocal arrangements is dealing with requests for urgent or immediate medical treatment. This can produce uncertainty as to how urgent the problem really is. For example, forgetting their usual medication when coming to the UK may be deemed non-urgent but the consequences of not taking it may precipitate an urgent problem. According to the NHS, the current planning assumption is that 37.5% (32% from EU and 5.5% overseas) of London 2012 Olympic and Paralympic spectators are expected to come from overseas. As London receives around five million visitors every summer and regularly hosts major events, it is used to and well-equipped for handling fluctuations in demand for health services, but the games will be the capital’s biggest test for some time. Apart from illness, it is expected that there will be an increase in incidents related to celebrations during the summer. However, it is anticipated that this increase should manifest itself chiefly in admissions to accident and emergency departments, rather than primary care practices. Emergency department statistics for substance misuse (primarily alcohol related) during the Vancouver 2010 Winter Olympic Games revealed an increase in attendances at emergency departments during the event. On some days, the increase in these attendances was more than 50% of their historical seven-day average. While the increase in workload during the games, may not be extreme, especially for those outside London, careful planning will be key to ensuring that the games prove to be enjoyable rather than stressful. Good communication with all staff members will be integral to make sure that things run smoothly.

The amount of visitors likely to use the service is low and should constitute within five per cent of normal workloads

june 2012 | practicebusiness.co.uk

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management | patient confidentiality

Secret service It is important for practices to keep patient information secure, in order to avoid embarrassing and professionally damaging leaks. GEORGE CAREY tells you how to make sure that private information, stays that way Patient confidentiality is a thorny issue and is at the forefront of peopleâ&#x20AC;&#x2122;s minds in this multimedia age, with so much information freely available at the touch of a button. While your practiceâ&#x20AC;&#x2122;s Caldicott lead will oversee confidentiality processes and ensure that the practice is up to date with current legislation, such as the Data Protection Act, there are many other ways that practice managers can get involved with helping to keep patients important information, confidential.

june 2012 | practicebusiness.co.uk

Telephone triage has become an extremely successful way of cutting down on waiting times and the amount of time GPs are spending on issues that a nurse or healthcare assistant could deal with. There are of course drawbacks to this method and the risks of mistaken identity are increased as visual aids are no longer an option. It is important for anyone working with telephone triage to go through a list of questions to establish that they are talking to the correct person. A caller identification function on

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management | patient confidentiality

the practice’s phone is also extremely useful, so that the number can be checked against that which is on the patient’s records. Even if you are happy with the processes in place to establish identity, it is a good idea to have a framework in place, for information that can and can’t be delivered over the phone. Pregnancy test results, for example, may be deemed too sensitive to give out over the phone, in case of mistaken or falsified information. A personal password allocated to each patient is an excellent way to add another obstacle to anyone trying to gain access to information that isn’t theirs. The arrangement of a waiting room can be a simple but effective way to stop sensitive information being overheard when patients are conversing with receptionists. Depending on the budget you have available, if any, there is a range of solutions available. Something as simple as moving those waiting further away from the reception desk can make a big difference, while a screen between those in the waiting room and the person talking will have an even more marked effect. Emails are an excellent time-efficient way to keep in touch with patients and colleagues, but they can cause concerns over security. All emails sent should be encrypted, but even then, it is advisable to keep private information to a minimum, as no form of electronic communication is 100% secure. If emails are viewed as an open letter, that potentially anyone can see, then troubles further down the line can be avoided. A consultation with an IT company can be an invaluable way to establish that you are being as safe as possible, while on-going technical support on such issues, is often significantly cheaper than you might expect. There is also extensive advice available from the NHS, which can provide a much needed boost to your practice’s computer security knowledge. For the information that is still sent out in letter form, it is a good idea to regularly check on home addresses to avoid sending information to the wrong people. This can be done easily enough by your receptionist when patients come for check-ups or with a biannual email shot. In addition to ensuring that information being sent from one place to another remains secure, it is equally important to keep the myriad of information safe, that your practice is storing regarding patients. The current trend is to use a cloud-based information storage system. Because the information isn’t physically kept on location, it will remain safe in june 2012 | practicebusiness.co.uk

