Practice Business August 2011

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august 2011 Your guide to managing commissioning inside

Know thy patients

There’s no time like the present to get your patients on your side

the good guys

Long live the primary care manager!

Sugar shock Why are GP practices letting down their diabetic patients?

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Editor’s letter EXECUTIVE EDITOR roy lilley www.roylilley.co.uk EDITOR julia dennison julia.dennison@intelligentmedia.co.uk FEATURES WRITER allie anderson allie.anderson@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER george petrou george.petrou@intelligentmedia.co.uk PUBLISHER david collingbourne david.collingbourne@intelligentmedia.co.uk ONLINE AND SOCIAL MEDIA MANAGER dan price dan.price@intelligentmedia.co.uk DESIGNER sarah chivers sarah.chivers@intelligentmedia.co.uk PRODUCTION ASSISTANT sinead coffey production@intelligentmedia.co.uk CIRCULATION MANAGER natalia johnston natalia.johnston@intelligentmedia.co.uk

CONTACT US intelligent media solutions suite 223, business design centre 52 upper street, london, N1 0QH | tel: 020 7288 6833 | fax: 020 7288 6834 | email: info@intelligentmedia.co.uk | web: www.practicebusiness.co.uk | web: www.intelligentmedia.co.uk | twitter: twitter.com/practice_biz

Managers to the rescue

Managers are getting their own back. If this issue was given a theme, it would be ‘in praise of the talented manager’. Both Roy Lilley (in his column on p8) and Roger Hymas (in his analysis on p12) sing those praises – the former in his highlighting the fact that countries, like France, often praised for their healthcare, actually see the merit of having a higher manager-topatient ratio, while the latter urges healthcare professionals to see the wood from the trees when it comes to bureaucracy – which he says shouldn’t be seen as the poison word it’s made out to be.

In other news, organisations, such as the NHS Alliance and even an SHA in south east England, are speaking out in support of the practice manager profession. The NHS Alliance, by way of its Practice Management Network, has put together a paper called ‘Liberating Practice Management’, echoing the government’s white paper of a similar title. Here, the alliance puts together a quality overview of what’s expected of practice managers in these challenging times and how to cope with the financial pressures that come with it. Meanwhile, NHS South Central has created a new training course for GP practice managers – which it loftily claims as the first of its kind in the country. Most readers will know of other leadership programmes available for the PM. However, the SHA claims this Leadership for a Purpose programme focuses entirely on skilling up those in the business of running a GP practice. For more details on both, see p6-7.

It’s clear, as these organisations can attest to, that the practice manager will be pivotal to keeping practices in business as commissioning comes into play. So where once half the battle for PMs in commissioning was getting the world to sit up and take them seriously, at least they can rest assured that is finally happening.

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SEE INSIDE FOR OUR GUIDE TO MANAGING COMMISSIONING

P.10

Contents SECTOR 06

news Top news for practice managers this month

08

executive editor comment The latest from controversial columnist Roy Lilley

COMMISSIONING 10

commissioning news A practice manager’s update on clinical commissioning

12

analysis Commissioning myopia Roger Hymas praises managers, bureaucracy and data

18

interview Strength in numbers Alison Dalal of Paddington Green Practice talks collaboration

PEOPLE 22

interview The patient comes first Richard Stead, PM at patient-run Arlesley Medical Centre

MANAGEMENT 26

clinical Sugar shock How practices are letting down younger diabetic patients

28

patients It’s better to know There’s no time like the present to get to know your patients

32

mfm This month: Malignant melanoma

WORK/LIFE 34

diary Michael Wright of Whyburn Medical Practice and NNE commissioning group

sector

06

Patients compare the market

The government is planning to publish comparative performance data on GP practices as part of its information revolution, including information on clinical outcomes and staff satisfaction.

The proposals, revealed last month, are part of the government’s larger plan for increased transparency in the public sector.

GPC chairman Dr Laurence Buckman said that while greater transparency could improve clinical standards, “simplistic” league tables taken out of context could make it “impossible for people to interpret the information appropriately”.

The plan is for GP data to be published online by December, which would allow members of the public to compare practices on prescribing data, staff satisfaction and comparative clinical outcomes. The RCGP says it will help the government to come up with appropriate indicators.

Reports point to NHS Choices as the channel of choice for publishing the data, as it already lists practices and lets patients review services.

Buckman commented: “Comparing the clinical outcomes of GP practices would need to be done in Key Facts a way that is fair and compares like with like – rates  GP data is set to be published and outcomes for chronic bronchitis, for example, online by December, most likely can differ markedly depending on the lifestyle and on the NHS Choices website even the occupations of the local population.  Topics open for comparison to “While greater transparency is a good thing, include things like prescribing it must be both appropriate and meaningful data, staff satisfaction and and that generally means context is important. comparative clinical outcomes Information concerning health treatment and  Critics worry this “simplistic” outcomes should also always form part of the approach to data could be taken out of context by patients. discussion that a patient has with their doctor as part of their overall care.”

PMs’ contract issues

your monthly industry lowdown

news

Contract law is the topic most frequently brought up by practice managers seeking employment law advice with a leading medical union.

According to the MDDUS, 46% of calls to its inhouse employment law advisory team this year were regarding contractual issues affecting practice managers. MDDUS’s employment law adviser, Janice Sibbald explained: “Practice managers have become more financially aware in the current economic climate. As a result, almost half of the calls we received asking for employment law advice have been contractual.”

Common issues include the employment of new staff on revised terms and conditions or guidance on contract interpretation, as well as issues surrounding maternity or sick pay.

“One of the day-to-day challenges facing practice managers is getting the best out of staff,” continued Sibbald. “Whether it’s dealing with personality clashes within a practice or simply giving a practice manager guidance and practical tips on an issue of concern.”

august 2011 | practicebusiness.co.uk

SHA train scheme NHS South Central has created a new training course for GP practice managers – which it claims is the first of its kind in the country.

Currently, practice managers can pursue qualifications such as the diploma in primary care and health management (DPCHM) from the AMSPAR, as well as the newly introduced IHM Accredited Manager Programme.

However, the SHA argues there has never been a formalised training scheme for practice managers, which it sees as a “disparate group”, “pivotal” to leading primary care staff through the changes to the NHS and supporting CCGs. Maggie Woods, leadership development manager at NHS South Central, commented: “The role of practice manager is both challenging and varied. The scope of work can vary widely, but the independence of some GP practices leaves many managers feeling that they work in isolation and that the opportunities for development in all but the essential skills are limited this encouraged us to design this brand new course.”

07

SECTOR

| news

clinical news Lansley challenged over manager cutbacks Health Secretary Andrew Lansley’s plans to cut healthcare administration by 33% and management costs by 45% by 2015 are being by challenged by the NHS Confederation and the King’s Fund, who are collaborating to develop indicators to measure the benefit managers have on clinical outcomes.

The organisations have voiced concerns that a reduction in management could harm patients and therefore seek to measure the value added by management in tangible terms, the HSJ reports.

To do so, the two organisations plan to publish a paper in spring of next year, setting out the contributions made by managers, along with the indicators that could be used to measure their value.

Research uncovered by the HSJ, and commissioned by the Department of Health to be published this summer, has already found a correlation between better management, higher staff engagement and good patient outcomes.

