Practice business December 2011 by Intelligent Media Solutions

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december 2011

Let the right ones in Why practice managers should be on the CCG board

Help at hand?

A look at the DHâ&#x20AC;&#x2122;s draft plans for commissioning support

Get CQC ready

Pilot practices give their registration advice

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FLU & YOU

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Sanofi Pasteur MSD supporting you, supporting them. ABRIDGED PRESCRIBING INFORMATION Inactivated Influenza Vaccine (Split Virion) BP. Refer to Summary of Product Characteristics for full product information. Presentation: Inactivated Influenza Vaccine (Split Virion) BP contains 15 micrograms of antigen (per 0.5 millilitre) from each of the three virus strains recommended by the World Health Organisation for the present influenza season. It is supplied as single dose prefilled syringes each containing 0.5 millilitre of suspension for injection. The vaccine contains traces of neomycin, formaldehyde and octoxinol 9. The vaccine virus is propagated on eggs. Indications: Prophylaxis of influenza especially in those who run an increased risk of associated complications. Dosage and administration:

Adults and children from 36 months should receive one 0.5 millilitre dose. In children aged 6 months to 35 months clinical data are limited and dosages of 0.25 or 0.5 millilitre have been used. Children who have not been previously vaccinated should receive a second dose of vaccine after an interval of at least 4 weeks. Doses should be administered intramuscularly or deep subcutaneously. Contraindications: Hypersensitivity to the active substances, to any of the excipients, to eggs, chicken protein, neomycin, formaldehyde, and octoxinol 9. Immunisation should be postponed in patients with febrile illness or acute infection. Warnings and precautions: Do not administer intravascularly. Medical treatment should be available in the event of rare anaphylactic reactions following administration

of the vaccine. Immunosuppressed subjects may not produce adequate antibodies. Other vaccines may be given at the same time at different sites, however adverse reactions may be intensified. Pregnancy and lactation: The use of this vaccine may be considered from the second trimester of the pregnancy. For pregnant women with increased risk of complications from influenza, vaccine is recommended irrespective of their stage of pregnancy. May be administered during lactation. Undesirable effects: Common side effects include: injection site reactions (redness, swelling, pain, ecchymosis, induration) and systemic reactions (fever, malaise, shivering, fatigue, headache, sweating, myalgia, arthralgia). These usually disappear within 1 to 2 days. Other serious side effects have been reported and

include, allergic reactions (in rare cases leading to shock, angioedema), convulsions, transient thrombocytopenia, vasculitis with transient renal involvement and neurological disorders such as encephalomyelitis, neuritis and GuillainBarré syndrome. 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 £6.59; packs of 10 single dose prefilled syringes, basic NHS cost £65.90. Marketing authorisation holder: Sanofi Pasteur MSD Limited, Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP. Marketing authorisation number: PL 6745/0095. Legal category: POM. Date of last review: July 2007.

08/11

Editor’s letter EXECUTIVE EDITOR roy lilley www.roylilley.co.uk EDITOR julia dennison julia.dennison@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER george petrou george.petrou@intelligentmedia.co.uk ACCOUNT EXECUTIVE gabriele zaccaria gabriele.zaccaria@intelligentmedia.co.uk PUBLISHER david collingbourne david.collingbourne@intelligentmedia.co.uk DESIGNER sarah chivers sarah.chivers@intelligentmedia.co.uk PRODUCTION ASSISTANT sinead coffey sinead.coffey@intelligentmedia.co.uk CIRCULATION MANAGER natalia johnston natalia.johnston@intelligentmedia.co.uk

Buying time

Care Quality Commission – remember those three words? With the deadline extended by a year, it’s unsurprising many of you have put CQC registration to the bottom of the to-do list, something to be picked up after you deal with the long list of other pressing issues overcrowding your in-tray. However, a deadline extension can be a blessing and a curse, because while it buys you more time and promises a more simplified application process, it can also mean a loss in momentum. Luckily, CQC registration doesn’t seem like something that will fall too far above and beyond your normal call of duty, and many of the tasks you do for QOF will help you meet the CQC criteria. The Family Doctor Association, which sits on the CQC stakeholder group, has assured its members that the vast majority of practices will have no problem with registration and that the CQC is more interested in systems and outcomes than processes. Also, if you don’t have time to deal with it yourself, remember the registered manager does not have to be the practice manager – it can be a GP partner too. As of now, no NHS organisation has been prosecuted for breach of contract or not being compliant, so, says the FDA, if you haven’t started reading the documentation, don’t – that is unless you’re worried. But who isn’t worried a little bit? It’s natural for your average practice manager to be concerned with ensuring their practice meets standards. With this in mind, we take the time to find out about the process from a practice manager and experts in their field who have already had experience completing the application form for other healthcare providers (see p32). Their general recommendation is that while it’s nothing to worry about in principle, it’s still worth getting your house in good working order. But that can wait until the New Year, because as you read this, Christmas will be just around the corner. Here’s wishing you a very merry Christmas and a happy New Year. See you in 2012!

editor

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P.12

Contents SECTOR 08

news Top news for practice managers this month

executive editor comment The latest from controversial columnist Roy Lilley

COMMISSIONING 12

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

comment A system of support? Roger Hymas looks at DH’s draft plans for commissioning support and why we should be looking to the US for guidance

case study A sweet pill to swallow The London Borough of Bexley has a forward-thinking approach to diabetes commissioning

comment A universal plan One PM’s perspective on why practice managers aren’t involved enough in commissioning and how that can change.

PEOPLE 26

interview Ask me if I care Practice manager Andy Haigh takes a big-picture approach to care planning at the Holycroft Surgery in West Yorkshire

MANAGEMENT 32

update CQC ready? Experienced practice managers give their CQC registration advice

clinical MFM This month: Pneumonia

WORK/LIFE 38

leadership

top tips

Taking the lead Advice on how to be a strong and charismatic leader Patient communication How to reach hard-to-reach patients

diary Debbie Gladwell tells a tale of security screens

Happy Christmas!

