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april 2012

Reduce and deliver

Working with CCGs to cut back on emergency admissions

Patients are your virtues Chair of the National Association of Patient Participation speaks up

Life after PCTs

What will happen to your practice after the PCT goes?

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ARE THEY REALLY READY TO GO?

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One dose, one visit protection against hepatitis A for their trip Telephone Customer Service on 0800 085 5511 or ask your Local Vaccine Account Manager. For more information visit VIS online at www.spmsd.com ABRIDGED PRESCRIBING INFORMATION AVAXIM®, suspension for injection in a prefilled syringe. Hepatitis A vaccine (inactivated, adsorbed). Refer to Summary of Product Characteristics for full product information. Presentation: Suspension for injection. Available as a 0.5 millilitre single dose prefilled syringe containing 160 antigen units of inactivated hepatitis A virus. Indications: For primary or booster immunisation against infection caused by hepatitis A virus in susceptible adults and adolescents aged 16 years and above. Dosage and administration: A single 0.5 millilitre dose should be administered by intramuscular injection in the deltoid region. Immediately before use the syringe should be shaken well to obtain an homogenous suspension. To provide long term protection, a booster should be given between 6 and 36 months later. AVAXIM may be used as a booster in subjects from 16 years of age, vaccinated with another inactivated hepatitis A vaccine (monovalent or with purified Vi polysaccharide typhoid) 6 months to 36 months previously. Contra-indications:

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Hypersensitivity to the active substance(s), to any of the excipients or following a previous injection of this vaccine. Known hypersensitivity to neomycin (which may be present in the vaccine in trace amounts). Vaccination should be delayed in subjects with acute severe febrile infections. Warnings and precautions: The effect of AVAXIM on individuals late in the incubation period of hepatitis A has not been documented. Immunogenicity could be impaired in immunosuppressed patients. Caution is advised for the use of AVAXIM in patients with liver disease. No clinical data on concomitant administration of AVAXIM with other inactivated vaccine(s) or recombinant hepatitis B virus vaccine have been generated. AVAXIM can also be given at the same time as immunoglobulin but at different sites, however, antibody titres could be lower than after vaccination with AVAXIM alone. AVAXIM must not be mixed with other vaccines in the same syringe. AVAXIM can be administered at the same time as Vi polysaccharide typhoid vaccine or with a yellow fever vaccine reconstituted with a Vi polysaccharide typhoid vaccine,

but at different sites. Pregnancy and lactation: AVAXIM should not be used during pregnancy unless clearly necessary and following an assessment of the risks and benefits. There are no data on the effect of administration of AVAXIM during lactation. AVAXIM is therefore not recommended during lactation. Undesirable effects: Common side effects include: mild local pain, asthenia, myalgia/arthralgia, headache, gastrointestinal tract disorders (nausea, vomiting, decreased appetite, diarrhoea, abdominal pain) and mild fever. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic NHS cost: Single dose prefilled syringes in single packs, basic NHS cost £18.10; packs of 10 single dose prefilled syringes, basic NHS cost £181.00. Marketing authorisation holder: Sanofi Pasteur MSD Limited, Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP. Marketing authorisation number: PL 6745/0070. Legal category: POM ® Registered Trademark Date of last review: January 2010

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291.

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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 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

Now’s the time to become a very willing provider What a difference a month makes. The last time I spoke to you, the health bill was getting batted around Parliament like a hot potato, but it managed to just squeeze though. This means the CCGs are all systems go (as if they weren’t already) and the PCT staff that moved over to become commissioning support units can sit a little more comfortably in their new role. I imagine CCGs will feel more confident about their shadow status this month and the result is those practices with a participating member of staff will see them less – cue the locum agency on speed dial. With all this change, you will notice that the format of Practice Business has changed too – albeit slightly. As you may have read last month, we have launched a new bi-monthly magazine for clinical commissioners called Commissioning Success, as a result of this, we have changed the commissioning section in this here magazine to one of provision. If you are a practice manager involved in commissioning, we still cover commissioning topics as usual, just from a provider’s point of view in our new ‘Primary Provider’ section. For in-depth commissioning advice, we would invite you to subscribe to our new magazine (subscriptions@intelligentmedia.co.uk). But for practices to find success under commissioning, they will have to become very willing providers, indeed. And we’re here to support you. This bumper issue looks at ways you can reduce emergency admissions among your patients (p12), how buying the right clinical machines can boost your practice (p16) and on p32 we look at how to better present yourself to would-be commissioners or patients. Speaking of patients, we interview the chair of the National Association of Patient Participation (NAPP), Patricia Wilkie (p20), who is a long-standing champion of patient rights. She talks about how PPGs are worth more than just some extra QOF points. You’ll also want to check out our legal article on what will happen to PCT-owned property after the PCTs are gone (p36). Here’s wishing you the very best of new financial years.

editor

Contents sector 06 news Top news for practice managers this month 08 executive editor comment Roy Lilley asks: Where are all the GPs?

primary provider 10 12

commissioning news A practice manager’s update on providing for clinically-led commissioning

advice reduce and deliver Working with hospitals and secondary clinicians in your CCG to reduce emergency admissions locally

16 technology as good as IT gets A guide to the technology that is making a difference to

general practice provision

PEOPLE 20 interview patients in the hot seat An interview with the chair of the National

Association of Patient Participation on PPGs and the health bill

24 interview a man of many talents Birmingham’s Gareth Williams juggles being a PM lead

on a CCG with a busy life at his practice

MANAGEMENT 28 HR away with the clouds One practice manager tells her story of planning a

practice away day

32 top tips it’s their thought that counts Five things you can do to spruce up your

practice’s reputation

34 clinical MFM This month: MS 36 legal life after PCTs What will happen to practice property after the PCTs?

Work/life 40 42

top tips cutting back Little things you can do to save money in your practice

diary Reader Stephen Humphreys challenges our executive editor on commissioning

SECTOR

Revised payment formula for dispensing Steps have been agreed to revise the formula for calculating remuneration paid to dispensing doctors. The agreement has been reached between NHS Employers, on behalf of the health departments in England and Wales and the General Practitioners Committee (GPC) of the British Medical Association and the Dispensing Doctors Association (DDA). The payments are reviewed annually but revisions to the formula for calculating them have become necessary after underpayments in each of the last two years. NHS Employers and the GPC have agreed that £10m in England and £700k in Wales will be paid to practices in lieu of underpayments in 2010/11 and 2011/12. The total available to dispensing doctors in 2012/13 will be £170m. It was also agreed that there will be annual revisions to take into account increases in GP pay and changes in the volume of medicines dispensed. In addition there is a new methodology that clarifies what will happen in the event of an over- or underspend.

FAST FACTS •

• •

£10m in England and £700k in Wales will be paid to practices in lieu of any underpayments in 2010/11 and 2011/12 The total available to dispensing doctors in 2012/13 will be £170m Dispensing doctors will receive £20 for each special medicine they dispense.

SURGERIES TO TRIAL CQC SIGN-UP FROM JULY

your monthly industry lowdown

news

From July, GP practices will be able to set up online accounts to start the process of registering to the Care Quality Commission. The news comes from a guidance document sent to all GP practices in England setting out details of the registration process. However, the amount practices will pay to register will not be revealed until after a consultation later this year. From this summer, the watchdog will carry out a series of pilot inspection programmes in the run-up to the real start in April 2013. Practices will receive letters from July inviting them to set up an online registration account, which will ask for basic registration details. They will then be asked to pick a 28-day

window between September and December 2012 to submit their registration applications. Professor David Haslam, GP registration adviser to the CQC, said: “We are confident that the majority of practices and providers of primary care are of good quality and are already doing everything that needs to be done to be compliant with the essential standards of quality and safety.” Practices piloting the registration process warn others to start compiling information now. Verity Shelton, practice manager of the Blue Dykes Surgery in Chesterfield, who trailed the application process last year, told Practice Business: “It’s not going to go away – they might change or tweak it a bit – but you need to just get on with it.”

Practices will have a 28-day window between September and December to submit their registration applications

april 2012 | practicebusiness.co.uk

SECTOR | news

clinical news Behavioural science could help reduce did-not-attends

Cancer toolkit for practices

Simple changes informed by social influence theory could reduce the number of patients who fail to attend appointments by nearly a third, according to behavioural scientists writing in. Did-not-attends or DNAs cost the NHS an estimated £700m annually. Latest figures show that up to six million appointments are wasted each year but scientists writing in a paper say small changes could reduce this waste by 30%. The report, published in the Journal of the Royal Society of Medicine, describes three interventions tested in surgeries in NHS Bedfordshire that could be implemented elsewhere: 1. Patients calling for an appointment should be asked to repeat back the time and date of their appointment before the call ends. 2. When booking follow-up appointments patients should write down the time and date on an appointment reminder card rather than healthcare or reception staff doing it for them. 3. Replacing common signs that communicate the number of patients who did not attend The amount the NHS spends on DNAs annually appointments in previous months with signs that conveyed the much larger number of patients who do turn up. Studies have also shown that DNAs can increase inappropriate and unnecessary accident and emergency attendance. Steve Martin, author of the paper and behaviour change lead at the BDO Alliance said: “While some DNAs are a result of transport issues or patients experiencing difficulty in getting through to cancel an appointment, a simple fact, backed up by surveys of patients themselves, is that one of the more common reasons why patients DNA is that they simply forget.”