The study, by Aston University, indicates that better management leads to higher staff engagement, which leads to staff being more committed to their job, able to work better with colleagues and therefore less likely to make errors in their patient care.

They said…

“” fact

“The education of children and the treatment of the sick should not be treated as a commodity to be traded, as if healthcare and educations were chocolate bars or washing powder.”

Obesity Every GP practice in the UK should have a team of obesity specialists in place, urges leading obesity specialist, Professor Tony Leeds of Central Middlesex Hospital on the BBC’s website. Obesity costs the NHS around £4.2bn annually and the wider economy £16bn, and he says practices having obesity clinics would help reduce the number of hospital referrals as a result of obesity. “Britain’s front-line obesity management could be done in primary care if adequate resources were provided,” he wrote.

Medical refrigeration Following the recent case of drugs tampering at a Cheshire hospital, practices are being urged to perform urgent security checks on their refrigeration devices and told to avoid using domestic fridges to store medical supplies. “As this case highlights, it is crucial that valuable drugs, vaccines and potentially dangerous substances are stored in professional medical fridges that come complete with an alarm and locks to restrict unauthorised access,” said Lucy Kinsella, medical marketing executive at Lec Medical.

Patient choice NHS patients will have more freedom to choose any qualified provider for their healthcare from April 2012 when referred by their GP for selected services.

These providers could be NHS providers, independent sector providers, or voluntary or third sector organisations.

Suitable services include back pain, diagnostics and talk therapies.

Tessa Jowell, shadow cabinet office minister, on David Cameron’s announcement of a free-market public sector that could see local health services going out of business without the government stepping in

Get the latest news in your inbox Fifth wave of pathfinders announced. In total, there are now 257 clinical commissioning groups across England, covering about 97% of the population (around 50 million people).

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. practicebusiness.co.uk | august 2011

08

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.

august 2011 | practicebusiness.co.uk

Some inconvenient truths

SECTOR | comment

Why is the NHS being reformed? Roy Lilley is left scratching his head Why is the NHS being ‘reformed’? Well, it depends who you believe and who your friends are. There appear to be three reasons: clinical outcomes aren’t good enough; the public want a better service and it is weighed down with management costs and bureaucracy. They would be good reasons if they were true. They are not.

The clinical outcome argument has been well-rehearsed. Data from the OECD, WHO, and the Commonwealth Institute all put the UK in the middle or top of league tables for just about everything. The NHS is far from perfect but it is not a ‘reform me now’ basket case.

Patient satisfaction? The DH’s own patient survey tells us 92% of people who have had a recent experience of the NHS are either satisfied or very satisfied with the treatment they received. I’ve not seen any street protests from patients wanting a better NHS, only from those who want to keep the NHS they’ve got!

What about management costs, bureaucracy and administration? The roportion of managers in the UK workforce as a whole was only 16% in 2009. In the NHS, only 13% of workers are employed in the dark arts of management.

What do you think management in the NHS costs? In the last year, before the ‘liberation reforms’ started chucking people out, the figure was five per cent.

Rather inconveniently for politicians, one of the lowest in the developed world.

McKinsey, the government’s favorite management consultancy, says the NHS has relatively very low management costs based on his own figures and those from further afield. He says in 2009, NHS management costs actually accounted for just 1.5% of the NHS’s total costs. This is a show-stopper moment.

If McKinsey is right, this places the UK 18th in a list of 23 global health systems. An inconvenient truth if ever there was one. Particularly as the RCGP has shown that bureaucracy in the NHS, post-reform, will triple. Where the NHS is presently run by the DH, 150-odd PCTs and a handful of SHAs, if Andrew Lansley’s reforms are enacted we will see 500-plus organisations, including the DH, National Commissioning Board (NCB), regional offices of the NCB, clinical commissioning groups, clusters of PCTs, HealthWatch, and clinical senates. The HSJ is estimating the cost of changes so farat around half a billion pounds. Heaven knows what the total cost is likely to be.

By contrast, Mexico’s management costs were 11.8%, the US’s seven per cent and France’s 6.8%. All these costs are lower than we might have expected and that is because there is no standard measurement of what constitutes ‘management costs’. Health services are peculiar. It is possible that a manager might also have clinical responsibility.

A second McKinsey analysis, using the broader definition of management costs and the same as that used by the DH, places the NHS 15th out of the 23. This is not good news if you’re justifying reforms with burgeoning management costs!

A more oblique analysis shows that NHS management spending funds 150 managers per 250,000 patients. In France, the same numbers of managers look after only 1,140 patients and in Italy the figure is an unbelievable 64. This means France and Italy have many more health service managers than we have in the UK. You see how easy it is to unpick the ‘too-manymanagers’ argument. If the politicians’ arguments about management are so poorly based, what does that say about their other arguments?

France and Italy have many more health service managers than we have in the UK

commissioning

10

Empowering practice managers in consortia

Welcome to Commissioning, a new section to Practice Business where we aim to cover the latest news in the new world of GP commissioning to better prepare managers and primary care professionals forming GP consortia

Leading the way Health Secretary Andrew Lansley has announced that 97% of the population of England will be covered by shadow commissioning groups.

In his speech to the NHS Confederation’s annual conference in Manchester last month, the secretary of state for health announced the fifth cohort of pathfinders – GPs and front-line clinicians who have come forward to lead the way in commissioning.

In total, 257 groups of GP practices from across the country, covering around 97% of the population (around 50 million people), have now come forward so they can directly commission services for their local patients.

Lansley said: “GPs know their local population best and they should have the power to improve care for patients. The fact that 257 pathfinder groups now do this for around 97% of the country is not only great news for patients but for the entire NHS, as front-line clinicians step forward to modernise services.”

The selected groups represent GPs and other health and care professionals who have demonstrated readiness to start taking on commissioning responsibilities. These emerging clinical commissioning groups are working together with patients, other NHS colleagues and local authorities to help manage local budgets and design services for their patients.

Pathfinders will become part of a national Pathfinder Learning Network and will be supported by the National Clinical Commissioning Network, the National Leadership Council and national primary care bodies.

commissioning in context

‘Pivotal’ PMs supported in commissioning challenges The NHS Alliance has published a document to help practice managers tackle a range of management challenges relating to clinical commissioning work.

‘Liberating Practice Management: How to create a thriving practice in challenging times’ offers case studies as well as practical advice and tools to help PMs realise the opportunities commissioning provides to improve patient care and manage NHS resources more effectively.

august 2011 | practicebusiness.co.uk

Topics covered include managing practice finances during difficult times, engaging with the local community, achieving excellent customer services and developing quality systems.

Caroline Kerby, co-lead of the NHS Alliance’s Practice Management Network, welcomed the report. She said: “During the health care reforms, practice managers will be pivotal in looking after their teams and making sure they are supported in developing the skills and abilities required.”

Practice insight

Visit the Commissioning Success blog at PracticeBusiness.co.uk/CS and stay up-to-date with all the NHS reform news and commentary affecting practice managers.

Commissioning ticks boxes The NHS Alliance and NAPC have published a paper explaining how commissioning will help to tackle the three major challenges facing the NHS in England over the next five years.