JANGRO

Here’s to a healthy 2012 with Jangro hygiene and infection control products – 41 local members delivering daily across England, Scotland, Ireland and the Isle of Man. 0845 458 5223 | www.jangro.net

microtest

Microtest would like to thank our customers for their support in 2011 and wish you all the best for 2012.

labcold

Labcold wishes everyone greetings of the season and a Happy New Year!

PELICAN

Pelican Feminine Healthcare would like to thank all PELIspec users for your continued support during 2011 and wish you all a merry Christmas and prosperous 2012.

williams

Merry Christmas to all practice managers! Call us for an equipment quote and you could win an Apple iPad 2.

olympus

Olympus would like to thank all Practice Business readers for your continual support throughout 2011 – and wishing you all a very Merry Christmas and Happy New Year.

sector

Practice manager salaries experience year-on-year growth Practice managers have experienced a three per cent pay increase over the past year, with larger practices paying more and many partners choosing to reward their managers in bonuses, a survey has shown. The research assessed over 1,100 UK practices and found that the average practice manager’s salary grew to £39,060 in 2011 from £37,800 in 2010. Greater London remains the highest paying region in the UK with average total earnings of £43,580 and nearly 71% of managers earning £40,000 or more. Scotland and Northern Ireland were the lowest paying regions, with average total earnings of £33,125, although they also have the most small practices in the UK, with 41% having fewer than 5,000 patients each. The number of practice manager bonuses, which had been in steady decline since 2007, has surged by 14% this year due to practice partners preferring to give a bonus to a raise. “Although the data shows that average practice manager salaries increased in 2011, a significant number of managers reported zero payrises for themselves and for their staff,” commented Steve Morris of First Practice Management, which conducted the study. “There is evidence that some practices are cutting back on their staff either Key Points through redundancies or  The average practice manager via natural wastage and salary is £39,060 that they are looking at  Most London-based practice other ways to save costs, managers earn over £40,000 such as revising staff  Scotland and Northern Ireland pay the least with an average sick pay schemes [and] PM salary of £33,125 per annum enforcing reductions in... working hours.”

NI practices extend services

your monthly industry lowdown

news

A review of health services in Northern Ireland is to recommend that GP practices offer more services for patients in the community to avoid costly treatment at hospitals. Undertaking the review, Dr Ian Rutter, a Yorkshire-based GP and former clinical advisor to the Department of Health, encouraged GPs in NI to develop specialisms wherever possible, which is something he’s done at his practice in Shipley, near Bradford, where extended services include dermatology, cardiovascular and geriatric clinics. Dr Rutter said rolling out a similar model in Northern Ireland could take two to three years to allow for GPs to gain the necessary expertise, but would be worth the wait. “I do think [GPs are] going to enjoy working in an environment like this because you are not endlessly dealing with people who keep coming back because the system is failing them,” he told the BBC. However, the BMA says practices should not expect extra funds to undertake the project.

december 2011 | practicebusiness.co.uk

Patient premium to mean less funding? The government and the General Practitioners Committee (GPC) have entered discussions to assess potential changes to the current system of GP practice funding. A rewrite of the Carr-Hill formula could see funding for GP practices vary by up to a third following new proposals to channel more capital into deprived areas, Pulse reports. The alterations to the current system could see some ‘overfunded’ practices have their income lowered and redistributed to subsidise ‘underfunded’ practices – in some cases by up to 30%. The GPC said they would consider supplementing deprived areas but would be “very careful” about the conditions and modelling of the arrangement. The move follows the Liberal Democrats’ pledge to encourage GPs to work in deprived areas through what they referred to as the “patient premium”.

SECTOR | news

clinical news New GP contract announced

A new GP contract has been announced, indicating higher standards, increased patient choice and a pay freeze for practicing GPs over the next year. Under the new GMS contract, practice boundaries will be relaxed to give patients more ﬂexibility over which GP treats them. Patients will be given the option “when clinically appropriate” to remain with their GP even if they move outside the remit of the practice. Stephen Golledge, lead negotiator for NHS employers, stated: “These changes to the GMS contract put a strong emphasis on improved patient care, greater choice for patients and value for money for the NHS. “This agreement will help in addressing the ﬁnancial challenges faced by the wider NHS but not at the expense of services for patients. The choice of GP practice pilots will also allow us to explore the best way for patients to access the services provided by GPs.” Furthermore, under the new arrangements and despite the GP pay freeze, the GMS contract will be uplifted by 0.5% to help meet the costs of increased practice expenses including pay increases for employed staff with a full-time equivalent salary of less than £21,000. Health Secretary Andrew Lansley described the new contracts as “a good deal for GPs, a good deal for patients and a good deal for the NHS”. Key Points The new contract also incorporates several  The GMS contract will be changes in the Quality and outcomes Framework uplifted by 0.5% to help (QoF) including the controversial quality and meet the costs of increased productivity indicators on prescribing that are to be practice expenses including replaced with a number of new indicators to persuade pay increases for employed GPs to reduce unnecessary accident and emergency staff with a full-time equivalent attendance. osteoporosis and peripheral arterial salary of less than £21,000 disease have been added as new disease areas to the  Lower thresholds for QOF QoF, while the clinical DeS funding for alcohol and indicators that are currently learning disabilities services has been extended a 40% are to be raised to 50% further year. In addition, all lower thresholds for QoF  Any indicator with an upper indicators that are currently 40% are to be raised to threshold of 70-85% will now 50%, while any indicator with an upper threshold of have a lower threshold of 45%. 70-85% will now have a lower threshold of 45%.

They said…

“”

“Given the complexity and uncertainty of the environment in which we are operating, this performance record is impressive: a testament to the commitment and professionalism of managers and clinicians across the NHS” NHS chief executive Sir David Nicholson on the publication of the new 2012/13 NHS operating framework

Antibiotics Ninety-seven per cent of patients who ask their GP for antibiotics get them, despite evidence that excessive use could lead to the general population resisting the drugs, according to the Health Protection Agency. Twenty per cent of adults visited their doctor with a recent respiratory tract infection, such as a cough, cold, ﬂu or sore throat, and half expected to be prescribed antibiotics for their illness.