£700m

They said…

“”

“CQC does not make any assumption about direct correlation between risk to patients and size of practice – or personal relationship between GPs and practice managers. Our assessment of risk will be made on a case-by-case basis based on information that we hold about individual practices.” CEO of the CQC Cynthia Bower when challenged by the FDA to retract a statement from CQC director Amanda Sherlock that said “singlehanded GPs who are related to their practice manager posed a particular concern to the CQC”.

movers shakers

Cancer – do you worry about your or your practice’s performance when it comes to this serious, sometimes emotive subject? How good do you think you are as a practice at cancer prevention and diagnosis? In collaboration with Macmillan Cancer Support, GP Update is offering practices a free cancer toolkit. To download, go to ‘latest updates’ at www.gp-update.co.uk.

Get the latest news in your inbox Want to be bang-upto-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 A NEW STRATEGY FOR NHS PROCUREMENT: SECURING THE FUTURE OF NHS SERVICES Manchester Conference Centre 17 April

SSPC ANNUAL CONFERENCE: IMPROVING CLINICAL CARE THROUGH RESEARCH Glasgow Hilton Hotel 24-25 April

GP leader receives OBE Dr James Kingsland, a GP of 23-years from Wallasey, advisor to the Department of Health, president of the National Association for Primary Care (NAPC) and supporter of GP commissioning has been awarded an OBE for his services to general practice in the New Year’s honours. He collected his award last month.

practicebusiness.co.uk | april 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.

Putting ‘em in their place

Have you seen your GP lately? ROY LILLEY suggests you check your local CCG meeting

GPs can’t be in two places at once. My view is their ‘place’ is in the surgery, looking after their patients april 2012 | practicebusiness.co.uk

How much do you see of your GPs? Do you have regular meetings? Do you all get together once a week to discuss practice ‘stuff’? The cost of the ginger biscuits and the reserved car parking? Only joking. But it is an important point. I expect you do have meetings (and if you don’t you should) and I expect it is a useful time for you to get together and figure out what’s happening and what’s not. I wonder if you will continue to have the luxury of this? Recent press reports claim that millions is being spent on locum cover for GPs who are off waging war at the front line of healthcare in CCG meetings. Apparently, in some areas GPs are spending two days a week away from their practice on CCG duties. These absences don’t come without a cost. As the Guardian reported recently: “The hourly rates charged by GPs for taking part in the CCG meetings varies. [From] £48 per hour in County Durham to £115 per hour in Hertfordshire.” GPs appointed to the board of a CCG look set to receive substantially more, with NHS Stoke-on-Trent intending to pay board members up to £100,000 each year. In Coventry, it is reported, the chairs of the CCG will each be paid £35,000, while a CCG chair in Croydon, south London, will be paid £30,000 per annum. In March the Guardian reported again: family doctors are devoting as many as four days a week to setting up clinical commissioning groups. But it costs the NHS up to £123,900 a year to replace a GP with a locum. In one CCG area alone, 15 local doctors are each spending up to two days a week away from surgery, at a cost of almost £1m a year. Aside from the cost of this, what about the patients? One of the reasons GPs claim their pivotal role in our NHS is the fact they are able to create a trust and confidence with their patients. A relationship based on intimacy, privacy and confidence. When we need them they are there for us. Well, it is no longer the case for out-of-hours services and it looks to be that it will soon not be the case for in-hours services. The good old days of the doctors ‘list’ have gone and now patients belong to the practice. Seeing a doctor, any doctor, might be good for a huge number of young, otherwise healthy, youngsters who want to pop-in and see a doc and get on with their lives. However, for the increasing army of people with long-term conditions, a long-term relationship is very important. My mind goes back to some research carried out by what used to be the Small Practice Association and the NHS Alliance that demonstrated the doctor-patient relationship was crucial in the general recovery of patients. This was some years ago but I doubt much has changed. GPs can’t be in two places at once. My view is their ‘place’ is in the surgery, looking after their patients. If they are bored with that, regard it as too mundane, and I suspect some do, then it is time for them to leave medical practice behind and become a manager. In the meantime, take a photograph of your GPs, it might be the only way to remember what they look like!

PRIMARY PROVIDER

HEALTH BILL BECOMES LAW The Health and Social Care Bill was finally passed by the House of Lords and is set to become law before Easter. MPs will then consider the amendments to the bill as agreed by the Lords. The act will see PCTs and SHAs abolished and budgets put in the hands of GP-led clinical commissioning groups. The health bill has been a point of contention across parties and throughout the healthcare sector, as the GPs prepare to take control of £60bn of the NHS. According to Prime Minister David Cameron’s spokesperson, there was “cross-party banging” of the table at cabinet to mark the imminent Royal Assent for the legislation. He told the BBC that it would become law before Easter Recess. Unions said they would continue to dispute the bill even after it becomes law. The RCGP says it will help the Government implement the changes, despite originally opposing it. Chair Dr Clare Gerada said that although they still oppose the bill itself, they believe that they must cooperate with the Government for the good of the patients and the NHS.

Delivering commissioning in practice

GPs PAID TO TAKE ON PATIENTS FROM SECONDARY CARE GPs in NHS South Birmingham’s primary care trust will be given extra funding to treat hospital outpatients after expressing concerns that they would be given the additional work but nothing to fund it. Birmingham CCG will meet to discuss how to implement the funding, which will be awarded to GP practices across Birmingham to pay for 700 patients with prosthetic heart valves. Chairman of the Birmingham CCG, Dr Gavin Rolston told GP Online: “We have to do what our members desire. It is going to mean extra work so we are aware that resources should follow. We have met the LMC and listened to its very reasonable concerns.” He added: “We are very aware that the proportion of funding for primary care has decreased over the past few years, so while trying to reduce overall expenditure it will be essential that, where appropriate, resources follow.” According to the report, the CCG will meet to discuss whether or not the funding will be given on a local enhanced service or per capita basis.

april 2012 | practicebusiness.co.uk

PRACTICE BUSINESS HAS LAUNCHED A NEW COMMISSIONING MAGAZINE

While we will still cover commissioningrelated topics from a primary care provider point of view here, 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 is 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 interestead in receiving a free copy, please email your details to subscriptions@ intelligentmedia.co.uk with the subject line “Commissioning Success”.

Experts give personal health budget warning England must learn from other countries if it is to avoid the same mistakes with personal healthcare budgets, say experts writing on bmj.com. The Department of Health in England is exploring the possibility of personal health budgets to give patients more control over their care. One option is for disabled and chronically ill people to hold their own budget and pay directly for services to meet their needs. Pilot projects are underway in 64 PCTs. But the Netherlands, which has had a similar system, is in the process of restricting it in light of several problems and the Dutch Ministry of Health has argued that it has become unsustainable. Since 1997, patients in the Netherlands have been able to hold a personal budget to purchase care, but between 2002 and 2010, the number of personal budget holders increased tenfold, while spending increased on average by 23% a year. There have also been credible reports of fraud and concerns about the growth of private agencies that broker arrangements between clients and providers. â&#x20AC;&#x153;Unless the lessons of the Dutch experience are learnt, the unintended and negative consequences will outnumber the positive, empowering role of personal budgets,â&#x20AC;? warns Professor Martin McKee from the London School of Hygiene and Tropical Medicine. He and his colleagues say many questions remain regarding these budgets. For instance, how will they be set? What will happen when the budgets are spent? Is there a risk that vulnerable individuals might be exploited by providers? A preliminary report also showed that patients might spend their budget on alternative treatments, like Reiki, reflexology, and aromatherapy, which are not supported by scientific evidence.

350%

The percentage increase in sales of a diagnostic equipment supplierâ&#x20AC;&#x2122;s 24-hour ambulatory blood pressure monitors (ABPM) over the last few months due to NICE recommendations last year that diagnosis of primary hypertension should be confirmed using the device.

provision | analysis

Reducing hospital admissions has been a hot topic for general practice for quite some time now. Even so, the problem has only worsened in recent years. Carrie Service looks at how some trusts are tackling the issue and how your practice can help make a difference

A matter of urgency Although the majority of health treatment actually takes place via primary care, hospital admissions still account for 52% of primary care trust spending. Emergency admissions are still on the rise and the only way to reduce this is to target patients who are at the most risk of being admitted to hospital; namely those with chronic conditions such as diabetes, asthma and COPD. To do this, there needs to be a great deal of cooperation between primary and secondary care providers and, of course, the patients themselves.