‘Clinical commissioning: securing better outcomes for the NHS and its patients’ outlines the role of commissioning in improving the health of the population; reducing health inequalities, and delivering better services to patients while achieving ambitious efficiency savings.

Dr Michael Dixon, chairman of the NHS Alliance, said: “This discussion is extremely important. Clinicians are in the best position to lead through the changes that will make the NHS not only sustainable, but also able to deliver better care for our patients.

“By working to overcome the barriers between the NHS and social care, [clinical commissioners] will be able to provide patients with better, seamless and more accessible care,” he added.

NAPC chair Dr Johnny Marshall added that clinical commissioners must accept a collective responsibility to deliver the best possible health outcomes for their populations.

“Whatever uncertainty there is yet to come, clinical commissioners must seize this opportunity to lead the NHS in doing what is right for our patients, their carers, their families and the public,” he said. “We must not let ourselves be deflected from that.”

A more efficient system “In terms of administration, EMIS Web is overwhelmingly superior.”

Joy Baker This month we speak to Joy Baker, practice manager at the Marden Medical Practice in Shropshire about the benefits of EMIS Web.

Staying local A DH report, ‘Healthy Lives, Healthy People: Update and Way Forward’, outlines how public health in local communities will be emphasised under commissioning. Highlights include:  Clarifying the new leadership role for local authorities and their directors of public health, across health improvement, health protection and population health advice to the NHS  Proposals for commissioning public health services  Establishing a new integrated public health service, Public Health England, to drive improvements in health and protect against health threats  Public Health England will be an executive agency of the Department of Health, to provide greater operational independence within a structure that is clearly accountable to the Health Secretary  Clear principles for emergency preparedness, resilience and response. www.emis-online.com

A busy urban practice in Shropshire is realising the benefits of EMIS Web for staff and patients after being among the first practices to switch to the new system last November.

Joy Baker, practice manager at the Marden Medical Practice, which serves 6,700 patients, said the administration side of EMIS Web was “overwhelmingly superior” and had the potential to deliver important clinical safety benefits. “Data searches are easier to put together and the results are more accurate and easier to understand. Practice staff have found the system easy to pick up.”

Using Concept Manager, Joy’s team has just finished adding comprehensive drug alerts to the system, which she believes will improve patient safety, help GPs in keeping their knowledge up-to-date and cut down on repeat visits to the surgery. “Now that we have instant alerts popping up on the records, patients won’t have to come in several times to have blood taken for different tests,” she says. “We will be able to roll several tests into one, making the process much more efficient and safer.”

Reception staff also appreciate the new appointment booking for EMIS Web, which makes it easier to plan a week’s appointments, add extra sessions and put together individualised templates for the GPs. Joy added: “Staff found EMIS Web easy to pick up and now, after more than six months using it, everyone is proactively looking for ways of developing the tools on offer to make sure it can do exactly what they want.”

12

COMMISSIONING | analysis

Commissioning myopia (or how to prevent short-sighted reforms)

Let’s not get carried away and discard management altogether, says columnist ROGER HYMAS. It’s management that will make the NHS better – as long as it’s the right kind

Roger Hymas Roger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is the founder of the Commissioning Community website (www. commissioningcommunity. co.uk) and a regular columnist on commissioning for Practice Business. You can reach him at rogerhymas@ btinternet.com

The trouble with writing for monthly magazines is that you get too much time to think. What you believe is going to be the theme for the next edition easily gets de-railed when something more topical or interesting comes along and sets you off in a completely different direction. So this is the third try at delivering this month’s piece and it might be a good idea if I explained the chronology of how I got to what you are reading now.

It all started with a white paper put out by experts from the prestigious King’s Fund. There is no doubt that ‘The future of leadership and management in the NHS’, http://www.kingsfund. org.uk/publications/nhs_leadership.html, is a functional, well-executed piece of work. It is particularly good at setting out the individual qualities of management and leadership and the

august 2011 | practicebusiness.co.uk

important distinction between the two. There is a difference, of course. ‘Leadership’ is all about vision, motivation and drive – to ensure the team, the enterprise, successfully executes the task in hand. We all know a good leader when we work with him or her. You can feel the inspiration.

‘Management’, technically, is a lot trickier.

Managers nowadays cover a broad range of roles and responsibilities. Everyone seems to be a manager, just as everyone is middle class. Job title inflation has seen to that. But it does make organisations like the NHS, which employs tens of thousands of ‘managers’, an easy target for the critics.

‘Management’ soon mutates into ‘bureaucracy’. It’s not long before the media, and increasingly the politicians, begin to characterise management as bureaucracy and, therefore, wasteful.

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14

COMMISSIONING | analysis

Personally, I’ve never seen ‘bureaucracy’ as a pejorative. Bureaucracy, correctly applied and executed, can deliver really significant benefits for organisations and society. Bureaucracy put the Industrial Revolution into overdrive and helped build the British Empire. Management has made just about every good thing we enjoy in life possible. It’s management that will make the NHS a better system, although we have to be sure that we get the right sort of management.

Thankfully, I’ve been the beneficiary of excellent management tutors for nearly all of my working life. One of those seminal experiences came when I was being mentored by a man who wrote himself into management history with his classic Harvard Business School paper, ‘Marketing Myopia’. Theodore Levitt’s point was that businesses would only succeed if they got over their short-sightedness, stopped focusing on what they made – with a kind of take-it-or-leave-it attitude – and started to think about what customers wanted to buy. Probably all of modern consumerism goes back to this single paper. The NHS has got both good and great managers, but you know when it comes to understanding what management can deliver, it really has got commissioning myopia.

Bells started ringing in my head when I was about halfway through the King’s Fund paper. What I did next was carry out a simple test that I do on most DH or NHS strategy papers and you can try it yourself.

Put “commissioning” into word search and apply it to august 2011 | practicebusiness.co.uk

the text of the KF paper. What you won’t find is the words “leadership” and “management” combined with the word “commissioning”. The paper is biased almost exclusively to care provision. When the King’s Fund decided to assemble a panel of worthies to ruminate on leadership and management in the NHS, it selected a team whose entire experience is hospitals, specialists, operating theatres, clinics and primary care practices, all the panoply of provision.

There’s not a commissioner in sight.

Now I think this is deep in the psyche of the NHS because the only argument I can put forward is that real commissioning hasn’t been invented yet. Nobody has established him or herself as a household name in NHS commissioning.

You can rattle off a list of the giants of NHS hospital leadership and the celebrated physicians and surgeons. But who are the heroes of the commissioning community? I’ll count up to 10 while you give me some names. In fact, you can email with your suggestions and we’ll start an NHS Commissioning Hall of Fame.

So, if we need commissioning education, training and development, we have to look at

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COMMISSIONING | analysis

international experience. The Nuffield Trust has just published a paper entitled ‘GP commissioning in the NHS in England: 10 suggestions from the United States’, http://www.nuffieldtrust.org.uk/ sites/files/nuffield/publication/gp-commissioning-inthe-nhs-in-england-ten-suggestions.pdf. Its eminent author, Professor Lawrence Casalino, an American commissioner, is a man who, uniquely, seems to have a PhD in practice management. This probably says a lot about the difference in the level of maturity of British and American commissioning.