Flu vaccine Nearly three times as many frontline NHS staff in England have been vaccinated against ﬂu compared with the same time last year, according to the Department of Health. Experts were conﬁdent that more healthcare professionals would be vaccinated this year than last. “Flu caused over 600 deaths last year and people with poor health are at greatest risk, including NHS patients,” said Dean Royles, director of the NHS Employers. “This is why it is essential to get as many staff as possible vaccinated.”

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 RECRUITING, SELECTING AND INDUCTING NEW STAFF

fact

Practice admin staff play a key role in ensuring patients get the right treatment. Receptionists and administrative staff play “important hidden contributions” in the process of repeat prescriptions, concludes a study by the BMJ. Despite electronic health records, staff often have to use “practical judgments” to ensure safety reliability of repeat prescriptions.

MDDUS Glasgow Ofﬁce 12 January

DELIVERING QUALITY IN PRACTICE

Aston Villa Football Club, Birmingham 19 January

practicebusiness.co.uk | december 2011

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

Is big beautiful?

With 25 quid-a-head commissioning budgets, Roy Lilley waves goodbye to smaller CCGs

The operating framework in less than the 140 characters allowed in Twitter: “More of the same, with less” december 2011 | practicebusiness.co.uk

Well, it’s out. It’s arrived. I doubt if any of you queued up outside the Department of Health waiting for its publication. It’s hardly Harry Potter and it’s not an Xbox, but it is important. The operating framework for next year has just been published. It is the route map, the plan and the direction the NHS will follow – and is a bodice-ripper if ever there was one. The truth is, if you didn’t know it was this year’s, you could be forgiven for thinking it was last year’s. Can I describe it in the 140 characters allowed on Twitter? (I don’t even need that many.) “More of the same, with less”, is all I need to say. Another year of austerity. Another year in which the NHS will improve services for old people, young people, tall people, short people. People in hospital, out of hospital, at home. Whatever you’ve got, wherever you are, it will be better – with less money. Thanks a bunch. There is one little nugget; one little factette that caught my eye: clinical commissioning groups can expect funding to the tune of £25 per head of population. That’s the money they will have available to run the show. It sends a message. Loud and clear, it says: “Small CCGs are not required, thank you.” You can’t run a five-practice CCG with 25 quid a head. The £25 limit says: forget the bridgeclub-sized CCGs; forget shaping services around the Masonic Lodge, the rugby club or your mates. Twenty-five-quid-a-head doesn’t get viable until you are looking at a population base of 250,000 and commissioning with balanced risk doesn’t work under about 300,000. In fact, if we learn the lessons from Denmark, half a million is about right. Boutique commissioning groups are out. Welcome to the big new world of industrial commissioning – about as far removed from the original idea as you can get.

hepatitis B how high are their chances? Hepatitis B is a serious, highly infectious disease.1,2 Some lifestyles, occupations, medical conditions, and having close household contacts or family with the condition can increase the chances of infection with hep B, which is why the Department of Health recommends vaccination for these groups.2 HBvaxPRO® offers effective, simple-to-administer protection against hep B and is reimbursed for all at-risk patients.3,4

Hepatitis B Vaccine (rDNA) ABRIDGED PRESCRIBING INFORMATION HBvaxPRO® suspension for injection. Hepatitis B vaccine (rDNA) Refer to Summary of Product Characteristics for full product information. Presentations: HBvaxPRO 5 micrograms, HBvaxPRO 10 micrograms and HBvaxPRO 40 micrograms are suspensions of hepatitis B surface antigen (prepared from yeast cells by recombinant DNA technology) adsorbed onto amorphous aluminium hydroxyphosphate sulphate. HBvaxPRO 5 micrograms is available as a 0.5 millilitre single dose prefilled syringe with two separate needles. 0.5 millilitre contains 5 micrograms of recombinant hepatitis B surface antigen. HBvaxPRO 10 micrograms is available as a 1 millilitre single dose prefilled syringe with two separate needles. 1 millilitre contains 10 micrograms of recombinant hepatitis B surface antigen. HBvaxPRO 40 micrograms is available as a 1 millilitre single dose vial. 1 millilitre contains 40 micrograms of recombinant hepatitis B surface antigen. Indications: For active immunisation against infection caused by all known sub-types of hepatitis B virus in subjects of all ages considered at risk of exposure to hepatitis B virus, or predialysis and dialysis patients. Dosage and administration: In neonates and children (birth through 15 years of age) 0.5 millilitre of HBvaxPRO 5 micrograms

– why let them take a chance?

should be given by intramuscular injection. In adolescents and adults (16 years of age and over) 1 millilitre of HBvaxPRO 10 micrograms should be given by intramuscular injection. In predialysis and dialysis patients, 1 millilitre of HBvaxPRO 40 micrograms should be given by intramuscular injection. In neonates, infants and young children, the anterolateral thigh is the preferred site of injection. In older children, adolescents and adults, the deltoid is the preferred site of injection. Before use the vaccine should be shaken to obtain a slightly opaque white suspension. A course of vaccination should include at least three doses given at least one month apart. Vaccination schedules vary and local guidelines should be consulted; for HBvaxPRO 5 micrograms and HBvaxPRO 10 micrograms, common schedules include vaccination at 0, 1 and 6 months or at 0, 1, 2 and 12 months. In immunocompetent vaccinees the need for booster doses is not yet defined. However, some schedules recommend periodic booster doses. For immunocompromised vaccinees a booster dose should be considered if the anti-HBs level is less than 10 International Units per litre. For HBvaxPRO 40 micrograms, the recommended vaccination schedule is 0, 1 and 6 months. A booster dose must be considered if the anti-HBs level is less than 10 International Units per litre. Contra-indications: Hypersensitivity to the active substance or any of the excipients.