An age-old problem With this goal in mind, NHS Highland launched a research project aiming to tackle rising hospital admissions, specifically those occurring as a result of an ageing population. They came up with the concept of ACP – anticipatory care planning. The idea involved a combination of educating elderly patients with long-term illness and promoting forward planning. Dr Adrian Baker, who headed the project, outlined the findings in an article for Pulse: “Given the inevitability of declining health, it is worth selecting patients most at risk of admission to hospital and having a discussion with the patient and their spouse, family and friends. This structured discussion has been shown to reduce hospitalisation, length of stay and some of the clinical chaos that can occur at the end of life. We saw specific clinical examples of patients who collapsed at nursing homes and were inappropriately resuscitated, and others who were clearly dying in hospital while undergoing futile investigations and treatment.” Planning for end of life care not only allows elderly patients a better chance of dying in the comfort of their own homes, it also reduces acute admissions costs and frees up hospital space for those who need it most.

Making choices NHS Northwest has an initiative in place known as the Choose Well campaign. This is aimed at encouraging people to think about self-care when they have a minor ailment rather than going straight to A&E. According to Choose Well North West’s facts and figures, the number of people going to A&E in the region has gone up by five per cent in the past year – and is continuing to rise. In the past two years, the number of people using A&E services in North West hospitals has gone up by over 177,000 and category A calls to 999 ambulance services went up by 25-30% last winter. Shockingly, 25% of people who go to A&E could have been treated elsewhere, or even self-treated. In a bid to educate patients about what constitutes an emergency, their website outlines the situations

april 2012 | practicebusiness.co.uk

provision | analysis

where patients should call 999, go to a walk in clinic, contact their GP, speak to a pharmacist, call NHS direct or self-treat the problem. By listing these options it provides patients with some perspective, prompting the question: “Is it really that serious?”

Who you gonna call? The rollout of non-emergency number NHS 111 hopes to employ the same initiatives by giving people an alternative to dialling 999. The idea is that the number will help to filter out those people who are in need of medical attention but are not in a life-threatening situation. Many people who are in a medical ‘predicament’ rather than an emergency might call 999 simply because there is no other health advice available, perhaps out of surgery open hours or because they are home alone and they panic. However, concerns have been raised about the quality of advice patients who use the number will receive, because the service will be run by specially trained advisors – not clinicians. The BMA has also accused the Government of rushing the roll-out of the project, with Health Secretary Andrew Lansley pushing for it to be across England within the next 18 months.

Being accessible Improving the accessibility of GP appointments has the potential to reduce emergency admissions. The A is for Access scheme rolled out in almost 100 practices in south west Wales in January aimed to encourage GP surgeries to consider how accessible their appointments were for patients. Practices that fit the following criteria were awarded with an ‘A’ grade for accessibility: n The surgery opens on or before 8am with a first appointment available at 8.30am or earlier n it is open at lunchtime n the last routine GP appointment of the day is at 5.50pm (or later) n a member of staff can be contacted directly by telephone (rather than getting a recorded message) between 8.00am and 6.30pm n patients can book an appointment during one telephone call, without the need for calling back, or alternatively book online. Working with other practices in your clinical commissioning group so that your open hours complement each other could help to improve accessibility for patients without you having extend your opening hours too much. This could involve april 2012 | practicebusiness.co.uk

being open on a Saturday morning on alternate weeks with another local practice, or alternating late opening in the evenings. Having an out-of-hours doctor who is readily available so that patients can be seen at home rather than calling an ambulance is another factor practices should consider, as this has been identified as a reason for patients calling 999 in the past.

The harsh truth There is no getting away from the fact that, ultimately, patients must be responsible for their own health and the most effective way of tackling the problem of admissions would be to better educate patients about their condition and what it costs the NHS. Talking to Gareth Williams from the Dove Medical Practice in Birmingham (see the full interview on page 24), it was clear just how frustrating it is for those in primary care who are expected to “absorb everything that comes through the door” as he put it. Williams strongly emphasised the need to better inform patients about how little money practices are given to manage their care: “We get paid £65 a year to look after a patient. The health service relies on people being healthy – which it should do,” he said. Although Williams voiced frustrations about the lack of awareness patients have about their impact on health budgets, he did seem positive about the way the NHS is changing to tackle this; by thinking about healthcare more holistically, promoting healthy living and keeping people out of hospital all together, rather than simply treating the symptoms of poor health. By implementing measures such as the ones above and utilising your PPG to communicate with patients direct, here’s hoping that patients do begin to wake up to what they are costing the health service, before it’s too late.

There is no getting away from the fact that ultimately, patients must be responsible for their own health

provision | ADVERTORIAL

PathFinderRF – supporting more effective referrals, cost savings and outcomes for CCGs Clinical Commissioning Groups (CCGs), such as Corby, Peterborough, Borderline, SE Staffordshire, Welland and South West Lincolnshire are implementing PathFinderRF across their practices to achieve substantial cost savings and improvement in the quality of referrals. PathFinderRF provides a fully supported referral pathway system that integrates national guidance, local procedures and patient information with an appropriately worded referral template. It also provides a portal to other useful information, such as local formularies and therapeutic policies, that can be updated by the CCG on a real-time basis. Furthermore, PathFinderRF can be audited at CCG or practice level to determine how templates are being used, so improving the consistency and reliability of care. The success of local healthcare systems depends on the quality of care pathways and the compliance of clinicians with these pathways. CCGs face the need to manage costs and quality, and so ensure that care pathways deliver the best affordable practice. Closing the quality gap often requires a change in clinical practice. With the need for redesign simultaneously across many care pathways, this presents a major challenge for commissioners going forward – but one that can be addressed with an effective referral management scheme. Successful referral management schemes should be enabling, rather than restrictive, and support commissioners’ need to communicate the desired changes to all clinicians, and so improve the patient referral pathway and experience within available resources. This should contribute to the QIPP saving plan for CCGs, and for GPs it should meet the requirements of QOF and also support efficiencies such as reducing administrative costs – so encouraging take-up and adherence. PathFinderRF is a web-based system that is now available nationally and is helping CCGs meets these objectives. It is based on a referral management system that has been widely used across Northamptonshire for some years. As Dr Darin Seiger, GP chair, Nene Commissioning, says: PathFinder ensures my colleagues and I have easy access to the latest referral guidance and forms that have been agreed with each trust and helps maintain consistent

adherence to evidenced and up-to-date clinical pathways. The benefits to patients, GPs and our consultant colleagues in Northamptonshire have been incalculable’. This view is borne out by local GPs, such as Dr Catherine Massey, who says: ‘PathFinder is great – easy to use, very useful to have everything in one place and speeds up time taken to process referrals’. In terms of saving time, the Redwell practice describes that ‘PathFinder saves each GP between 30 and 45 minutes of administration time each working day’. Hospital specialists are also keenly in favour. For example, Kheng Chew, a local obstetrics and gynaecology consultant, says: ‘I have found that referrals received from GPs supported by PathFinder are much easier to use as they provide consistent information in a set format’. A unique strength of PathFinderRF is that its referral templates can be amended as required by a local CCG to reﬂect local requirements. The templates are interactive, and can be integrated with all the main GP systems as well as with Choose and Book. They support referral decision-making through prompts and guidance on the history, examination and investigations that should be completed prior to referral. Suggestions for alternative management plans are also available with each template. Embedded in the pathway prompts are local and national guidance which can be assessed by selecting the appropriate link, together with relevant patient leaﬂets and/ or other useful information. Updates to national guidance (for example, NICE guidance) are provided on a regular basis, and the local CCG has the option of accepting or declining each update, based on local guidance and needs.

practicebusiness.co.uk | april 2012

provision | technology

With increasing pressure on practices to seek new revenue streams and set themselves apart from the rest, in-house diagnostic services are a great way to get ahead. George Carey looks at some machines that can help to make the difference to patients and practices alike

Diagnosing success Diagnostic machines have enjoyed increasing prevalence in primary care over recent years as surgeries have to cut down on referrals and offer their patients the broadest possible spectrum of services, without sacrificing quality of care. Constant advances in the field also means that it is important to stay ahead of the curve in order to avoid falling behind other practices in your area. This focus on primary care diagnostics is particularly evident in 2011-2012â&#x20AC;&#x2122;s GMS contract changes. The General Practitioners Committee (GPC) and NHS Employers have agreed to a number of changes to the Quality and Outcomes Framework (QOF) effective from April last year. These changes april 2012 | practicebusiness.co.uk

will see the implementation of new clinical indicators recommended by the National Institute for Health and Clinical Excellence (NICE). The quality and productivity indicators are aimed at securing more effective uses for NHS resources through improvements in the quality of primary care by rewarding more clinically and cost-efficient prescribing, reducing emergency admissions by providing care to patients through the use of alternative care pathways and reducing hospital outpatient referrals. These indicators have only been agreed for 2011-2012 thus far, but may be extended for a second year if significant progress has been made in achieving productivity savings at the mid-year point.