It is important for anyone working with telephone triage to go through a list of questions to establish that they are talking to the correct person the event of any damage to the building, and can’t be removed in the event of a robbery. The cloud does have its detractors, who claim that it is more vulnerable to hacking, than a hard copy, but popular opinion in the ICT industry is leaning heavily towards the relatively new technology. Even with the most stringent technological checks in place and a purpose-built practice, designed to keep noise flow down and vision of the reception desk to a minimum, without welltrained and responsible staff, it is useless. An information management contract should be written up for all staff to agree to and sign, and extensive training undertaken to ensure that staff are aware of the correct procedures. Of equal importance to procedures for keeping information private, are those for staff to follow if they suspect that information may have already been mistakenly given out, and potential remedies. Through a combination of simple procedures and staff training, it’s possible to greatly improve the chances of keeping your patients’ confidential information safe without spending a large amount of money. Not only will it give them peace of mind, it could also save your practice damaging legal costs.

management | mfm

Paul Lambden Dr Paul Lambden is a practising GP and a qualified dentist. He has been a GP for 35 years, over 20 of which have been in practice. He has previously worked as an NHS trust chief executive, principal of a medical defence organisation, LMC secretary and Parliamentary special adviser. He is a writer and broadcaster

Tuberculosis

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: TB In the 1950s, tuberculosis was a declining disease. As a student in the ‘60s I was told that it would be extinct within 10 years. Alas, it is not and the incidence globally is increasing despite improving living standards and the development of effective medication. Tuberculosis has been known for millennia. It is believed to have first been acquired by humans from cattle and has been found in the skeletons of Egyptian mummies from 3,000 BC. Originally called phthisis, Hippocrates wrote about it as the most widespread disease of his time. He described fever and coughing of blood which was virtually always fatal. The disease later became known as consumption. The existence of the bacterium causing tuberculosis was identified by Robert Koch in 1882. The first success in immunisation was achieved by Calmette and Guérin in 1906 using an attenuated (weakened) bovine form of TB (BCG – the Bacillus of Calmette and Guérin). BCG is no longer used routinely unless the child is thought to be of higher-than-usual risk. In 2009, just over 9,000 new cases of TB were reported in the UK. The disease was a major killer right through the 19th century. However, the recognition that it was contagious resulted in campaigns to stop people spitting in public and the infected people were taken to sanatoria. Better housing and improved cleanliness and the development of drugs in the 1940s resulted in declining incidence. However, the development of drugresistant organisms has resulted in an upsurge of the infection, fuelled in part by immigration from areas where it is still endemic. TB is caused by Mycobacterium tuberculosis. It is usually transmitted by inhalation of droplets through proximity to an infected person who is coughing or sneezing. It commonly affects the lungs but other parts of the body, particularly bones, lymph nodes and nervous tissue, may be affected. Six weeks after infection the bacteria in the lungs establish a small primary infection, which is usually symptomless. The body’s defence system in a healthy individual will prevent the infection spreading and it will destroy the bacteria. Alternatively it may build a defensive barrier round them. Such patients are said to have latent TB. In patients with lowered immunity the bacteria spread through the lungs causing active TB. People who are most vulnerable are children and older people, those living in poor and overcrowded conditions, smokers, those with poor diet, and those with weakened immunity because of, for example, diabetes or HIV or treatment with immunosuppressive drugs. The classic symptoms of TB are a chronic, persistent cough, weight loss and night sweats. Patients will also suffer from fatigue and lowgrade fever and, in the advanced stages, the cough will be productive of blood stained sputum (haemoptysis). The differential diagnosis is from chronic bronchitis, pneumonia and cancer of the lung. The diagnosis is usually made from a chest X-ray once suspicions are raised because of a persistent cough and other symptoms. The sputum is also cultured for six weeks to grow and identify the M. tuberculosis bacteria. The Mantoux test may also be used. Tuberculin, an extract from the bacteria, is injected into the skin. A strong positive reaction within 72 hours suggests either that the patient has previously had a BCG vaccination or that the infection is active.