Vaccination should be postponed in individuals with a severe febrile illness or acute infection. Warnings and precautions: Appropriate medical treatment should always be readily available in case of rare anaphylactic reactions following the administration of the vaccine. Vaccination may not be successful in patients who are in the incubation phase of hepatitis B infection at the time of vaccination. The vaccine will not prevent infection caused by other agents such as hepatitis A, hepatitis C and hepatitis E. Hypersensitivity reactions to formaldehyde and potassium thiocyanate used in the manufacturing process may occur. Use caution when vaccinating latex-sensitive individuals since the vial stopper contains dry natural latex rubber that may cause allergic reactions. HBvaxPRO 5 micrograms: The potential risk of apnoea and the need for respiratory monitoring for 48-72 hours should be considered when administering the primary immunisation series to very premature infants (born ≤ 28 weeks of gestation) and particularly for those with a previous history of respiratory immaturity. As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed. Pregnancy: Do not use unless the anticipated benefit outweighs the risk to the foetus. Breastfeeding mothers: The effect on breastfed infants has not been assessed. Undesirable effects: Common side effects include: transient soreness, erythema and induration

at the injection site. Very rarely, serious side effects have been reported although in many cases causality has not been established. These include thrombocytopenia, serum sickness, anaphylaxis, paralysis (Bell’s palsy), peripheral neuropathies (polyradiculoneuritis, facial paralysis), neuritis (including Guillain Barré Syndrome, optical neuritis, myelitis including transverse myelitis), encephalitis, demyelinating disease of the central nervous system, exacerbation of multiple sclerosis, multiple sclerosis, seizure, bronchospasm-like symptoms, erythema multiforme and angioedema. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic NHS cost: HBvaxPRO 5 micrograms, 0.5 millilitre single dose prefilled syringe with two separate needles, basic NHS cost £8.95; HBvaxPRO 10 micrograms, 1 millilitre single dose prefilled syringe with two separate needles, basic NHS cost £12.20; HBvaxPRO 40 micrograms, 1 millilitre single dose vial, basic NHS cost £27.60. Supplier: Sanofi Pasteur MSD Limited. Their address is Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP Marketing authorisation number: EU/1/01/183/024 (HBvaxPRO 5 micrograms) EU/1/01/183/028 (HBvaxPRO 10 micrograms) EU/1/01/183/015 (HBvaxPRO 40 micrograms) Legal category: POM. ® Registered trademark. Date of last review: June 2011

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291. References: 1. WHO/CDS/CSR/LYO/2002.2: Hepatitis B 2. Immunisation against Infectious Disease. Chapter 18: Hepatitis B chapter, updated November 2009. Department of Health. www.dh.gov.uk/en/Publichealth/ Healthprotection/Immunisation Greenbook/ DH_4097254 Accessed October 2011 3. HBvaxPro® Summary of Product Characteristics 4. NHS Business Services Authority at: www.nhsbsa.nhs.uk/ Prescription Services/933.aspx Accessed October 2011 UK15324g 10/11

Commissioning

Empowering practice managers in CCGs

Small CCGs ‘not viable’ Clinical Commissioning Groups with populations of fewer than 100,000 patients have been deemed unviable by a Clinical Commissioning Coalition report, which recommended that larger CCGs could delegate authority to smaller groups. The report, by the recent NHS Alliance and the National Association of Primary Care partnership, explained that a CCG of that size would be too small to act independently under its own management team and fulfil its statutory functions. The research was based on the potential budgets of CCGs covering populations of 50,000, 100,000 and 300,000, with a running cost allowance of £25 and £30 per patient head. The coalition stated that “to maintain a sense of localness for the clinicians forming the group, whilst having a critical mass for managing clinical and financial risk, organisations will need to have a population base of at least 100,000”.

It said that smaller CCGs may be “stifled” by the running and administrative costs, but encouraged larger CCGs to delegate some responsibility to smaller groups. “Localism, flexibility and identity are critical,” so larger CCGs may want to delegate authority to sub sets within the CCG, said Julie Wood, national director of the NHS Alliance. “This is work in progress and the paper will be refined following discussions with a number of CCG leaders… We need to look at a number of models CCGs of different sizes could use, such as incorporate delegated budgets for prescribing, community services and acute services,” she added. A meeting of a small group of CCGs has been scheduled for 14 December and a revised paper will be published for wider discussion, with a view to complete the work by the end of January 2012.

commissioning in context

CCGs push for reduced referrals GPs in one CCG have been told to try and limit patient referrals to secondary care down to four per week as part of a scheme to reduce costs and patient numbers within NHS hospitals. The information was revealed by an investigation by Pulse, which also reported that a separate CCG is restricting GPs’ physiotherapy referrals, while a third group is caught in a debate over the limitations on surgery for smokers and the obese. The potentially erroneous restrictions on practices emerged just one week after the chair of the General Practitioners Committee (GPC), Dr Laurence Buckman, warned that some CCGs were trying to enforce “untried and unacceptable measures to micromanage practices”.

“”

december 2011 | practicebusiness.co.uk

Dr Sarah Heyes, a CCG clinical director and GP in Wanstead, said: “Each practice has been allocated a fixed amount of money from which the price of a first referral is averaged out. Obviously cardiology is much more expensive than, say, dermatology, but we average it and then work out the number of referrals allowed per year per GP. “In our practice’s case, it came up with the figure that I was allowed four referrals a week. To be honest, I had sleepless nights and was quite panicked, thinking it would restrict my practice as a GP.” Dr Heyes added that the target given by the CCG had not stopped her making necessary referrals and had made her “more aware of the numbers”.