The Nuffield Trust asked him to wander around England for six weeks and draw some conclusions about where GP commissioning should go. In essence, this is what he emphasised (though to get the best out of it you should read the paper in full): • GP commissioning groups will have to invest heavily in leadership, management and infrastructure. This means lots of training and significant investment in back office management systems.

• From each clinical commissioning group at least two skilled clinical leaders must spend the majority of their time on commissioning. A few hours here or there is no good.

• Contracting with external organisations, like the local trust, will only be effective if consortia have strong contracting and negotiation management.

• There should be meaningful incentives for GP practices to achieve cost savings.

• Each GP commissioning group must have something at risk, something that they can control, although the ‘insurance’ risk needs to be minimised.

• It doesn’t matter whether clinical commissioning groups and practices get real or virtual budgets, but it is critical that commissioners have timely and accurate information about the services they buy for patients.

It’s this final bullet – having the information – that I regard as key to the success of commissioning and right along, on cue, came my third piece of serious reading for the month. This is the granddaddy of the lot. It’s called ‘Big data: the next frontier for innovation, competition and productivity’ and it’s published by the McKinsey Global Institute – http:// www.mckinsey.com/mgi/publications/big_data/ pdfs/MGI_big_data_full_report.pdf. This is where the commissioning telescope gets turned round and everything starts to look a lot bigger. august 2011 | practicebusiness.co.uk

‘Big data’ is all the world’s industrial knowledge stored on computers. Computing scale is now impossible to comprehend – we moved on from gigabytes, terabytes, petabytes to exabytes. McKinsey demonstrated the point by telling us that all the world’s music can now be stored on a £500 disk drive.

There’s a really excellent section on health care that I want to commend to you. Those of you who read this column regularly know this is what I bang on about almost incessantly. Commissioning will only deliver its full potential when we unlock all of the knowledge about the patient experience that is sitting in NHS repositories, including, of course, the umpteen terabytes of practice data. Only when this information is extracted, sorted and combined with data from other sources, for example from hospital systems, will we be able to gain the insights about what can be commissioned better and what shouldn’t be commissioned at all.

Real knowledge-led commissioning is still in its infancy in this country, but if McKinsey is to be believed, it is going to be a seriously big business, worth more than $10bn globally by 2020. But it also brings the promise of huge savings, maybe as much as $300bn a year. In the US it is reckoned that improved health care data management could save up to eight per cent of national expenditure. Applied to England, this level of saving on the £60bn GP commissioning budget would easily deliver David Nicholson’s target for 2015.

Beyond the financial benefit, what’s in it for the patient? McKinsey sees a huge opportunity to raise commissioning effectiveness and secure vastly improved outcomes across a wide range of diseases and conditions. I like in particular the final promise, what eventually happens when the patient experience data – the stuff you have in your practices – gets combined with information about the patient’s genetic predisposition to a range of illnesses. The answer takes us all to a new era of personalised medicine, as patients begin to be identified and treated according to their molecular signature. That’s the end game for real commissioning.

Does this seem like a long way ahead? Yes it is, but all journeys start with the first step. All we need now is some leaders to guide us there. Stand up and be recognised.

Everyone seems to be a manager, just as everyone is middle class

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COMMISSIONING

| interview

Learn by example Alongside her day job as practice manager partner at Paddington Green Health Centre, Alison Dalal is practice manager representative on the Central London Healthcare commissioning board. She reveals to Julia Dennison where she thinks opportunities lie for those in her profession august 2011 | practicebusiness.co.uk

19

COMMISSIONING | interview

What few members of the public realise – and even those in healthcare sometimes forget – is GP practices are private businesses contracted out to the NHS. And like all private businesses, the key to a successful GP practice is working efficiently and maintaining a healthy bottom line. With the onset of clinical commissioning groups, or CCGs, these private companies will have to work with other similar private companies or fear losing their NHS contract. It is a given that there will be as many differences as similarities between these once-competing businesses and getting them to collaborate will be no easy task. Practice performance will have to be monitored to ensure the larger group benefits from the diverse skills and facilities within its membership and doesn’t suffer as a result of one practice lagging behind. Under the umbrella of commissioning, the task of monitoring practice performance is likely to be bestowed on a CCG’s practice manager board member.

Alison Dalal is one such practice manager. A partner at Paddington Green Health Centre, a busy GP practice just off Edgware Road in central London, her role is as diverse as the community that surrounds her.

She keeps herself even busier these days as a practice manager representative on the board of the Central London Healthcare (CLH) commissioning group. One of her main tasks on the leadership team of this central London pathfinder is working out how to support quality improvements in practice and performance manage practices as commissioners – in other words ensuring its 24 member practices engage in the commissioning process.

Practice management in action Coordinating a large team is nothing new to Dalal. There are 14 clinical staff at Paddington Green, including GPs, registrars, F2s, practice nurses and a healthcare assistant.

The practice also houses its attached staff on site, which means a team of district nurses and health visitors works from the top floor of the building. The administrative team is equally substantial to support all these clinicians, with seven receptionists, a reception manager, a deputy practice manager who specialises in IT, and two secretaries. Altogether, there can be up to 40 staff on site at any one time.

“All that makes patient care amazing,” says Dalal of the substantial practice team. “They’re all talking to each other so they can just pass each other [in the corridor] and share their experiences.”

One of Dalal’s unique selling points when she came into general practice was her previous experience working as a manager in government and also for Oxford and Gloucestershire family health service

authorities (FHSAs) – “on the other side of the tracks”, as she calls it. This experience of managing healthcare on a grander scale and her contacts in the PCTs have come in handy under commissioning.

Dalal and her practice team are also no strangers to working with other practices in their area. The surgery took part in fund-holding as part of a multi-fund conglomerate of London practices that would eventually become the CLH commissioning group under practicebased commissioning and now, in its latest incarnation, is a pathfinder that takes up half of Westminster PCT. While CLH’s 130,000 patient - strong list doesn’t make it the smallest pathfinder around, it’s not the largest either and even that size sometimes feels small to be conjuring adequate resources in the busy capital.

“What we find is we don’t have the resources or capacity to deliver all the work streams that we need to be doing,” Dalal says of the pathfinder. “There is a small core of employed staff that is growing at CLH, but they can’t do everything and they rely on the board and any other interested GPs or practice managers to get on with the work.”

Strength in numbers Stepping in and getting on with the work is what landed Dalal her role focusing on practice performance. “That’s an interesting area for us because there’s a very clear divide – CLH doesn’t hold the GMS/PMS contract for general practices; that’s going to be held by the NHS Commissioning Board, which will monitor our performance against them,” she comments. “But of course, it’s in CLH’s interest to want its practices to be excellent and to perform well, because if we can’t perform well ourselves, how can we be commissioning well?”

The capital’s PCTs and Londonwide LMCs have signed up to a pan-London framework, which exists to track practice standards across the capital regarding quality, access and patient experience. It’s this framework, with which Dalal acts as a practice manager observer, that CLH plans to emulate with its own practices.

Working together is something that comes fairly easily to CLH. The commissioning group has regular plenary meetings (participation in which is growing thanks in part to the hot meal guaranteed with attendance) and three annual away days for member practices, practice managers and practice nurses. It also has practice manager, practice nurse and senior administrative staff forums that meet once a month.