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provision | technology

Vascular conditions The British Heart Foundation estimates that 2.7 million people in the UK currently suffer from heart disease, so efficacious testing for the condition is an important service for any practice to offer. Portable cholesterol profiling systems offer direct low density lipoprotein (LDL) testing. This type of test eliminates the need for patients to fast beforehand so it is a much more attractive proposition. The unit delivers diagnosis in two minutes and can store up to 200 results. Another related condition is peripheral arterial disease (PAD), which is found most commonly in patients over 60 and can have serious implications if left undetected. Ankle brachial pressure index (ABPI) testing is the most accurate and cost-effective form of vascular testing and will detect the disease at its early stages. The test compares the systolic blood pressure of the ankle to that of the arm (brachial). ABPI testing kits provide an objective baseline to follow the progression of the disease process and evaluate the effectiveness of the treatment plan. The ABPI results are usually combined with photoplethysmography (PPG) sensor or pulse volume waveform analysis. The entire process can be carried out in 15 minutes, cutting down on the number of appointments necessary for patients to receive results and advice.

systems deliver standardised, semi-quantitative, one-at-a-time evaluation of urine test strips. The unit connects to your computer system to illustrate results and also offers the input of patient data via barcode or keyboard. Diabetes is still a big problem in the UK; 2011â&#x20AC;&#x2122;s QOF figures show that on average 4.45% of the population are sufferers. Point of care diabetes analysis systems can deliver albumin and creatinine tests and albumin-to-creatinine (A:C) ratio results. These units can deliver results within seven minutes while printed patient records and transmission to electronic medical records allows for reduced transcription errors. These Devices produce trending graphs which are an easy way to present results to patients and enable comprehensive disease management.

Melanoma Siascopy is a relatively new technique in the fight against skin cancer which uses light to analyse moles in order to identify melanoma. There are products on the market that deliver non-invasive, rapid, and painless screening by measuring the amount of haemoglobin, melanin and collagen in the stratum corneum, epidermis and dermis to a depth of 2mm, and identifing whether melanin is present in the epidermis or the dermis. The information is presented as SIAscans, that then show how these components vary within the patientâ&#x20AC;&#x2122;s skin. The visual results serve as an extra tool to explain diagnosis to patients and offer GPs a means of tracking any changes in moles over time.

Fluid analysis Urinalysis is nothing new in primary care and can diagnose a host of conditions including kidney disease, diabetes, liver disease and urinary tract infections. There is a range of urinalysis machines on the market that deliver on-the-spot accurate diagnosis, saving your practice time and money and giving patients greater peace of mind. Avanced april 2012 | practicebusiness.co.uk

Sleep conditions According to research carried out by the British Snoring and Sleep Apnea Association, 25% of the UK population suffer some form of sleep disorder that results in excessive daytime sleepiness. Screening systems are designed to detect obstructive sleep apnea (OSA) â&#x20AC;&#x201C; the most common form of sleeping disorder which accounts for 80% of sleep apnea cases. Systems can be loaned out to patients for a night in order to measure four key factors, relating to OSA. The unit then generates an easy-to-interpret report with a colour-keyed risk indicator, pulse and oximetry signals, detailed SpO2 information and cheyne-stokes probability. With the range of products available and an ever changing QOF, it has never been more important to make sure that your surgery can offer a comprehensive range of in-house diagnostic procedures, helping to ensure the safe future of not only your patients but the practice itself.

people

one-to-ones with the people making a difference

With patients in the spotlight more than ever, Julia Dennison interviews Patricia Wilkie, chair of the National Association of Patient Participation on what practices can do to reach out to patients

A patient’s best friend Dr Patricia Wilkie has always been a staunch advocate for patient rights. A social scientist by training, she has been the link between medicine and society for the better part of the last 50 years. Her first work was to set up the National Childbirth Trust in Scotland in the early 1960s and from then she took on a string of different responsibilities in organisations focusing on everything from HIV to genetics, always taking the perspective of the patients. Her posts have since included acting as chair of the Patients’ Association and

april 2012 | practicebusiness.co.uk

she now acts as chairperson of the National Association of Patient Participation (N.A.P.P.). She is also the joint editor of the journal Quality in Primary Care, has fought for and won battles for single sex wards in hospitals and patient reporting on new medicines. “I think it’s important that healthcare professionals work with patients – and I do mean as equals; I don’t mean an Upstairs, Downstairs relationship – through professional bodies at a national level to try and influence [their decisions],” she explains.

people | interview

Participation in practice Wilkie’s work with primary care was honed as chair of the Royal College of GPs’s patient liaison group, where she worked as an advocate for patients surrounding issues like patients getting removed from GP lists. As the result of one heated example when one man felt he was unfairly taken off his GP’s lists for simply questioning a mix up with a prescription name, the RCGP produced a guidance document for maintaining patient lists. Since the introduction of the patient participation DES, Wilkie has been working with GP practices to set up patient participation groups and make sure they understand the benefits of having one – QOF points aside. “It’s such a valuable relationship,” she says of a practice and its patients. “Practices that have active, good [patient] groups can see how a patient group in the practice can continue to help improve the quality of patient care, but also be responsive to what patients need. We know anecdotally that many practices that did sign up for the DES are now really understanding the benefits of this special relationship with patients.” Having a PPG is not just a benefit to patients, but can help practices too. Wilkie tells the story of a patient in a group who facilitated a relationship between his GP practice and a local traveller site that had had little access to medical services. Having the help of this patient opened up the traveller community to better healthcare, including vaccinating their children, and the practice to a wealth of new patients.

Working towards a better PPG The DES is certainly accelerating the implementation of good patient groups in practice. Around two-thirds of practices in England have patient participation groups registered with N.A.P.P. – this has gone up from just over half before the DES and it’s going up still. However, not all practices with PPGs are registered with the N.A.P.P., so there could in fact be more. Any practice that has tried to put together a PPG will know it’s no easy task. Wilkie’s recommendation for practices forming a PPG is not to be too prescriptive – start small and work your way up to a wider demographic. “It’s better to get a group going with people who are enthusiastic and then move out,” she says. “One cannot expect to begin with to get representatives of the 90-year-olds and teenagers, but one will eventually get that.”

I think it’s important that healthcare professionals work with patients – and I do mean as equals; I don’t mean an Upstairs, Downstairs relationship Once you want to branch out further, Wilkie recommends putting up notices or advertisements wherever you can – both in the practice and wider community – outlining the commitments required and details, like whether travel expenses will be paid. She also says it’s important to not be put off by the “moaners”. “It’s better to have them inside than not at all,” she explains. “They’ll be in the minority so the others will control it and eventually they’ll go or keep quiet – or they may have a valid point.”

The health bill and beyond Wilkie hopes that with the onset of clinical commissioning, patients will have more of an opportunity to voice their opinions through local clinical commissioning groups – however, she insists that not enough is being done to explain this to patients. “My feeling is that the momentum to involve the patients or public is now on a roller that cannot be stopped,” she says – and this is the first time she says she has felt this. She feels self-care and telehealth could be what saves the NHS. “Economically, the government needs to take the patients on board,” she explains. “You can’t introduce all these cuts unless you explain to people the Jeremy Bentham principal – that we have to work out the greatest good for the greatest numbers.” However, getting the patient to take responsibility for their own health will take hard work. “The danger with self-care and telehealth is that unless you explain that it’s to our advantage as individuals to know about these things and to try and work them, the public will just think it’s a cheaper option.” In all, primary care has made headway when it comes to improving patient-practice relations, however, there is still scope for GP surgeries and CCGs to do more. The health bill has left the public confused over the changes to the NHS, so with people like Patricia Wilkie and the N.A.P.P. leading the way, now is the time to reassure them that all these changes are, in theory, for their benefit. What better time is there than the present to reach out to those who matter most? practicebusiness.co.uk | april 2012

VENDOR PROFILE | First Databank

A sweeter to swallow As commissioning takes hold, GPs and their practices will need more guidance than ever when it comes to medicines management. First Databank is here to help with a new medicines optimisation suite of solutions The NHS has been put to the test with the infamous ‘Nicholson Challenge’ – the daunting task of saving £20bn by 2014. One of the areas the Government has identified for efficiency savings is spend on medicines and variation in prescribing practices. According to a McKinsey analysis, commissioned by the previous Labour government but released by the coalition, the NHS could save 10 to 15% by managing medicines better and prescribing more generic medical products. Furthermore, the King’s Fund recently identified wide variation in prescribing practices between localities that could not simply be put down to demographics. It recommended clinicians and their managers use clinical decision support software to help redress the problem. With this in mind, GP practice managers should be prepared for the phone call from their clinical commissioning group asking for their prescribing data and what procedures are in place to tackle medicines management. A team from the CCG might even pay you a visit to put your prescribing policy right. With a sophisiticated software system in place, practice managers can stay one step ahead of the CCGs and lead from the front. april 2012 | practicebusiness.co.uk