They said… “The year-long cover-up is a disgrace, especially when doctors, nurses, patients groups and the public are all so worried about the Tories’ NHS plans. The commissioner’s report is a demolition job of Lansley’s attempts to keep the truth from the public” John Healey, Labour’s ex-shadow health secretary, on the Information Commissioner ordering Health Secretary Andrew Lansley to release a document outlining the risks associated with the health bill

Practice insight

CCGs to go private on back-office functions

“EMIS Web is a very flexible system. There are so many different ways to use it”

Kate Jacques This month we talk to Kate Jacques about how EMIS Web is making life easier for staff at the Rendcomb surgery near Cirencester

Photo: BMA on Flickr

The BMA Council has requested an urgent meeting with Health Secretary Andrew Lansley to discuss concerns over the government’s commissioning plans, which it says are likely to lead to support services for clinical commissioning groups in England being provided solely by large commercial organisations after 2016. Draft guidance from the Department of Health – ‘Developing commissioning support: Towards service excellence’ – makes a number of recommendations about how CCGs should function, including how they should access technical and “back-office” support to help with things like analysing population data. Current primary care trust clusters are forming commissioning support units and, from 2016, would be encouraged to form social enterprises and partner with the private sector, rather than remaining part of the NHS family. Commercially-focused criteria to determine eligibility for providing commissioning support would also be introduced, which the BMA says would make CCGs having their own, in-house support staff “almost impossible”. Dr Hamish Meldrum, chairman of BMA Council said: “A key plank of the government’s NHS reforms was to entrust GPs and other health care professionals to lead on the commissioning of services for patients to ensure local health needs were met. “These latest proposals from the government have the potential to seriously undermine this role, restricting the freedom and independence that clinically-led commissioning groups need to make locally sensitive, locally accountable, patient-focused decisions,” he continued. “Doctors tell us about the chaos they are already seeing on the ground as more and more change is implemented. The government should be focusing on ensuring the skills and experience of staff in current PCT clusters are retained. They will be invaluable in supporting the development of CCGs and providing much needed continuity during this period of huge financial pressure and structural overhaul. “We will be urging CCGs to urgently review and, where necessary, change their structures to ensure they are able to fulfil their statutory functions without becoming dependent on external commissioning support.”

Making QOF simpler

www.emis-online.com

Staff at a small dispensing surgery near Cirencester are finding life easier since switching to EMIS Web. Kate Jacques, practice manager at the Rendcomb surgery, says consultations, data searches and QOF claims are streamlined because EMIS Web is so flexible and user-friendly. “It’s modern, and for anyone who is used to a Windows-based system, it’s very natural. With EMIS Web, it’s so easy to create templates and it has made search and reports quicker,” she explained. “It is a very flexible system. There are so many different ways to use it; practices can set up systems that work for them.” Since the 3,500-patient surgery went live with EMIS Web in August, its three GPs have been reaping the benefits. “They love the Zap – the QOF alert that prompts them if there are any outstanding actions and brings up the relevant templates, to make QOF claims simpler,” said Jacques. The GPs are also finding consultations smoother, because EMIS Web makes it easier to review the patient’s past and current medical history at the click of a mouse. “It is easy to search and filter information on an individual problem, and GPs can filter their own consultations. It has got to improve patient care,” added Jacques. Her verdict? “Switching to a new system has been challenging, but EMIS has been very supportive. The training was fantastic and the operations manager has been readily available for advice since we went live.”

COMMISSIONING | analysis

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

Honourable intentions

Roger Hymas

Or why we need more of them

Roger Hymas looks at whether the DH’s draft plans for commissioning do enough to help CCGs get statutory status and why we should be looking to America for inspiration

december 2011 | practicebusiness.co.uk

We’re practically at the end of the year. How was it for you? Somehow, I’m feeling rather glum, but maybe it’s because I’m the eternal optimist, a glass-halffull kind of person, and I had high hopes that 2011 would be a breakthrough year, one that we’d always remember as the starting point of something really big and worthwhile happening for the NHS. But, here we are at the end of the year and my impression is that we spent the time not making any meaningful progress. It’s my job in Practice Business to look at the strategic aspects of commissioning – to anticipate how the 2010 white paper (doesn’t it seem so long ago and so full of promise?) would move through stages, become a bill, then an act and lead us to a fundamentally different brave new world of GP-led commissioning. But what I observe at present is commissioning falling between the cracks of the old PCT system, which is disintegrating, and the GP-led version, which is a long way off being properly formed. The consequence, and it’s a very dangerous one in my opinion, will be that, for some time yet, the controlling influence in the NHS will continue to be the acute trusts, which will have the largest, disproportionate influence over care design, delivery and finances. These are big businesses that need to keep growing their incomes; it’s not unreasonable for their senior management to be ambitious for their organisations. However, from the commissioner’s perspective, I don’t see how it’s possible to maintain cost control and improve care design if you don’t have adequate commissioning, contracting and performance management processes. If not, acutes stay in the dominant position and the real losers in this scenario will be the patients of community care and mental health organisations as the money is gobbled up by their sophisticated FT colleagues. I know I’ve been harsh on PCTs for their lack of rigour and professionalism in pursuing the commissioning agenda, but PCTs were getting better – a lot better – before the decimation and

COMMISSIONING | analysis

clustering that has taken place in the past year. We now face a situation where, as we go into the 2012/13 commissioner/provider contracting season, we’ll be in a worse state of negotiating equilibrium than last year, in fact any year since 2006/07 when PCTs were invented. This will mean that powerful provider interest will largely maintain its grip in local healthcare ‘markets’. Let me give you just one small example. Last year’s DH contract guidance made a plea that GPs should be involved in the annual contracting process. This year, they have been told to lead it. I’d like to ask you: How many of you in GP practices and CCGs have been involved over the past couple of months in developing your local ‘commissioning intentions’ for 2012/13? These set out the local framework for the next NHS financial year, establish the commissioning priorities and start to lay down the rules of engagement ahead of the contracting round. They are also intended to get stakeholder feedback – information from the local authority, voluntary organisations, the public and patient groups – on what is good and bad in the local provider scene and how improved contracts, signed next March, can get the best out of the resources available. Putting commissioning intentions into the public domain is also a practical demonstration of the transparency that is a major feature of the 2010 white paper. I write this article at the beginning of November, but as I Googled “commissioning intentions 2012/13”, I didn’t find more than a handful of recent references to the subject. Arguably, there should have been a minimum of 51 – for all ‘clustered’ PCTs – and a maximum of 152, representing the original number of PCT organisations. If these programmes had been executed – and they are an essential part of any commissioner’s patient and public engagement programme – they should by now be within the view of the eagle eye of Google. There are, however, some examples of excellent commissioning intentions initiatives out there on the internet. Full marks go to Kingston – one of my favourite PCTs for a long time. The Kingston CCG got its commissioning intentions out as early as October. (Take a look at: http:// www.kingstonpct.nhs.uk/Downloads/KCC%20 papers/4%20October%202011/Att%20D%20-%20 KCC%20Commissioning%20Intentions%20-%20 working%20draft%20_2_.pdf.) I think the 21-page document is a beacon in what seems otherwise to be a very dark, empty commissioning landscape. Hats off