The key to facilitating communication between practices, according to Dalal, is a robust back-office system and CLH has a long-term plan to get all member practices on the same clinical IT system, or at least

»

practicebusiness.co.uk | august 2011

20

commissioning | interview

facilitate communication and integration across existing systems.

All of this will aid CLH to monitor its member practices’ participation in commissioning. Criteria for this include: whether they are helping them make savings against hospital budgets; reducing referrals; using the patient referral service; engagement in cost-effective prescribing; and forum attendance.

CLH has always had an incentive scheme that rewards practices for releasing practice managers, practice nurses and doctors to attend the commissioning group’s meetings, and they will continue to do so under clinical commissioning. “We want to really encourage people to be engaged and take an active role, so we’re developing that side of it,” says Dalal. “We’ve got to think how we get practices to be fully engaged in commissioning and making savings, and what kind of rewards do we give them and how do they get a share in any savings we make or business opportunities that creates?”

CLH aims to get practices involved by supporting them to make savings and, perhaps more importantly, paying them for running services that might otherwise be run at the local hospital. Dalal gives the example of anticoagulation, which she feels is a service that is wellplaced at practice level. Not only would many patients find it easier to access, but the practice benefits by getting paid for the service.

When it comes to pracatice engagement, Dalal believes it’s important to consider the needs of practices of all sizes within the group. Specifically, she worries that smaller practices won’t have the resources, size or adequate premises to provide some services, so could feel left out of commissioning and the incentives that come with it. “We’re lucky; we’re big, we’re well organised, we’ve got space, and we’ve got a management team with time to meet and think about whether we want to offer a service, where we would put it and whether we would offer it just to our patients or to other practices’ patients as well,” explains Dalal. “Some practices just don’t have that capacity, so how can they develop the service?”

The only way these small practices stand a chance at participating in commissioning, it seems, is if they make

an extra effort to be involved. Otherwise, Dalal worries, they will lose out because they “won’t be able to share the rewards of commissioning with practices that are not fully engaged”.

Opportunity knocks Apart from simply participating more, Dalal has another suggestion for smaller practices: to form group practices that outsource and/or share administrative duties like HR, accounting, IT and even the general business of running your practice under an overarching practice agreement. “To free yourself up to be involved in new clinical pathways for chronic conditions and the ageing population, you’ve got to shed all the other rubbish – it just takes up too much of your time,” she recommends.

“You can get on with the business of offering care to your patient group and if you want to offer anticoagulation, for example, other practices can refer in or vice versa.”

She points to similar models with vet and optician practices and says even larger practices like hers would benefit from something similar. “I think even for practices of our size, we need to be looking at going down that route because all of the regulatory activity we now have to take part in is so onerous,” she says, referring to things like registering to the CQC and information governance, health and safety and employment law. “It’s impossible for a practice manager to do all of that – and QOF and enhanced services.”

As a fellow at the Institute of Healthcare Managers and with a masters degree in Leadership and Health from Kingston University London, Dalal is certainly a champion of the practice management profession. Her advice for practice managers keen to get the most out of commissioning is to get knowledgeable – read articles, subscribe to newsletters and participate in commissioning wherever possible. “If you can do nothing, read and if you can do something, get involved in the group and network with your colleagues,” she says. “Each practice manager has their own area of interest. You don’t have to be on the board – if you see the board is working on something your practice is doing, you can offer to be part of it.”

If you can do nothing, read, and if you can do something get involved in the group and network with your colleagues august 2011 | practicebusiness.co.uk

Fact box: Practice manager: Alison Dalal Time in role: 22 years Background and training: Dalal started her career in government and IT. She later worked for several health service authorities and became practice manager of Lisson Grove Health Centre, now Paddington Green Health Centre, becoming partner in 2009 Practice: Paddington Green Health Centre Patients: 8,500 Contract: PMS Partners: Six Clinical staff: 14 (and a team of district nurses and health visitors on site) Support staff: 11 PCT: Westminster Pathfinder: Central London Healthcare

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people

22

one to ones with the people that matter

Alternative medicine The Arlesey Medical Centre in Bedfordshire is a social enterprise in the hands of local patients. Julia Dennison speaks to practice manager Richard Stead about the benefits of this alternative approach to general practice Bedfordshire primary care trust opened the Arlesey Medical Centre in late 2003 in direct response to requests by local people who wanted a local service that met their collective need.

The town of Arlesey has a semirural feel to it, which, despite being commuting distance from London’s King’s Cross, makes it seem a million miles away from the urban landscape of the capital. The medical centre itself is housed in a building complex that is home to a range of other local services, including a library, nursery, lower school and village

august 2011 | practicebusiness.co.uk

hall – making it every bit the picture of David Cameron’s Big Society.

The practice’s philosophy is a simple one: to provide a service that is responsive to its population’s collective needs – open when they need, locally accessible, and personal service delivered to the highest standards. This ethos of a commitment to the community was reiterated in April when the practice became a not-for-profit social enterprise.

I met with practice manager Richard Stead two months later to ask him about the process.

23

people | interview

You started at the practice in 2004 – not long after it opened. Were you the first practice manager?

Effectively, yes. There used to be a small branch surgery run from another doctor’s practice here, but it wasn’t open full-time and the PCT decided they would take it on and run the surgery. So they revamped the whole building, which is shared with a library, community centre, a nursery school, a village hall and the town council offices on the end, and looked for a GP to run it. Dr Mike Attias was asked if he wanted to start it up, which he did with one assistant and a part-time nurse – so it was just the three of them. With the new surgery opened, it was quite attractive to a lot of the local residents and the patient base grew fairly quickly. When I joined it was about 1,000 and now we’re up to around 2,800.

Can you tell me about your recent transformation into a social enterprise?

The PCTs had to divest themselves of services with no choice, really, and we researched the issue and found out we could do one of two things: do nothing and be hived off with the rest of the services that the PCT provides, such as wheelchair services, district nursing or dentistry, and if that was the case then we would be taken on by whoever got a successful tender for the PCT’s services, which hasn’t been finally decided as we speak. The other option was that we took control of our own destiny. As we’re all NHS employees we had what is known as the ‘Right to Request’ (see box out) from the Department of Health, so if we wanted to take over the business then we didn’t have to go to tender. So we put our proposal forward and were successful; the contract was signed on 31 March at 10pm and we became a social enterprise on 1 April.

Becoming a social enterprise is pretty unique in the health sector.

The most well-known social enterprises, I think, are Jamie Oliver’s Fifteen restaurent and the Big Issue.

We’re not the first surgery to be a social enterprise, but I think we’re the first in this region. When we were owned by the PCT, they were responsible for all our payroll and HR activities, but now, as a social enterprise, we have our own responsibility for that, which is a bit of a double-edged sword because now we’ve got the extra work, but at the same time we’ve got more freedom.

Can you tell me about its set up?

It’s a not-for-profit organisation. There are shareholders, the basis of which within the

memorandum and articles of association are four executive directors, who effectively are the employees, and two non-executive directors who are patients.

So it’s not a partnership?

No, it’s not a partnership. We have a nominal £1 share as directors with limited liability.

Has your role changed since becoming a social enterprise?