The most common cause of failure to cure the infection is non-compliance by the patient june 2012 | practicebusiness.co.uk

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TB is managed in specialist chest clinics. The original treatment was to use two of the three antibacterials streptomycin, isoniazid and para-aminosalicylic acid but they had toxic effects and resistance developed. There are now more modern antibiotics which are used in combinations of three or four over six to nine months to avoid the development of resistant strains. Unfortunately the most common cause of failure to cure the infection is non-compliance by the patient. Negative culture after more than six months from sputum from a patient who has been treated indicates a cure. Clinics treating sufferers will also review the patient’s environment and family members will be required to have a chest X-ray. Other contacts may also be followed up. Of course, prevention is better than cure and anyone suspected of suffering from or carrying the disease should be isolated and treated before they can spread it to others. People with persistent coughs should be avoided and if travelling in areas where the disease is endemic, such as sub-Saharan Africa and Southeast Asia, at-risk people should be avoided and ensure that they are vaccinated.

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management | employment law

As a practice manager you have a responsibility to see that your staff are treated fairly and their needs are catered for. Carrie Service gets advice from an employment law expert and speaks to practice managers about how they organise flexible working hours for employers with family commitments

aw and order

With information widely available on the internet, employees are increasingly savvy about their legal rights june 2012 | practicebusiness.co.uk

Employment law can be a bit of a contentious subject for most managers and the cause of many sleepless nights. Knowing when to be flexible and when to stand your ground can be a little confusing and can often lead to the feeling of being pulled in two directions. The key is to try and stay on top of changes in employment law as best you can so that you don’t trip up, especially as your employees are probably more than aware of their rights, says Alan Lewis, employment partner at law firm Linder Myers: “With information widely available on the internet, employees are increasingly savvy about their legal rights and practice managers can find themselves falling foul of family friendly employment legislation.” As GP practices often employ a high proportion of female workers, a common issue is the legislation surrounding maternity leave; when new mothers should return to work and whether or not they should be granted part-time hours.

What to expect if she’s expecting This is something that can often be sprung upon a manager unexpectedly, so being prepared in advance to have the answers to questions about working hours and maternity leave is vital. Lewis advises all employers to ensure that they follow current legislation to the letter and always consider any requests for flexible working hours or part-time employment for new mothers objectively and thoroughly before a decision to reject it is made. “Failure to do both can result in costly claims” says Lewis. “An unhappy female employee for example, can bring a sex discrimination case against her employer.” The Sex Discrimination Act currently has no limitations on the amount that can be awarded the employee if they are successful in their case against you. So not being fully aware and compliant could have serious financial implications for the practice. It’s vital that you consider Flexible Working Regulations as well as the Sex Discrimination Act (both of which can be found on legislation. gov.uk) so that all bases are covered. This is something that frequently catches employers out: “The Flexible Working Regulations are only the tip of the iceberg in terms of potential liability” says Lewis. “Many practice managers often fail to consider their exposure to sex discrimination claims, even if they have complied with the Flexible Working Regulations to the letter”.

Workers with sick relatives All employees have the legal right to take time out of work to tend to sick relatives or deal with family emergencies, but this should be unpaid unless holiday is used. These allowances only apply if the sick person in question is a dependent of the employee, which is classified as either a spouse, civil partner, child or parent. However, Lewis has found that many practice managers are unaware that this time should be given only as unpaid leave, and many are allowing workers to take time off with pay. This can cause problems if an employee comes to expect this every time they are absent

management | employment law

from work to care for a sick or disabled dependent, so it is important that you remain consistent and get it right from the start. Again, there is no better way of preventing problems and confusion than keeping fully up to date on the law – it is, after all, beneficial to you as an employee yourself. The Disability Discrimination Act includes sections that protect those who have disabled relatives, as well as the rights of disabled employees, so be aware that this may be applicable to more of your staff than perceived.