practicebusiness.co.uk | december 2011

COMMISSIONING | analysis

as well to Oldham and Croydon (in the same London cluster as Kingston). But, at the time of writing, that’s just three out of 51 PCT clusters across more than 250 CCGs. The situation must be better than what I’m seeing and I’d be relieved if you could put me right and confirm all of your GP practices are now engaged in the 2012/13 commissioning/contracting programme. Perhaps a lot more CIs will flood onto the internet before you read this piece. I hope so, because if the annual commissioning and contracting round doesn’t get off on the right footing, it doesn’t tend to get better – a belief that comes from my experience of working with upwards of 30 PCTs over the past five years. Kingston PCT was always progressive and so will be its CCG. I’d commend other pathfinders to keep an eye on their progress. Not only were (it’s weird to be using the past tense) they always strong with their commissioning intentions, but there was a follow-through with provider performance management. Here was a PCT that really started to challenge the local trust over its numbers and pushed for greater efficiency and effectiveness. I’m not up-to-date with what’s been happening with the local commissioner/hospital relationship but clues are given in an article I found on Google that shows that there has been a real local tussle – http://www.surreycomet.co.uk/news/threat_to_kingston_hospital/8090224. Kingston_Hospital_wins___2m_funding_battle/, which brings me to my hobby horse of commissioning support for CCGs. The conclusion I’m reaching is that commissioning practice development is not getting that much airtime from most GP practices. This will mean that in the same way many GPs delegate practice management to expert dedicated help, we will see the same happening for CCG commissioning. A lot of guidance has come out of the Department of Health in the past couple of months about how commissioning support should be organised. Unfortunately, it’s the usual laissez-faire kind of stuff from the DH, which always seems happier avoiding the need to be prescriptive and lay down the law about how commissioning should be delivered. What we are seeing at present is a range of discussion documents, where CCGs, PCTs and the NCB can all consider a range of options, rather than any real action. I’m sorry but I don’t think we’ve got the time to do this; the urgent need is for commissioners to get in control of all the financial risks in the system as soon as possible. As I’ve made the point, you start doing this with commissioning intentions and you then take the output of this consultation to create strong contracts that you then enforce and performance manage. After all, this is a £60bn market, which makes it about the size of Tesco’s UK turnover. Can you see Tesco asking branches how they want to work things out for themselves? I’ve made the point continuously over the past 12 months about how commissioning is one of the densest and most complicated of all industrial practices. Certainly, I think it’s infinitely more complex – and more dangerous – than running Tesco. Some research work carried out by West Midlands SHA in 2008 is worth quoting: ‘The best American commissioning groups have concluded that healthcare is far more complicated to purchase than anything – mainframe computers, aircraft, telecoms, you name it.’ Dr Johnny Marshall, chair of the

The urgent need is for commissioners to get in control of all the financial risks in the system as soon as possible december 2011 | practicebusiness.co.uk

COMMISSIONING | analysis

NAPC, recently made the point that it was so important that the world should be scoured for the best solutions for CCG commissioning. So, where do you find the best help? I’ll have to whisper this: the US healthcare industry. There you will find a vast number of organisations that have taken all aspects of care commissioning to what can be truly defined as state-of-the-art industrial performance – check out Kaiser Permanente, WellPoint or Humana, for example. You get lots of clues from their websites about how they commission. I accept that the American healthcare scene is a complete mess, but this is principally because the commissioner purchasers (the insurance companies) have never been able to control the behaviour of either care providers (hospitals, clinics, consultants, GPs) or consumers (patients). Together, these two latter groups have conspired to create an inexorable demand for healthcare. It would have been much worse if commissioners had not resorted to a huge range of measures to control demand, improve effectiveness and raise quality. In the late 1980s, when this process was invented, it was called ‘managed care’. (Wikipedia covers it well.) Eventually, the initiative ran its course. The medical lobby resented the attempts at challenging its power and attempting to introduce structural change and derailed it. As a consequence, the US has experienced healthcare inflation getting on for 10% per annum. Now, I’d be accused of being crass if I suggested that we should bring all of the techniques of managed care here, lock stock and barrel, but someone has to find a way of introducing a more professional commissioning discipline to the NHS in England. I’ve worked with lots of PCTs and what I know is that if you put together the best practice that exists, PCT by PCT, initiative by initiative, we wouldn’t be far off creating a pretty workable solution. But no single PCT has come anywhere near close to providing an integrated commissioning system, not even my friends in Kingston. Currently, there is no DH-mandated solution for commissioning support and I believe there is little hope of one emerging soon. Indeed, the make-it-up-asyou-go-along situation that prevails in the DH seems to work on the basis that each of the 150 PCT organisations – and now 250 even worse-equipped CCGs – are miraculously going to stumble on the right configuration through some process close to serendipity. The challenge is not quite in the dimension of the infinite monkey theorem, teaching chimpanzees to write Shakespeare, but you know what I mean. It’s just not going to happen. The guidance in the latest paper from the DH, and this is important, does give permission to CCGs to go out and find the best, even most radical, solutions. The DH recognises that external help will be necessary, particularly for services such as back-office support. In ‘Developing commissioning support’, published in October, the DH says it ‘cannot afford to constrain the opportunities to innovate’. Furthermore, ‘CCGs [need to] harness techniques [and think] of bringing ways of working from other sectors’. Also, that ‘CCGs will be given the freedom to secure their commissioning support from wherever they want’. It might seem self-serving, but I think time is running out for polite encouragement. Go to the Commissioning Community website and you’ll see how I think it can be done. If any CCG board wants help, I’d be happy to advise. All the best for the holidays and the New Year. Maybe 2012 will be that breakthrough year. Let’s hope so.