There’s certainly more responsibilities in terms of the administrative side, like HR functions and dealing with payroll, although we’ve outsourced that and it’s just a case of liaising with an agency and providing them with details of hours worked, and starters/ leavers, which got that big headache out of the way!

You’re operating with very few staff. Do you see staff numbers growing?

One full-time GP, a practice manager, a part-time nurse and part-time receptionist is insufficient to run a surgery of our size because it means approximately half my working day is spent covering the reception.

We’ve recruited another part-time GP to do two days a week and another part-time receptionist, who combined with the other receptionist will equal slightly more than one full-time member of staff.

Fact box

Are you hoping to increase your patient numbers?

Non-clinical staff: One practice manager and a part-time receptionist

Yes, we would like to be at 3,200 within two to three years.

Practice: The Arlesey Medical Centre Patients: 2,800 Clinical staff: One fulltime GP and a parttime nurse

Contract: APMS

How are you going to do that?

We haven’t gone out and sold our services – it’s not something we’ve ever needed to do and much of our growth has been through word-of-mouth or patient recommendation. As a small surgery, I would admit having worked in large and small units in banking, it’s far easier to present a cohesiveness and a friendly approach to patients. I think, particularly in a village, they appreciate the intimacy of it. With my background, I’m used to dealing with customers and our doctor is very friendly and approachable – so it’s just been that kind of service proposition.

Do you think it’s important to treat your patients as you would customers?

Oh, absolutely. I think historically, practices haven’t necessarily done so but they are improving a lot. We try to treat our patients as individuals. If you have a look at our NHS Choices page you’ll see there is some quite positive feedback from patients, and

»

PCT: Bedfordshire Commissioning group: Ivel Valley Commissioning Group Practice manager: Richard Stead Time in role: Seven years Background: Richard Stead became practice manager at the Arlesey Medical Centre in late 2004. With a banking background, he has over 20 years’ experience in management. His particular specialisations have been in customer service and resource management.

practicebusiness.co.uk | august 2011

24

people | interview

indeed, that has helped us recruit new patients – even when we’re not the nearest surgery for them.

Have you signed up for the new patient participation DES?

What about your opening hours –are you going to extend those at all?

Yes. There is still a lot of work involved in it but we do hope it will be relatively straightforward for us to integrate it.

Because we’re small in terms of resources, it’s not been easy to expand too much but we have been able to meet the requirements of the PCT and we now open from 7.30am three times a week and those appointments are always taken. We normally open at 8am, which is earlier than a lot of surgeries anyway, but by opening that bit earlier it’s useful because we’re on the line into King’s Cross and so we quite a few commuters in the village and they tend to be the ones who take advantage of it. Over a period of time we do want to extend our opening hours even further. We are looking at opening one Saturday morning every other week, for example, or maybe one late night. We want to be flexible about it to see what the patients want and what demand there is.

Do you have a patient participation group?

Yes, we started a patient participation group when we decided to go down the path of becoming a social enterprise so we could formulate our ideas and get some feedback from them. That’s developed into the social enterprise set up we’ve got at the moment, and the two patients on our board of directors aim to organise a meeting with a group of patients three or four times a year. Between 40 and 50 patients have registered an interest in being involved in how the surgery is operated.

That’s quite a lot, considering your size.

We do tend to get a lot of support and we value that. august 2011 | practicebusiness.co.uk

To return to the subject of the practice as a social enterprise, it’s still early days, but are you confident it’s going to work?

Oh, yes! We wouldn’t have jumped through all these hoops if we didn’t think it was the right thing to do because, as I said, we could have just sat back and done the same thing we were doing before, just with different bosses. There’s no reason for a social enterprise not to work. To some extent, we feel it is the way of the future. There’s always going to be doctors in partnership – this is just another alternative and I think you can really get your patients to buy in and be part of it all.

Jargon buster Right to Request The Right to Request enables frontline primary care trust (PCT) staff to apply to their PCT board to deliver specific services through a social enterprise.

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MANAGEMENT

26

A youth movement The recent National Diabetes Audit presented a damning report on the state of diabetes care for younger patients in primary care. JULIA DENNISON looks at what this says and what practices can do to up their game The NHS could be facing a diabetes time bomb.

Shocking evidence published this summer in the shape of the 2010 National Diabetes Audit revealed a major problem: GP practices are not doing enough to treat the hundreds of thousands of young people with diabetes, and as a result the health service could suffer.

Nearly 300,000 children and young adults with diabetes have high-risk, and 144,000 dangerously highrisk blood sugar levels that will lead to high levels of severe and disabling complications like kidney failure, limb amputation and stroke - and they are the ones who are less likely than older or elderly adults to receive the basic checks required to monitor their condition from their GP. This has led to concerns that a whole generation with diabetes will only require more substantial hospital care in a few years’ time. It’s up to practices to act now to ensure their services are adequate before it’s too late.

the situation at hand Only 42% of 24- to 54-year-olds receive all nine recommended basic care processes with their GP annually, such as blood pressure, blood sugar and foot checks, compared with 54% of adults aged 55 and over, according to the diabetes report. Overall, the percentage of patients receiving every process is improving each year, but two thirds of Type 1 patients and almost half of Type 2 patients still do not receive all nine.

Dr Bob Young, lead clinician on the audit and consultant diabetologist and clinical lead for the National Diabetes Information Service, said at the

august 2011 | practicebusiness.co.uk

time of the report that the results “ring alarm bells”, showing that “younger people make up a quarter of all those with diabetes yet have the highest risks of potentially preventable complications”. “If these risks could be reduced much future disability and shortened life expectancy could be prevented.”

PRactices MaKe PeRFect Primary care plays a pivotal role in ensuring that people with diabetes receive effective diabetes care.

This is recognised by the inclusion of clinical indicators for diabetes in the Quality and Outcomes Framework (QOF), including two new 2011/12 indicators on foot examination to improve diabetes-related foot care and to improve patients’ outcomes. As a result, many patients with diabetes are now managed solely or mainly in primary care.

The proposed healthcare reforms are putting practices, which have frequent contact with patients with long-term conditions like diabetes, in the driving seat. GPs will be the ones who can prevent unnecessary referrals to hospital through commissioning services on a local level.

Speaking on the 63rd birthday of the NHS, Health Secretary Andrew Lansley referenced the work frontline staff in his own constituency of Cambridge have done to improve care for diabetes patients. He talked about how doctors from Addenbrooke’s Hospital took the initiative to work with local GPs and invest in community care to improve glucose control in diabetics and to help improve self-management. As a result,

27

management | diabetes

inpatient admissions fell by 40% almost immediately.

If rolled out, the pilot could save the NHS in Cambridgeshire around £5m a year. Extrapolated up for the rest of England, that’s an annual saving of £400m.

What can practices do?

While each practice should have a named clinical lead for diabetes, practice managers can also play a part in improving diabetes care at their practice.

Patient care for diabetes involves both organised reviews within designated diabetes clinics, often run by a practice nurse, and day-to-day care patients.

Back office systems should facilitate practices to call in the people with increased risk of developing diabetes, for example those with insulin resistance, so they can be offered preventative support. People with diabetes should have annual health checks and practices should ensure they attend them.