Investing in the right solution First Databank (FDB), the UK’s leading provider of drug knowledge bases and clinical decision support, specialises in medical databases with clinical decision support built in them. Its main database features an electronic listing of over 70,000 drugs and appliances, alongside advice on how these should be administered to patients, which can help prevent doubling up or dangerous combinations of medications being prescribed. To date, the database has been embedded as a component in a vendor system, so the name First Databank has been somewhat invisible to GPs and practice staff – until now, when a new medical database solution suite, called Medicines Optimisation, has been launched to the primary care market. A bit of background First Databank has over 30 years of experience, transforming drug knowledge into practical informatics solutions to improve patient safety and outcomes from within the clinical workflow. The firm is taking its knowledge and expertise, and is applying

First Databank | VENDOR PROFILE

this to its new market solution to support the effective management of medicines. Its new solution suite promises to provide an insight into the medicines usage within a practice and across a CCG, highlighting deviations from best practice and the cost of those deviations, as well as identifying LTC patient cohorts requiring interventions and opportunities for further medicines swapping and cost savings. It will be what FDB called “vendor agnostic”, so can be used with the practice’s existing software system. The suite of products will also support GPs to make effective medicines choices using patient level information that is cross referenced with NHS best practice guidelines and cost comparisons. The FDB solution will enable the medicines management teams to focus on engaging in more frontline interventions with GPs and LTC patient cohorts, rather than laborious report running.

interrogate your whole prescribing behaviour,” explains Mark Treleaven, product and marketing director of First Databank. “Previously, with the clinical decision support that we had, the only opportunity that we had to intervene in prescribing behaviour was the time at which the GP was making the prescription.” Now practice managers are given the control they need to manage prescribing in their surgery, which means they can intervene at the point of repeat prescribing, for example, to catch patients who may not have been seen by a GP in a long time and need to be seen, or at a wider population level, which will help CCGs. Darren Nichols, MD of First Databank, explains the problems facing many GPs in the UK: “Clinicians cannot reduce cost and improve quality through prescribing interventions while the level of granularity of information about the interaction between the patient and their medicines is not fully available. That is why we are investing in patient level medicines optimisation support within the primary care sector. The new solutions, OptimiseRx and AnalyseRx will help CCGs and GPs meet some of the budgetary targets that are set whilst keeping patient care at the centre of the solution.” Of course, no two practices are the same, and FDB has accounted for that by providing a flexible solution depending on the level of medicines management a practice already subscribes to. “Some people have really done a great job with their medicines management budget and are looking for very sophisticated ways to tighten things up,” says Treleaven, “others are looking for ways to manage their long term condition cohorts more effectively. So we’re working with different vendor partners to provide different solutions.”

Some people have done a great job with their medicines management budget and are looking for sophisticated ways to tighten things up

The importance of managing medicines FDB have invested in an extensive research programme, building upon two significant UK research reports: namely, the 2009 McKinsey Report and the King’s Fund report into the Quality of Prescribing in General Practice (July 2011). Both reports identified significant unwarranted variations in prescribing practices and potential savings of between £550m and £880m per annum across the UK. FDB’s new solution will enable clinicians to make better informed prescribing decisions that are cost sensitive, specific to a patient’s history, safe in situations where polypharmacy and comorbidities are present and are aligned with best practice. Using the FDB system, practice managers can find out the proportion of medicine spend per patient, prescribing variations between GPs, monitor locum activity, or target data surrounding specific long-term conditions in your practice – all of which will prove useful for the CCGs, which will be keen to know this kind of information for localised commissioning. “It allows you to

The financial benefits of a system The advantage of using a system like FDB offers is it can save GPs and commissioners money. With more than 670 million prescriptions generated each year in primary care, there is a huge potential for medication error and variability of prescribing. Taking the two main areas of variability, FDB believes the potential savings are up to £850,000 per working day (£4.2m a week) across the NHS medicines budget. That will certainly make more than just some headway in meeting that £20bn goal.

Mark Treleaven Product and marketing manager First Databank 01392 440 190 mtrealeaven@fdbhealth.com fdbhealth.co.uk practicebusiness.co.uk | april 2012

people | interview

Positive change Gareth Williamsâ&#x20AC;&#x2122; background is not typical, spending the first 18 years of his working life in the RAF; then 12 years managing a large practice of chartered surveyors in Londonâ&#x20AC;&#x2122;s west end. After tiring of the commute, he got into practice management. Carrie Service finds out about initiatives he put in place at Dove Medical Practice april 2012 | practicebusiness.co.uk

people | interview

You’ve had an unusual route into practice management; do you think your background has prepared you well for working in general practice? It’s quite normal now; they aren’t looking for a specific medical background, particularly in larger practices, because practices vary hugely. You can be in a single-handed practice run by a couple…[with] a small patient list and...a cottage industry…to an organisation like this with 10,000 patients. They are completely different business markets. Now, with commissioning, we are much more concerned about the finances of the [clinical commissioning group] than we’ve ever been before. So, how much has the role of practice manager changed since the white paper? The role of PM hasn’t changed, [but] it’s still too early days…maybe because we’re not running the budgets – yes, we are developing new pathways and yes, we are trying to make pathways more efficient now. But the full scrutiny of monitoring our costs has not hit general practice yet. I think it will hit in the next 12 months – from April 2012 to April 2013. Then we will see practices having to be much more aware of their referrals, non-planned secondary care attendances, and A&E attendances. We will be doing a lot more monitoring of that because the financial burden will come down to general practice. You are obviously pretty involved with commissioning yourself, being on one of the largest CCG boards in the country – how integral to commissioning do you think practice managers are? Unless clinicians engage fully with practice managers [clinical commissioning] will never work, because your practice managers are going to collate the data from patient participation groups and the data of the impact of your new healthcare pathways; they will collate the data on how you are keeping your budgets. Practice managers are core to the new CCGs working and at the moment, in this area, we’re not particularly well engaged. That’s no fault of the CCGs; the CCGs are [busy] looking to authorisation, so it’s a process problem we have with the way the government is driving the changes…we don’t have the resource. A big

Unless clinicians engage fully with practice managers clinical commissioning will never work

problem is that running a board to cover 600,000 patients is a full-time job and these GPs have already got full-time jobs – as GPs. GPs generally haven’t run major organisations, they don’t have great organisational skills – they’re very good doctors and they’re highly intelligent. But relating to and being able to motivate a large work force is a different set of skills, which I believe you can learn, but this is happening very, very quickly. Do you think that the negative press coverage we have seen surrounding the NHS reforms is representative of how people in general practice feel? Overall, I think the new white paper has huge potential to make a big difference to patient care. I think generally we are very positive about it. We are on huge financial constraints and for any business, your two main out goings are cost of the buildings and your staff – and the only one you can really affect is staff. So there are going to be redundancies; it’s the only way you can get the health care bill down. Closing the ward doesn’t save money unless you make the staff associated with that ward redundant and people don’t like to have to see their organisations shrinking… people don’t want to see that disruption. I think we are seeing a lot of bad press for the wrong reasons. The country cannot afford to carry on running healthcare as it was doing. Tell me a bit about the sexual health clinic you have here: We offer a service which is very highly regarded by the patient group, because it’s discreet, it’s at your local GP (although we take any patient) and we are managing to de-stigmatise sexual health. We are now managing to encourage sexually active patients to come in for a sexual health MOT, as many sexually transmitted infections are asymptomatic. We are offering a better service cheaper here than people having to go to a hospital or a GUM clinic in the centre of town…those clinics do have their role and they’re great sources of excellence to which we refer complex patients to. But we’re a great complementary service to them and a very efficient complementary service. The UK has the highest [teenage pregnancy rates] in Europe and this area has one of the highest rates in the UK, so it’s trying to address that need and also the resurgent of HIV and Hepatitis. Preventing sexual health infections is much cheaper than treating major infections afterwards.”