This is a £60bn market, which makes it about the size of Tesco’s UK turnover. Can you see Tesco running a poll of branches asking them how they want to work things out for themselves?

december 2011 | practicebusiness.co.uk

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commissioning | case study

An insulin world Health providers in the London Borough of Bexley have radically changed diabetes care in the area, moving it from secondary to primary care and positively impacting patients and budgets alike. Chris Mahony reports People with diabetes are used to having a hand in their own care – quite literally given the selfadministration of insulin. In Bexley, south east London, however, they have become active partners in a radical overhaul that has seen much of their care transferred from secondary to primary care. Historic patterns of care and the high and rising number of people with the condition mean diabetes poses a major financial challenge to the NHS. It accounts for 10% of NHS resources with diabetes patients occupying 15-20% of a typical hospital’s beds. UK prevalence of the disease is expected to soar from 3.5 million today to five million in 2025 as obesity rises. The Bexley Community Diabetes Project has had some form of contact with nearly all the 11,000 diabetes patients in its area. Of those, around 1,000 are now expert patients. This has underpinned the transformation in how their services are delivered. Changes include: • training GPs, practice nurses and other health professionals in insulin conversion, patient reviews, care planning and management of type 2 diabetes • more than 80% of practices provide care planning for diabetes patients and their services are audited twice a year – ensuring that response to patient need is based on strong evidence • ongoing training, mentoring and advice for health professionals has supported the safe, effective

Historic patterns of care and the high and rising number of people with the condition mean diabetes poses a major financial challenge to the NHS december 2011 | practicebusiness.co.uk

transfer of the care of hundreds of people from secondary to primary care • specialists work with patients and health professionals in virtual clinics to address specific concerns. Since launching in the spring of 2010, the initiative has seen patients working with their GPs and other primary care team members to take greater control of their care – and produce savings. Project manager John Grumitt says engaging patients, GPs and other primary care professionals has been crucial. “There was real enthusiasm from GPs with 100% representation of practices at the first engagement session,” he says. Meanwhile, a survey of patients showed interest in a structured patient education programme. Referrals to hospitals have halved, leading to significant direct and indirect savings. Patients starting on insulin no longer attend hospital, but are instead advised and supported in the community – saving £510 per patient. The Bexley figures are impressive but its legacy on both patient health and NHS finances might be even greater in the years ahead. Supporting and incentivising GPs to reduce HbA1c (three-month blood glucose) has resulted in a 1.3% reduction – the highest fall anywhere in the UK. A one per cent fall in HbA1c equates to significant lessening in microvascular complications such as kidney disease and blindness (37%), amputations (43%) and heart attacks (14%). It results in overall deaths related to diabetes falling by more than 20%. David Colin-Thome, former national clinical director for primary care, described the initiative as “the most impressive application of QIPP” he’s seen. For those seeking to follow, even Grumitt acknowledges that Bexley has worked particularly intensively in researching and developing options.

REDUCE DIABETES APPOINTMENTS BY HALF With diabetes on the increase in the UK, and costs rising with it, technology provides an instant solution to improving care in the community There are currently 2.8 million people over the age of 17 diagnosed with diabetes in the UK, according to Diabetes UK – an average of 4.26% of the population. Over 100,000 people are diagnosed with diabetes each year. Not only is this a concern for the general health of the UK population (see box for diabetes prevalence by country), it is a problem for the taxpayer too. Diabetes is expensive. It is estimated that 10% of the NHS budget is spent on diabetes – this equates to a shocking £286 a second. Most of this budget is spent in secondary care. Estimates indicate that the NHS spends some 9% of total hospital expenditure on treating diabetes and diabetes’ complications. Furthermore, an estimated 10% of NHS hospital beds are occupied by people with diabetes. This leads to diabetes having a total estimated cost of £3.5bn per annum, according to a recent report entitled ‘Diabetes in the NHS’, which equates to over £9.6m each day. With an NHS initiative to save £20bn by 2014, diabetes care is clearly an area to be improved. TECHNOLOGY TO THE RESCUE Practice managers need to be at the forefront of delivering efficiency and improving patient care. One way of saving money on diabetes care and management is by taking much of it out of secondary care and into the community. The Siemens DCA Vantage Analyser POC Diabetes Blood Testing System, available from Williams Medical Supplies, is an invaluable tool for GP practices looking to improve their diabetes services to patients. The easy-to-use system uses a finger prick test to deliver accurate, lab-quality results for HbA1C and A:C Ratio blood monitoring in as little as six to seven minutes (see box for its benefits). This fast delivery of the results, as required for QOF (revised levels 2010), saves money on costly lab test referrals and can halve the amount of appointments for diabetes testing, which minimises patient inconvenience. It also provides on-board printed results, eliminating transcription errors and saving time. Quick results are also beneficial to a patient’s health. Studies have confirmed that immediate feedback of haemoglobin A1C results improves glycaemic control in type 1 and insulin-treated type 2 diabetic patients.

DIABETES PREVALENCE BY COUNTRY Country

Prevalence

Number of people

England

5.4%

2,338,813

Northern Ireland

3.7%

68,980

Scotland

4.1%

223,943

Wales

4.9%

153,175

KEY POINTS: • •

•

It is estimated that 10% of the NHS budget is spent on diabetes, equating to £286 a second Estimates indicate that the NHS spends some 9% of total hospital expenditure on treating diabetes and diabetes’ complications. Furthermore, an estimated 10% of NHS hospital beds are occupied by people with diabetes A report entitled ‘Diabetes in the NHS’ estimated a total cost of £3.5bn per annum, over £9.6m each day.

THE BENEFITS OF USING A SIEMENS DCA VANTAGE ANALYSER • • • • • • •

Results provided rapidly following blood collection Minimises patient inconvenience Reduces the number of extra visits to the clinic HbA1C and A:C Ratio testing results in just 6 and 7 minutes Proven to provide accurate and precise lab-quality results Onboard printed results; eliminates transcription errors and saves time Studies have confirmed that immediate feedback of haemoglobin A1C results, improves glycemic control in type 1 and insulin-treated type 2 diabetic patients.