For those who are not yet diagnosed, Steve Dunn, CEO of Williams Medical Supplies, says more point-ofcare testing is needed. “In the UK there are 2.8 million people diagnosed with diabetes, but more worryingly

there are approximately 850,000 people who have the condition but don’t know it,” he says. “With better diagnostics, practices can make a big difference to this statistic.”

Dunn urges practice managers to look for costeffective diabetes solutions that will improve patient care and cut down on repeat visits and did-not-attends.

“This means looking again at the whole range, from equipment through to disposable items such as testing strips,” he says. As with anything, a good service is paramount – and with obesity prevalent among younger patients and diabetes on the increase, there is no time like the present to improve your practice’s service.

Younger people make up a quarter of those with diabetes yet have the highest risks of potentially preventable complications script file

A safe pair of hands “Our streamlined system has clinical safety checks embedded at every stage. Nothing is done without speaking to the patient and, if need be, the GP”

Phil Day Clinical pharmacist Pharmacy2U

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NHS mail order pharmacy Pharmacy2U is trusted by 300 GP practices to manage repeat medication for patients who choose to use its time-saving home delivery service.

It’s a responsible task, and the online pharmacy has developed a sophisticated system to ensure its service is safe and secure at every stage. For example, it can only request prescriptions for current medication and only on instruction by the patient. At the heart of the system is the company’s clinical pharmacist Phil Day, who checks many of the prescriptions received.

Regulated and secure Pharmacy2U is regulated by the General Pharmaceutical Council, like other pharmacies, so practices can be sure it is working to the highest standards. “However, unlike most community pharmacies, our system makes extensive use of technology which improves clinical safety in a number of ways,” says Phil. “For example, many prescriptions that have been authorised by a GP

come directly to us as an electronic message.”

This reduces the potential for error, as Pharmacy2U doesn’t need to re-input any information. “Our system also allows me to see the patient’s recent prescribing history, which is helpful when I’m checking the dosage and potential interactions,” comments Phil.

Authorised prescriptions are picked by one of the pharmacy’s dispensing robots, which use barcodes to identify the medication – reducing the potential for human error. Specially trained members of the dispensary team do a final check before the packaged medication is sent to the patient.

Three hundred GP practices currently use Pharmacy2U’s free prescription service, enabling patients to have their scripts dispensed without having to contact their GP directly or collect the paper prescription. Medicines are delivered free of charge to patients’ homes or workplaces. www.pharmacy2u.co.uk/practice

28

management | patient feedback

Know thy people Practices are under scrutiny. Events including the CQC, a patient participation DES, GP league tables and revalidation are upon us, and mean a practice manager has to think carefully about their relationship with their patients. JULIA DENNISON asks: how well do you know your public?

GP practices are businesses, despite being funded by public money. And just as a good business knows its customers, a good GP practice knows its patients. With the microscope focused on practice performance in the shape of CQC registration, new GP league tables, a patient participation DES and the revalidation of GPs by the GMC in 2012, not to mention the relaxation of practice boundaries in April, there is no time like the present to get to know your patients and make sure they are on your side.

practicES unDEr ScrutinY Changes to the NHS aside, GPs and their practices are under increased scrutiny – on both practical and clinical levels. The impending CQC registration will require all surgeries to operate at a certain standard. Despite the delay in deadline for most general medical services to April 2013, this remains imminent and practices are encouraged to consider health and safety and quality provision as early as possible to ensure they are in good stead for when the application process opens next year.

Another incentive to ensure your practice meets standards – both clinically and in terms of staff satisfaction – was the announcement by the government last month that it would be publishing GP league tables in a bid to raise transparency within the public sector and as part of its wider ‘Information Revolution’. august 2011 | practicebusiness.co.uk

The plan is for GP data to be published online by December (likely to be on the NHS Choices website, according to reports). Much like consumers shop for insurance on comparethe-market- style websites, patients will be able to compare practices on prescribing data, staff satisfaction and comparative clinical outcomes.

With this information at hand, patients will then have the power to vote with their feet from April 2012 onwards, when a relaxation (or abolition) of geographic practice boundaries is due to come into effect.

Clinical outcomes will be under fire further next year when the General Medical Council (GMC) plans to introduce medical revalidation, something often overlooked in amid the hubbub of NHS reforms. Anticipated to occur every five years, this new requirement is intended to ensure licensed doctors are fit to practice and will demand the collection of patient information.

patiEnt FEEDBacK But should GP practices wait until the revalidation demands it before patient feedback is taken seriously? Bob Marsh, director of Jayex says there’s no time like the present: “By continually monitoring real-time patient feedback, healthcare organisations can analyse performance on an on going basis, share best practice and

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transform services to specifically meet the needs of the patient.”

The NHS is so keen to get practices speaking to their patients that it is even incentivising practices to do so under a new patient participation-directed DES for the GMS contract.

Under the conditions of the new two-year directed enhanced services, worth £60m, practices must set up a patient participation group and undertake patient surveys annually to be eligible for payments of £1.10 per registered patient.

The survey for the DES must look at a broad range of areas, including convenience of access (opening times, booking ahead, ability to be seen quickly, telephone answering), patients’ experience of the treatment and service they receive, the surgery’s environment and other issues specific to each practice.

Participating practices must also consult their patients before making any significant changes to their services, including opening hours, and gain the patients’ formal approval.

With so many clear reasons for practice managers to proactively consider ways of gathering feedback from patients, acting now is a good option and there are easy, free ways of surveying your patient population – whether through free web services like SurveyMonkey or Google Docs.

Of course, not all of your patient population will be using the internet, so one option is to extend a self-service touch screen

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management | patient feedback

patient registration system in the reception area to undertake patient surveys.

These surveys can be completed anonymously if required to meet revalidation requirements, and practices can even monitor patients who have attended a specific doctor.

“Every modern business needs to be able to react fast to customers and leverage opportunities to achieve greater efficiency,” comments Marsh.

“In an increasingly patient-centric NHS, there is a clear need to improve understanding of the customer experience, from the difficulties of making appointments to feedback on the cleanliness of the waiting environment or a demand for specific local services.”

Encouraging participation Setting up a meaningful patient participation group, or patient reference group (PRG), can be an onerous process for those practices starting from scratch – though according to the National Assocation of Patient Participation (NAPP) four in 10 English practices already have one.

To meet the DES, practices have had to ensure the groups they form are an adequate demographical representation of the community. Certain groups are hard to reach, such as young people, who are often working and typically have ferwer reasons to visit the GP. Getting these groups to participate is no easy task, which is something Tom Kerr, practice manager of the Manor Street Surgery in Berkhamsted, found when he signed up to the DES this April. While he thought his patient participation group of around six people would be adequate, the PCT come back and said those six should be accompanied by a PRG of around 50 people (though the NAPP says the quoted membership of a PRG is nearer to 100 than 50) and the inner group would therefore meet and engage with the wider group via email.

Kerr has advertised for this PRG in the reception area and as we went to press only around 15-20 people had registered an interest, the majority of whom were elderly, which proves a problem if he is trying to meet any demographic targets. “We have one 33-year-old, no one disabled, and Berkhamsted is a very white, middle class, affluent town, which makes it quite difficult to get a real representation,” he explains.