Keeping the peace Having spoken to practice managers about the issues surrounding employment law, it’s clear that many are not only worried about the legal and financial implications of not being compliant; they also genuinely care about their staff and do not want to risk any ill-feeling between themselves and other workers. One PM who I spoke to from a practice in Northumberland had a very considerate approach to the matter: “Two of our admin staff have close relatives who are poorly at the moment, and I have worked with them – and the rest of the team – to allow them to work at times that are suitable for them. We review this every few weeks to see how everyone is coping with it, and so far so good.” Similarly, she also makes special arrangements for employees who have been suffering from chronic illness themselves: “We have worked with them to return to work gradually, a few hours a week to begin with, and gradually building up to their usual hours,” she tells me. “I have found that this works a lot better than expecting the member of staff to return to work on their usual hours after a long period of illness. They feel more supported and cared for and of course; I need to make sure that they are safe and productive while they are here.” She also said that in her experience this has led to far fewer periods of illness for these workers and so has meant better efficiency for the practice. Taking a proactive and collaborative approach means that employees are less likely to question what their legal rights are; if their needs are already being catered to and they know they have the sympathy and consideration of others, a legal battle is far less likely to occur. Likewise, if you need a favour yourself in the future, staff will be more inclined to help you out if they know that you have a reciprocal working relationship. practicebusiness.co.uk | june 2012

work/life

How did we get here?

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We at Practice Business are more than aware of the varied role you have as practice managers, and such a varied role requires a unique skills set. Carrie Service surveys our readers to find out what it takes to be a good PM â&#x20AC;&#x2DC;Practice managerâ&#x20AC;&#x2122; is one of those job titles that is subject to interpretation, and duties can vary depending on the size and location of the practice, or the proficiency and workload of other staff employed there. It should come as no surprise then, that the role attracts people from a variety of working backgrounds, each bringing different skills to the table. So which skills did you think were essential to the role?

june 2012 | practicebusiness.co.uk

Good with numbers Unsurprisingly, many of the practice managers I contacted during my research came from a background in finance. One PM from a practice in Nottinghamshire moved over to the role after a long career in the banking industry, which he believes prepared him well for the challenges presented by general practice: â&#x20AC;&#x153;I had a varied banking career, including branch work, management of a high value customer portfolio,

work/life | reader survey

regional office work, management of premises schemes and budgets and change management project work. Without realising it, I had gained some excellent transferable skills.” But how important did our readers think having specifically finance based experience was? Your responses were a bit of a mixed bag – one said: “Very important. A GP surgery is a business.” Another said: “This is essential. GPs are now moving away from the traditional model of receptionist/secretary/manager route to becoming a PM. Instead GPs are looking for added value from their managers, and will inevitably focus on looking for skills that they don’t have. A prospective manager who can bring financial acumen and business/leadership experience will stand a stronger chance of selection at interview.” Some of you thought that having financial skills was useful but not completely essential and also depended on the size of the surgery you were working in. One PM, who had a background in the civil service and had no business or finance experience, certainly found this to be the case: “In my current role, the principal partner keeps control of the accounts and I deal with payroll. In a larger practice I know that finance/business experience is essential. And with the future needs for GPs to be much more in the driving seat of commissioning, it will be even more essential.” Another respondent also pointed out that although having a business background proved useful, there are courses available for those who lack confidence in specific areas and would like to brush up on their skills. Clinical know how The general consensus seemed to be that practice managers are there to handle the day to day running of the practice – HR issues, health and safety, number crunching, payroll, and facilities management – and therefore a working clinical background is not a necessary attribute. I asked how important having some knowledge of certain clinical conditions was for a PM and most seemed to think that knowing the structure of the NHS and how services are procured and delivered was more important. There were some exceptions to this however, with one respondent saying it was “essential”. He added: “Not having any [clinical knowledge] to begin with, I have had to learn a lot and still need to learn a lot more, but clinical CPD is a way of life for a practice manager.” Another felt that their non-clinical background was actually an advantage as it helped them to communicate with patients in plain English rather than jargon, acting as