practicebusiness.co.uk | april 2012

people | interview

In the last issue of Practice Business, we looked at how staff can be upskilled, allowing the practice to get the most out of their man-hours. Is that an initiative you employ here? We’ve trained our healthcare assistants to a pretty high standard so they will do home visits and take blood pressures and take bloods. They will run clinics in their own right; they will order our vaccines; they will make sure cold storage is correct. We’ve a policy of training people in house and we’ve just had a receptionist who has moved across to become a HCA – and she’s excellent. We are supporting a nurse through her degree, as she hadn’t got nursing a degree, so we are part funding her. She will then do her nurse prescribing [course] which means she will be able to prescribe antibiotics etc. in the walk-in clinics, which keeps the doctors upskilled. We’ve changed the system now so that the nurses triage… we have a walk-in clinic in the mornings from 8.30 to 10.30 with a nurse triage. The nurse will deal with 50-75% of the cases on her own and have an on-call doctor so she can escalate cases if she is concerned. If people want to carry on with their training here, we will train them. You have 10,000 patients; how do you manage appointments here? We don’t have on-the-day appointments. It was causing huge frustration because we had a torrent of telephones at quarter past eight. Now you can ring and get an appointment up to four weeks in advance. If you need to be seen on the day then you can come to the walk-in clinic. We’re going to trial an afternoon april 2012 | practicebusiness.co.uk

clinic, so we’ll effectively have a nearly all day walk-in clinic with a duty doctor, so you’ll be able to come in at any time of the day. The downside to that is you may have to wait, but the upside is you can just [turn up]. We [also] book appointments online. The trouble with this is if you’re not careful you are giving a group of your patients an advantage over the others, so we have a few appointments that go out to the internet but reserve the rest for the phone. This is an impressive building, what were the motivations behind building such a big practice? It was a private-public partnership. It is a nice building, but whether its long term economics will say it was value for money or not, I don’t know; it’s very expensive. The minor ops suite for example has never been fully functional and there was big capital investment into it. But that was a function of the PCT; restricting what GPs with a special interest in surgical operations can do on their own premises. In theory we should be able to do anything that doesn’t require a local anaesthetic, providing the GP is qualified. But PCTs tended to be very risk averse rather than risk aware, so it was historically very difficult to make a change in treatment pathways with the PCTs. It is likely to become much easier with the new commissioning groups. Do you think the emergence of CCGs will see a change in how this building is used? I’d like to think so. We’d like to think we’d be able to develop. It was a great, great, vision which has never been fully realised.

Practice Dove Medical practice, Erdington Patients 10,000 Clinical staff 5 partner GPs, 2 salary GPs, 5 nurses (one part time), 4 HCAs 13 admin staff Annual rent approx £750,000 Background Gareth Williams is practice manager at the Dove medical centre in Erdington, the third biggest GP practice in Birmingham, serving 10,000 patients. He is also on the board of the Birmingham clinical commissioning board which represents 600,000 patients; one of the largest in the country.

If at first you don’t succeed… …you’ll kick yourself if you don’t try again. Sue Shone, practice manager of Branch End Surgery in Northumberland tells us about how a failed team bonding exercise and some ladders in her tights resulted in an away day no one would forget

business intelligence and management sense for practice managers

management

april 2012 | practicebusiness.co.uk

management | comment

Deciding what to do on our practice’s annual ‘away day’ was proving to be something of a nightmare. For years they had become less and less fun for the team so just the mere mention of it brought rolling eyes and grumpy faces to the admin staff. Our GPs and nurses didn’t mind them so much, as historically the team had been split into clinical and non-clinical and they could cover QOF areas and other clinical matters that never managed to make the agenda of our fortnightly PHCT meetings. Yet for the rest of the team it had become a drudge. The agenda for the day was repetitive – just looking at the main issues in the practice and what changes could be made in the next year. It was dry, boring and never gave back as much as it took. Having only been at the practice for a few years I didn’t (and couldn’t) change certain things immediately so had hung back a while before trying to change the format. We still split into two groups and I tried some team-building games and exercises with the admin staff and then a more serious admin meeting after this once we were all team-built, relaxed, enthused and bonded. However it turns out I had been much too idealistic in my methods and they found my team-building session too different,

too challenging and downright awkward. Their resistance to the session meant I ended up doing all of the work while they watched from a distance with looks of sheer terror and amazement on their faces. I remember my drive home that day and the feeling I had of getting something so wrong – although I did feel like I had bonded with myself a lot more; especially the bit where I’d straddled a waiting room chair in what was meant to be a hilarious game of charades and ripped a hole in my tights. I learned so many lessons after this failed attempt yet resolved never to give up my hope that I could come up with something better, more productive and more inspiring. So almost a year goes by and in July my diary tells me to ‘start thinking about the annual away day’ and to ‘get it right this year’. I had been there longer; maybe the staff all knew me a bit better now? And maybe I knew them a little better too? I had certainly grown to love them more, respect them more and had much more insight into how hard they all work and what wonderful people they all are. What to do? I had no idea! I needed time to think. I had to go back to the drawing board. I had to ask: “Why an away day? What’s the purpose? How can I make it work without scaring them away or making myself look like an idiot?” Well, in my world, an away day must always be fun. That should be the main ingredient. If it isn’t fun, then no one will learn from it or want to go to another one. What else should an away day be? About the team. Something worthwhile; something that connects us to our jobs and motivates us. A celebration. And I had to plan it so that there was no way I could end up destroying another decent pair of tights. So the beginnings of a plan became hatched – and my plan looked like this: n Entire team involvement – including attached staff, district nurses, health visitors, midwives etc. and let’s get the domestic help involved this year. They’re part of our team too. n A ‘treat’ for everyone – A special event; something inspiring. n Something to confirm how good we are at our jobs and how much our patients like us. A reminder that we all want to be happy in our work and deliver the best we possibly can. n Confirmation of what a good team we are – how we all want to help one another and if things go wrong, we’re there to support each other. n A look to the future – agree on what we need to keep doing a good job, despite the cut-backs and negative feeling surrounding the NHS right now.

practicebusiness.co.uk | april 2012

management | comment

I looked at this plan and loved it. But thought: “Uh-oh, Sue. You’re being too idealistic again. You can’t do it; it is doomed to fail.” But I couldn’t let it go. I loved this plan so much I had to do something about it. I wanted to be the pioneer. The manager who changed the face and meaning of away days once and for all, and forever for the better. I wanted to ‘boldly go’. What did I have to lose apart from my dignity, respect from the team and possibly an article of hosiery? I’m not usually that attached to any of these things, and didn’t the team deserve this? They work so hard every day dealing with all manner of abuse and frustrations. They deserved to feel motivated and positive. My gift to them. But how on earth do I do this? Where do I begin? So I sat at the window and thought. I thought as big as I could. I thought of what inspires me; I thought of times when I had been inspired and I thought of people who had motivated me. I remembered a TV programme I’d seen years ago about this motivational guy who was drafted into large organisations to help the teams become so inspired and motivated they couldn’t help but do a brilliant job and feel happy about it. If I could get someone like him to help me with our away day then that would be wonderful. But he was famous and a big cheese, and even if he could come to the surgery he’d cost half a million pounds wouldn’t he? Wouldn’t he? And he probably wouldn’t even speak to someone like me. Would he? It didn’t take me long to find an email address for Nigel Risner. I Googled his name and no surprise there were a thousand links to him. So I took a chance and told him my big idea in an email. I left my mobile number asking him to give me a ring if he was interested in helping me. I felt very brave. Five minutes later my mobile rings. I answer it without a thought and there on the other end of the line is Nigel Risner. The first thing he does is congratulate me on being so bold as to approach him. I swoon. As it happens he’s going to be in the area on the day of our planned away day. I’m speechless and excited, talking rubbish to him all at the same time. He will come and help us and as he’s in the area anyway will give us a small reduction in his fees. So I book him. Not thinking of how on earth I can afford him. I just can’t let this incredible opportunity go. He’ll be in touch soon about the day etc. I do a little dance around my room; I make suppressed squealing noises, punch the air a few times and finish up the rest of the little excited dance. Wow! Blimey! It’s going to happen! I just need to stay calm and think about getting the money together to pay for him. april 2012 | practicebusiness.co.uk

Their resistance to the session meant that I ended up doing all of the work while they watched from a distance with looks of sheer terror and amazement on their faces It did all come together. I managed to think creatively in how to pay his fee. I called on some colleagues for support of the event and they were happy to help. I booked a venue nearby and got another colleague to help out with the lunch. I got the day I had dreamed of and I saw the plan I loved so much become real. All of the PHCT attended as I promoted the away day like it was going to be some royal command performance. And in a way it was. Nigel delivered all of the elements we needed – the recognition of how hard we work, the praise for how we support one another, and he gave us a bright positive vision of our future. He encouraged us to see opportunities and be proactive in how we approach things. And it was indeed like a ‘gift’ to the team. A truly memorable away day. The team talked about it for days afterwards, and the difference in the practice was palpable! We were charged and fired up and all pointing in the right direction. I did it! I had tried before and failed so tried again without a dent in my dream and it worked. This time with not a ladder in sight.

management | comment

practicebusiness.co.uk | april 2012

management | top tips

Better presenting your practice will make it more appealing to all. Practice Business highlights five things you can do to spruce up your reputation Service with a smile Reception staff are the first contact new patients will have with the surgery, so it is vital that they give a good impression. Receptionists receive a lot of criticism, but much of it is unsubstantiated and many fail to appreciate the difficult job they do. The BMA’s ‘Developing General Practice: Listening to Patients’ report acknowledges the importance of front desk staff: “Friendly, helpful, understanding and well-organised reception staff can make a huge difference to patients. Really good staff can help outweigh intractable problems with premises, ease frustrations with delayed appointments and help build the relationship between patients, practices and GPs. Unfortunately patients sometimes report difficulty with this relationship and see reception staff as a barrier to seeing a doctor leading to tension on both sides.” The report suggests that this could be eased by perhaps providing them with some generic customer service training as it is easy to forget that patients are for all intents and purposes, customers.