“Hard-to-reach groups are by definition a challenge,” agrees Edith Todd, an NAPP trustee.

august 2011 | practicebusiness.co.uk

“Practices have to demonstrate how they have attempted to recruit within the practice and by outreach into community groups.”

Furthermore, just getting patients involved is rarely enough to get useful feedback. “Patient involvement as opposed to consultation is about meaningful purpose; clear frameworks of involvement; an understanding of the output required and the definition of success,” explains Sue Hodgetts, chief executive of the Institute of Healthcare Managers. Some practices she’s worked with have actually given patients training in how to effectively participate, which has included assertiveness training and an understanding of the systems they are asked to comment on.

For any practices in doubt, there is plenty of evidence that patient involvement improves the quality of service delivery at a practice and puts practices one step ahead of the plethora of standards they will be asked to meet in the near future. If you still don’t know your patients, never has there been a better time to get to know them and get to know them well.

Patient involvement, as opposed to consultation, is about meaningful purpose; clear frameworks of involvement; and an understanding of the output required

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32

management | MFM

Paul Lambden Dr Paul Lambden is a practicing GP and qualified dentist. He has been a GP for over 30 years, with over 20 in practice. He has previously worked as chief executive for an NHS district, LMC secretary, and special adviser to the Parliamentary Health Select Committee

august 2011 | practicebusiness.co.uk

Malignant melanoma

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: malignant melanoma A malignant melanoma is a skin cancer that is increasing in incidence in the United Kingdom. Indeed, over the last 25 years, it has risen more quickly than any other common cancer. It develops as a result of malignant change in melanocytes, which are pigment-producing cells in the basal layers of the skin that normally protect the skin from the damaging effects of ultraviolet radiation. Melanoma accounts for about 2,000 deaths a year and develops in about one in 10,000 of the population each year – 10,670 cases were diagnosed in 2007. Incidence is approximately equal in men and women.

Melanomas may occur on any area of skin and at any age, although they are rare in children. They become invasive after malignant transformation and they penetrate through the epidermis into the underlying tissue (dermis) and beyond.

Different types are recognised but essentially it depends on whether their growth is confined to the skin or they spread from their original site and whether they grow slowly or rapidly. Although usually occurring on exposed skin they can also develop on the palm, sole or under nails, in which case they are often recognised late, or occasionally in the eye, nervous system, lip, penis and the anal or oral mucosa. Once the tumour has reached beyond the skin, spread is through the lymph system to lymph nodes or in the blood stream. It is a dangerous cancer and survival depends on early diagnosis and effective treatment.

Some patients are at greater risk of developing melanoma. Having fair skin, freckles and red hair increases risk. Dark-skinned people are only rarely affected.

If an individual has more than one hundred naevi (moles), the risk of developing a melanoma is increased five to 10 times. Sun exposure increases risk and it appears that childhood exposure and short, severe episodes of exposure are more dangerous. Sunbed use may also increase risk. The chance of developing a melanoma is increased by having a first degree relative with the disease.

The recognition of possible malignant change is crucial to minimise the risk of spread. There has been much patient education and aide-memoires to help in recognising the change.

Things to look out for include: n change in size or shape over weeks or months, and if the lesion

is greater than 7mm in diameter n change in colour with irregular pigmentation and different shades of colour n change in outline, often sharp but irregular (like an island on a map) n itching and bleeding n inflammation and oozing.

practicebusiness

None of these changes is pathognomonic (entirely reliable as an identifier of disease).

Investigation and diagnosis of melanoma is principally by visual inspection and excision of the lesion for histological diagnosis. Any pigmented lesion that is excised should be sent for histology. If a melanoma is suspected, clinical removal in primary care should be avoided. Normally they are excised with a wide margin of apparently healthy skin to minimise the risk of recurrence. If the patient has evidence of spread of the disease, they should of course be managed by a specialist oncologist.

Treatment of malignant melanoma beyond local wide excision is disappointing and, in advanced disease, no form of treatment has really shown any significant effect on survival. Where the tumour has spread chemotherapy has at best a marginal effect on disease progress and survival. Radiotherapy has little effect on most types and locations of melanoma. Sometimes the removal of a single metastasis in someone who has been free of the disease for a long time may be beneficial. Only in specific individual cases does any intervention make a significant difference to the progress of the disease. Survival rates for women seem to be rather better than for men.

Prevention is particularly important, given the disappointing results that accompany late diagnosis and frequently rapid spread of the tumour. Avoidance of excessive sun exposure may be of some importance in avoiding melanoma and protects against other forms of skin cancer too. Of most importance is avoidance of sun exposure without high factor protection and actual sunburn. It is advised that sunbeds should be used with caution or avoided, particularly in individuals with multiple naevi, pale skin and red hair. Advice on skin monitoring is also essential, particularly in vulnerable people and those with family history.

Vigilance is the watchword for this dangerous cancer if the inexorable increase in the disease is to be avoided.

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34

Work/life | diary

Practice diary Michael Wright Michael Wright is practice manager at the Whyburn Medical Practice in Nottingham and sits on the board of Nottingham North and East (NNE) clinical commissioning group

If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk august 2011 | practicebusiness.co.uk

Practice Business welcomes a different columnist each month to share their experiences and provide their view from the practice manager’s desk.

THIS MONTH: Michael Wright discusses working together for the greater good We all know that practices work differently but we all exist to deliver high-quality healthcare to our patients.

So as a practice manager how do you know if you’re doing your job properly? Take the common saying, “You don’t know what you don’t know”, but isn’t that scary in a role where the parameters change all the time and the demands on the service are transient and many?

A positive consequence of the white paper is to encourage practices to group together and work on shared aims.

I am on the executive board of Nottingham North and East (NNE) clinical commissioning group and we work hard to support practices to thrive. It is in our interests to help all our practices for the greater good of the population we serve and we put emphasis on fostering a true community feel within our member practices.

We are working on measuring practice performance in a number of areas that NNE can use as a means to get a snapshot of how each member practice is performing and us practice managers can utilise as a supportive tool to help managers to compare themselves with their peers. We all sometimes wonder what is ‘normal’ for our size of practice, and this scorecard would help managers old and new to get to grips with the many vagaries of our job as it provides a multi-factorial look at what it takes to run a practice.

NNE has started locality groups of practices working on commissioning priorities but also helping to inform the commissioning agenda with a ‘bottom-up’ approach involving those at the front line including patients themselves. This helps us to do our day-to-day jobs with peer review of referrals and prescribing thus helping with the new QOF indicators. This is a very different relationship to the ‘top-down’ approach that many of us experienced with the primary care trusts.

I feel that as practice managers we should understand our business; Tesco knows how many tins of beans it has sold at any given time and when. We should know who and how many we’re referring, what our capitation changes are and what influences that, the peak times for the phones to ring, when people tend to ask for visits and how many requests we are getting etc. In short, we should know the ins and outs of our practices to ensure that we can serve our population looking at our provision intelligently.

We can compare with our neighbours and use this for discussions that can then help us redefine how we work and improve our standards of care.

As a practice manager I see the need for us to pull together for the greater good in what are challenging times so here’s sending a virtual group hug! It can be a lonely job so let’s look out for each other.

For practices, splendid isolation is definitely not splendid!

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