the go-between from GP to patient and vice versa: “My lack of clinical knowledge enables me to ask questions that demand answers provided in a nonclinical clear and concise manner.” This highlights an interesting issue, as it is important to acknowledge that although a GP surgery is a clinical environment, patients want easy to follow instructions and information, and having a non-clinical senior member of staff at the surgery is invaluable. Job satisfaction So, how did you get into practice management? Some of you worked your way up from a receptionist or administrative role. Others, particularly those who came from corporate environments, just wanted to do something that mattered: “I could utilise my talents and qualifications in a caring environment,” said one respondent. Another, who had previously worked at a factory, said “doing a job that is very worthwhile” was what attracted them to the role. A PM who had come into practice management after retiring from the army said that the “peoplecentric” nature of the job appealed to him: “I formed the strong view that practice management was all about people; relationships, management and skills.” Another respondent, who had a background in IT service management, felt his background in IT proved very useful because of the heavy use of back-office systems and large volumes of data involved in practice management. One PM had come from a commercial background in the medical devices industry and wanted to work in a smaller environment where they could “change things and make a difference, rather than have to work through a large corporate structure”. Many said that new challenges presented by changes in the NHS had actually inspired them to take on the role. “Practice-based commissioning had just been announced and it was obvious that the change would be exciting and suit my skill set. I would have been less interested in the role 15 years ago,” said one PM. Practice managers are not afraid of change, as this response demonstrates: “There has to be a balance between patient service and business objectives; the NHS continues to change and there will be a need for practices to adapt and be flexible. The practice manager will need to lead this change.”

Many said new challenges presented by changes in the NHS had inspired them to take on the role practicebusiness.co.uk | june 2012

Work/life | diary

Practice diary Ann Boyle Ann Boyle started working in the NHS just over 15 years ago as a receptionist and soon worked her way up to become manager for a large GP practice in the North. You can follow her blog at BeyondtheReceptionDesk.wordpress.com

If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk june 2012 | practicebusiness.co.uk

The position of receptionist at a GP practice is no “nice little job”. They are busy, short-staffed and come across all walks of life. It’s like Marmite: you either love it or hate it. Practice blogger Ann Boyle gives her tips THE WAITING ROOM The waiting room will be the main part of a receptionist’s working environment and is often the part of a surgery where patients spend most time: it follows that the condition of the waiting room can leave a great impression on patients, good or ill. Before every session you should ensure that: • The waiting room is clean and tidy • Identify any hazards and report them • Ensure fire notices and leaflets are up to date • Keep magazines fairly up to date • Ensure that there is nothing left lying on the floor that could possibly cause an accident.

works from the patient’s point of view so that you can explain these transport arrangements to them.

FOLLOW UP APPOINTMENTS If possible, arrange it so patients leaving the surgery must pass by the reception desk after a consultation so it’s easier to make follow-up appointments.

MAIL Incoming mail should be sorted daily, date stamped and any enclosures securely attached – and if any missing items are identified this should be recorded and followed up with the recipient.

APPOINTMENTS Consultation by appointment rather than queuing in the waiting room is now almost universal. A bad system means patients have to wait a long time for an appointment and become frustrated and angry; a good system works to the advantage of both doctors and patients. A receptionist should be encouraged to feedback to the practice manager any areas they feel could be improved.

PATIENTS Remember, patients are the core of the practice – without them you would not have a job. You must remain calm at all times and be able to prioritise and ensure that you follow-up every task that you are given. If you are unable to do so then you must ensure that you pass on your tasks to another.

PETTY CASH You will be required to have a small amount of cash at reception since patients sometimes pay for some services. Ensure that you have change – not just notes and all petty cash should be kept in a locked box and topped up regularly.

TRANSPORT As a receptionist you may be required to organise transport for a patient. Ensure that you are aware the procedures for arranging transport and how it

AT THE BEGINNING/END OF THE DAY As a receptionist, you are often the first into the building or the last to leave. It is advisable to have a check list of things to do on such occasions.

CQC Registration deadlines…closer than you think? CQC Registration has to be finalised by April 1st 2013, BUT you only have the last four months of 2012 to submit your completed registration and declare compliance. On this basis 25% of applications will need to be completed in September 2012, and there are time windows of 28 days that you will need to select when you enrol. Although a minimum of 80 hours’ work may not sound too bad, the pressure is on to start climbing the learning curve and get all of your documentation in place. Lasermet have already climbed the learning curve having helped over 500 clients obtain their CQC Registration.

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