Are you sitting comfortably? This is perhaps an obvious point, but an important one none the less. Do patients walk into your surgery and feel comfortable and at ease? Or nervous and stressed? You don’t need a newly refurbished practice to create a pleasant environment for patients. Even something as simple as an informative well-presented wall display, which could be maintained by your patient participant group, could make all the difference. Ensuring that there is an area for children to occupy themselves as they wait and a non-cluttered seating area are obvious but effective ways of making patients feel comfortable. april 2012 | practicebusiness.co.uk

Get online A good website allows prospective patients to find you, it creates a good impression of the practice and, by posting information about opening hours and additional services, it reduces the amount of telephone queries receptionists have to deal with.

Informed marketing Nick Mayhew from PLM Communications, believes you should know your patient demographic before embarking on marketing: “There has never been a greater need to create an identifiable brand that reflects your proposition, supports the tendering process and helps with patient loyalty. There is also a greater need to communicate with patients and key decision-makers in a more meaningful and impactful way. With this is mind, answer the following questions: Do you have a clear understanding of your brand and its proposition? Do you have a thorough understanding of the demographics of your area and the demand? Do you understand where there will be gaps in delivery when PCTs disappear? Are you actively managing relationships with your patients...and stakeholders?”

Positive attitude It’s important to remember that the patients aren’t the only people you are trying to impress – prospective partners and salaried GPs looking for work are all judging you when they enter the practice. A GP surgery in Swindon was recently in the press because they believed their recruitment problems were due to the bad reputation Swindon town has. If your practice is perhaps in an area of social deprivation, or even just in a town that doesn’t have much going for it, you need to try harder than most to make a good impression and market yourself as a forward thinking practice with prospects. Being in a socially deprived neighbourhood could actually be used as a selling point recruitment-wise, by highlighting the difference the practice makes to people who really need help.

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

Multiple sclerosis

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: MS The very name of multiple sclerosis sends shivers through most people and it is viewed with great fear. It feels sinister and deadly, yet for many patients it presents a relatively benign course. The disease, which was first identified by the French neurologist Charcot in 1868, affects the brain and spinal cord, producing changes that are initially intermittent but some of which become permanent at a later stage. Essentially the disease produces symptoms because small patches of inflammation develop within the brain and spinal cord. They cause localised nerve transmission failure which results in disturbed sensory or motor function through nerve damage as a consequence of damage to the fatty myelin sheaths which surround and insulate every nerve fibre or damage to the nerve fibres themselves. Although healing occurs and the symptoms usually subside, repeated episodes result in scarring (sclerosis), which produces permanent damage and defective function. The cause is uncertain but has been suspected to have genetic, environmental and infective factors and it may be an auto-immune phenomenon, one of the strange group of diseases which occur essentially because the bodyâ&#x20AC;&#x2122;s defence system attacks itself. MS occurs in about one in a thousand people and affects women twice as commonly as men. It is the most common disabling condition in young adults in the UK. There is a genetic component and the risk to an individual is increased if another family member has the disease. MS presents in a variety of ways and is unpredictable. Most commonly it presents as a relapsing and remitting disease where episodes of symptoms occur, usually last for anything between one and eight weeks (though sometimes much longer) and then subside or disappear altogether. The intervals between symptoms are described as remissions. After a variable period, a further set of symptoms develop which may be the same as those experienced previously or may be new. Relapses often occur about once or twice a year. After about five to 15 years the symptoms tend to become more permanent as the scarring within the nervous system accumulates and the overall degree of disability gradually worsens. In about 10% of patients with MS there is no intermittent phase and symptoms which develop become permanent from the outset and the disease steadily worsens. In another 10%, at the other end of the scale, relapses occur only infrequently and do not persist. The disease follows a benign and mild course in such patients. Although most relapses do not occur for a specific reason, they may be triggered by such things as infections, strenuous exercise or by high ambient temperatures. For many sufferers the first symptoms affect the vision as a result of optic neuritis (inflammation of the optic nerve). There may be blurring or loss of vision in one eye, pain in the eye or double vision. Other symptoms may include muscle pain, spasm or tremors, sensory disturbances such as tingling and numbness, emotional lability, weakness, loss of balance (ataxia), difficulty swallowing (dysphagia), bladder symptoms or erectile failure. Later in the disease progression, loss of muscle function and wasting with reduced mobility may occur. Diagnosis of MS is often difficult in the early stages when any symptoms may be minor and transient. It is often not possible to tell whether any given initial symptoms represent the early presentation of the

Most patients with a diagnosis of MS can expect some disability after between five and 15 years april 2012 | practicebusiness.co.uk

disease, or a disorder completely unrelated to MS. The diagnosis is usually made with two or more sets of relapsing and remitting symptoms which may be spread over months or even years. Tests may be helpful but do not conclusively confirm the diagnosis. MRI scans can visualise small areas of inflammation or scarring together with evidence of previous lesions. Lumbar puncture may identify abnormal proteins in the fluid surrounding the brain and spinal cord to provide evidence of chronic inflammation. Testing the electrical activity of nerves may show slowed or abnormal patterns. None of these tests are diagnostic of MS but, taken together and with the physical symptoms, can make the diagnosis reasonably certain.

Treatments do not cure MS. They may, however, modify the attacks. Steroid drugs are believed to reduce the duration of a relapse by reducing inflammation. A variety of other drugs are available, including Natalizumab which is new and appears to reduce the number of relapses by about two thirds and slows disease progression. These drugs are available for use by neurologists. The drugs do have side effects including liver damage, heart damage and infertility. Specialist nurse support, occupational, speech and physiotherapy may relieve symptoms and psychotherapy, psychiatry and counselling may ease the emotional and depressive symptoms that may accompany particularly the later stages of the disease. Most patients with a diagnosis of MS can expect some disability after between five and 15 years. The mean survival of patients with MS is reduced by, on average, five to 10 years. However, a lot of people continue to enjoy normal lives for many years following diagnosis and new treatments promise significant improvements in the near future.

MANAGEMENT | legal

Following the Department of Health’s announcement that NHS Property Services will take over much of the property currently owned by PCTs, leading healthcare lawyer INGRID SAFFIN discusses its impact on GPs

GPs who own their own surgeries will not be affected by the transfer of PCT premises to NHS Property Services april 2012 | practicebusiness.co.uk

Life after the PCTs For many GPs, the landlord of their surgery is their local PCT. When PCTs cease to exist in April 2013 – a year from now – where will that leave them? Details are emerging from the Department of Health. NHS trusts, foundations trusts and community foundation trusts will have the opportunity to acquire PCT-owned ‘service-critical clinical infrastructure’ – that is hospitals and other premises integral to the provision of services by those trusts. The trusts will not be able to acquire the PCTs’ interests in operational primary care properties, including GP surgeries, dental surgeries, pharmacies and ophthalmic surgeries. LIFT schemes, private finance initiative/public-private partnership properties and third-party developments are also excluded from this process. Those properties not transferring to trusts will be transferred to NHS Property Services Limited, a new company that will be owned by the DH. Objectives of NHS Property Services is to deliver value for money; cut administrative costs by consolidating the management of the properties; and to deliver cost effective property solutions for community health services. A clear theme here is value for money and the drive for great efficiency. The DH says that savings will be used to invest in other frontline services. Fitness for purpose and protecting the availability of premises for the provision of services are also key considerations. PCTs are being encouraged in advance of transferring their properties to put in place proper documentation for occupiers of those properties. Where properties are being transferred to trusts, it is not anticipated that there will be model documents for occupational arrangements. If this principle is adopted for NHS Property Services’s properties then where arrangements with occupational primary care providers are currently undocumented, NHS Property Services will be free to agree documentation that is tailored to the circumstances specific to any terms that are agreed and to the given premises. Where NHS Property Services does not own the freehold itself, its freedom will be limited by the confines of its contractual position with its own landlord, being the primary care provider’s superior landlord at those premises. It is anticipated that maintenance and management staff currently employed by PCTs will transfer across to trusts that are taking over PCT premises. It is not clear yet if the same will apply to NHS Property Services properties. As to the wider management of these premises, the umbrella LIFT Council has been reported as saying that LIFT companies see a role for themselves in relation to management of the NHS estate and are hoping to become involved in strategic planning. GPs who own their own surgeries will not be directly affected by the transfer of PCT primary care premises to NHS Property Services. Similarly, GPs whose landlord is not a

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commissioning HAS LANDED A new bi-mo

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So whether you’re on a the board of a clinical commissioning group, participating in commissioning, a provider or interested from the side-lines, stay one step ahead of the Government’s plans to give clinicians power over £60bn of the NHS’ budget. This magazine is aimed at GPs, practice managers, secondary healthcare clinicians and nurses – anyone who has an active role in commissioning. It will provide them with the must-have tips and tools to make a success of clinically-led commissioning.

Be one of the ﬁrst to sign up and receive a six-month subscription for free (worth £69.99) commissioningsuccess.com editor@intelligentmedia.co.uk BROUGHT TO YOU BY THE TEAM BEHIND

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MANAGEMENT | legal

PCT will only be affected if a PCT is a superior landlord of their premises (that is, a landlord to the GPs’ own landlord or ‘higher up the tree’). GPs in this category or whose direct landlord is a PCT should make sure that they understand the terms on which they hold their premises and that those terms are clear and unambiguous. There are a number of statutory obligations that are placed on occupiers of premises and with which the documentation for the lease of the surgery should deal. In so far as GPs may not have complied with such obligations yet, CQC inspections may prompt compliance. An example is compliance with disability discrimination legislation to ensure that disabled patients have proper access to patient services at the surgery. Another example is carrying out an asbestos survey and dealing with the safe removal and/or ongoing management of asbestos at the surgery. Is the PCT responsible for the cost of this or are the GPs? Will this remain the case when NHS Property Services takes over? The state of repair of the surgery and, if it is part of larger premises, the premises of which it forms part is another key issue. Which repair is the responsibility of the GPs? To what standard of repair must the GPs keep the surgery premises, particularly if the premises were in poor repair when the GPs took up occupation? If the PCT provides services of repair, maintenance or common areas, is it clear the basis on which they collect a contribution from the GPs for those the repairs?

KEY TERMS THAT GPS SHOULD KNOW: 1. How long your agreement runs for. When this period expires you will need to renegotiate the key terms with your landlord; 2. The rent and other sums you must pay 3. When the rent will be reviewed and on what basis 4. What alterations you are permitted to carry out 5. Limitations on your ability to transfer your premises to others, for example new partners 6. What ongoing personal liability there will be on outgoing partners.

PRACTICAL STEPS GPS SHOULD TAKE: 1. Find out who owns what interest in your surgery 2. If your landlord is not your PCT, check if your PCT has a superior lease of or the freehold interest in the premises 3. Check that you have a clear, formal written agreement for your premises, fully setting out your and your PCT’s rights and obligations. april 2012 | practicebusiness.co.uk

4. If you do have a written agreement, make sure you understand what it means. Your solicitor will be able to help you with this. In particular, it may not be clear from the face of the document the extent of the personal liability of the GPs – the words in the document often do not specify the actual position because of the impact of other legal principles that apply. Also, there might be provisions in the document such as the payment of monies for building insurance or services provided by your PCT that your PCT has not enforced to date but that NHS Property Services, with its focus on cost savings, will enforce. Make sure you budget for this. 5. If you do not have a written agreement or if some of the terms that you thought were agreed are undocumented, work now with your PCT to put formal documentation in place. You should seek legal advice and, if appropriate, surveyors advice regarding this. 6. On a practical day-to-day level, the management of your surgery premises is likely to be centralised when NHS Property Services takes over the PCTs’ primary care property portfolio. It is anticipated that NHS Property Services will be primarily run from administrative offices in Leeds, with three additional centres across the country. The individuals at the PCT with whom you currently have a relationship and who have knowledge and experience of your premises and your individual circumstances may not be the people who will work with you in the future. If you have any ongoing issues, you will need to build a relationship with your new contacts at NHS Property Services and make sure that they are aware of your key concerns. Bear in mind that all this will take time. April 2013 is approaching fast. Ingrid Saffin is head of healthcare at Mundays LLP

Work/life | top tips

to a thrifty tips practice

Top

Looking for a way to minimise costs without causing chaos? Follow our five easy tips and you’ll see that a few little changes can make big savings

Use your PPG: If you have a patient participation group, see if you can get their help to do anything from keeping waiting room displays tidy and up to date to helping organise larger projects to free up your time to be better used elsewhere (possibly saving on man hours further down the line). One PPG at Church View Medical Centre in Silksworth, Sunderland, was involved in the planning and construction of a new premises for the practice. They also organised a voluntary driver service for patients who would ordinarily have a home visit, thus saving the doctor time for more appointments.

People power: Are you using your staff to their full potential? Are there any additional duties that your HCAs or administration staff could undertake? Giving those who are lower down the payroll some of the less demanding duties of more expensive staff can allow you to take advantage of cheaper man hours, for example: the receptionist doing some of the administrator’s duties and HCAs being trained to do vaccinations instead of the practice nurse

april 2012 | practicebusiness.co.uk

Take stock: Keep track of all stock items you have on the premises to ensure that nothing has been buried at the back of the store cupboard, reducing over-ordering and duplicate items. This also gives you the opportunity to see whether there are any items that you could order less of in future, for example: if you are contacting patients more by email do you need to order as much letterheaded paper and envelopes?

Shop around: Reassess any contractors/ suppliers you may be using to make sure you’re still getting the best price. Many suppliers give a special rate to newcomers and then put the prices up after six months, so your prices may have increased without you knowing it. It’s worth shopping around to see if any other companies are offering discounts and either switching or asking if your current supplier will price match. This can apply to anything from stationery to contract cleaners.

Go green: Making sure that your practice is running as energy efficiently as possible could result in significant savings on your energy bills. Assess which areas really need to be heated and switch off in areas that can do without. Set computers to energysaving settings, encourage staff to only print when necessary and ensure all computers, photocopiers and printers are switched off in the evening.

WORK/LIFE | diary

Practice diary Stephen Humphreys Stephen Humphreys is a practice Manager in Hertfordshire. The opinions expressed here are his own and should not be read in any way as being endorsed by others at his practice.

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

Practice Business welcomes a new columnist each month. Stephen Humphreys explains the health bill story Roy Lilley recently asked the question: “What is the point of commissioning?” in his column in February’s Practice Business. He suggested that one of the reasons the Lansley reforms of the NHS are so unpopular is that there is no “narrative”. I wish to explain the narrative that appears to have eluded Lilley. Seat-belts on, here goes. The first thing to note is that the narrative, while not exactly complicated, is fairly rarefied. And the story goes back to at least 1995 when Britain became a signatory to the General Agreement on Trade in Services (GATS) and so undertook to open its public services to international (private) trade. The commercial sector was to have an increasing role in what had traditionally been publically provided services. It all flowed as part of the process that began with the Thatcher government’s transferring hospital cleaning services to private sector cleaning companies as the state began to withdraw from actually providing services. The public-private finance initiative was another part of the policy tool-kit. The Labour party did little to resile from the policy and this would have been difficult for it because GATS is an international agreement binding those countries signed-up to it. It is part of a long-term international, intergovernmental policy involving transnational corporations and deemed necessary for the on-going success of capitalism. The point is that the policy is in place and requires the Government to fulfil the commitment made under GATS – hence we see moves to privatise Royal Mail, schools are becoming private academies, universities are moving towards private-sector involvement and the health-sector must be given up to private providers too. Of course, one cannot come out and say all this

because it will be unpopular. This is a story that the Government does not want telling but it is an account able to explain its health (and other) policies, in the face of unprecedented opposition. The strategy involves giving the GPs commissioning control knowing full-well they will not be able to manage. Hence it does not matter that the many doctors do not want the policy or responsibility, nor does it matter that they do not have the skills to commission. In fact if they did have such skills then this would wreck the policy. They are meant to fail. Once the GPs have the responsibility but realise that they cannot cope they will find, waiting patiently in the wings, pre-approved private-sector organisations ready to offer ‘commissioning support’. These companies will of course charge a fee (or a commission) for commissioning. With this the privatisation of the NHS begins to shift-up a gear. These commissioning support organisations should be able to get seemingly good deals at first as their co-conspirator multinational providers will not attempt to make fantastic profits in the first few years but will wish to undercut competition (the NHS acute trust providers) until the competition has been quashed when they can begin to put the prices up and collect the monopoly profits available. The existing free-at-the-point-of-need NHS will rapidly become unaffordable (this is not accidental) and the healthcare system will have to move to a model more akin to the private sector model typified by the arrangements in the USA. This will be more affordable to the government of the day, who can blame their predecessors (while toasting them for getting them out of the anticipated crisis that looms large as so many live longer, draining taxes and health care resources).

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