To order the Siemens DCA Vantage Analyser for the new lower price of £2,900, contact Williams Medical Supplies on 01685 846666 or visit www.wms.co.uk

commissioning | comment

exclusivity Field of

If practice managers have proven a necessary addition to a CCG board, why are they are still under-represented? Darryl Braham, a practice manager from East Berkshire, gives his views and explores whether practice managers should be incentivised for their commissioning work

Much of the topical press surrounding practice managers and CCGs seems to be centred upon the dichotomy of the willingness of practice managers to participate and the unwillingness of consortia to recognise their worth. My experience within our locality area is that practice managers are willing to engage and indeed have the business experience and practical know-how necessary to support the nondecember 2011 | practicebusiness.co.uk

clinical aspects of consortium work, yet entry into CCG work is not always a level playing field. Our local commissioning board has been established and the members voted into their positions, using a proportional representation system based upon the population size of each of the member practices. Though at least one practice manager and a practice nurse stood, none were

COMMISSIONING | comment

voted in. Some might argue that they were neither qualified nor suitable for the board roles. Yet conversely, with GPs being the only people with voting rights, it is perhaps not unsurprising that only GPs were elected to the board. Indeed, according to Pulse, 95% of GPs appointed to the boards of CCGs have not faced a contested election, leading to claims of a “jobs for the boys” culture and “widespread disengagement among grassroots general practice”. Of course, we all understand that CCGs must establish themselves and during this pathfinder period certain assumptions have to be made and organisational structures drawn to enable them to start navigating the troubled waters of NHS reform. Yet at a recent practice management event in London, one of the key themes I witnessed from the floor was the under-representation of practice managers within CCGs. Our consortium has several practices managers actively involved at committee level, me included, developing and driving policy forward. We have much to offer and bring expertise and practical skills that are much needed by consortia. Further engagement by practice managers is not about willingness but more about acknowledgement by the commissioning group of their expertise and worth. Currently many CCGs remunerate participation based upon ‘the cost of backfill’ at practice level and indeed our own PCT has been investigating this conundrum across other localities. It concluded that a remuneration system based upon the cost of backfill at practice level was the norm across much of the country and was therefore recommending this system for adoption here. It has been pointed out that such a system could be described as discriminatory, as it fails to equally reward two individuals undertaking the same roles or functions. This certainly seems at odds with current employment legislation but seems to be widespread across consortia. Many practice managers undertake CCG roles with the backfill rates being paid to the practice as the role is being undertaken during practice time. They then return to their primary appointment and are obliged to catch up on the work missed with no overtime or additional remuneration paid. The same is not always true of doctors who employ locum cover and/or pay themselves the backfill rates, as this is seen as an additional appointment not fulfilled by other colleagues in surgery. This is of course individual practice policy and therefore should not be leveled at the consortia.

Backfilling a practice manager is perhaps not always easy nor is it probably desirable for many reasons that I will not go into here. Therefore upon returning from consortium duties a manager must then launch him or herself into catch-up mode. Each practice has its own coping mechanisms for covering absence but there are certain matters that cannot be handled by other colleagues. No one person should ever be indispensable but the backfill of practice managers is not a tried or tested concept like it is for locum doctors; therefore managers will always be expected to return to work and undertake those aspects of the role that have been left unattended. What does need to be addressed within some CCGs is that roles are being remunerated based on backfill and not the role’s contribution and worth to the group. There are of course clinical roles that can only be undertaken by a doctor or nurse, but there are many other roles where a clinical background is not essential. Indeed, it can be argued that practice managers are more suited to these organisational functions because of their business and financial backgrounds. Managers are not best motivated to undertake such roles when they find themselves being rewarded at 60% less than a clinical colleague performing the same or similar function. Such a system does not incentivise managers to give freely of their time. Many of the practice managers I have spoken to are somewhat reluctant to undertake too many roles in the consortium while juggling a busy day job. This is further compounded when they see they are not being rewarded for these additional duties. To encourage managers to become more involved in CCGs they must be properly incentivised to take part. This perhaps means paying them their worth and allowing them to financially benefit from their increased workload and commitments. The current inequalities fail to recognise the important roles managers have to play and the professional qualifications and experience they bring with them.

With GPs being the only people with voting rights, it is perhaps not unsurprising that only GPs were elected to the board practicebusiness.co.uk | december 2011

people

Private in practice Holycroft Surgery in Keighley, West Yorkshire is a forwardthinking practice. Ever since he came over from a career in finance two years ago, practice manager Andy Haigh has introduced innovative ways of looking at care planning and practice management – reminiscent of the private sector he comes from. Julia Dennison reports

You’ve been in practice management for two years now – does that still qualify you as a rookie? Yes, I think it does – compared with other people in the role. There are those who have been in it for years and years. I still don’t feel I’ve been tainted by any ‘NHSness’ – I still look at things in a slightly different way sometimes.

private sector, in terms of trying to look at how you do something and not just doing it because you’ve always done it that way. If you look at GP practices, they all get from A to B, but they seem to get there in a myriad of different ways. The fact that different systems have been set up over the years and then clung to for no apparent reason is really strange.

Coming from the commercial sector, do you think there’s anything GP practices could learn from private businesses? I think there probably is. My first impression of the NHS as a whole is that people find the most difficult way to do something, make it more difficult and then set a committee up to crack on with it. That was a bit of an eye-opener. I brought some ideas from the

Do you think that culture will have to change with clinical commissioning? Yes, any environment where there’s a lack of money brings about innovation. I’m looking forward to the impact it will have. It’s been difficult this year as you’ve got a lot of uncertainty and previous income has been dropping off – but we’re out and about trying to be involved in the whole commissioning

december 2011 | practicebusiness.co.uk

PEOPLE | interview

process. We’re conscious that where we might suffer as a result in the short-term, it brings a lot of opportunity with it too. We’re really working hard at the moment on getting our house in order, so that if any opportunities do arise, we can take maximum advantage of them. When you started as practice manager two years ago, what did you want to change ﬁrst? The first thing i changed was to take a bit of pressure off the reception area. We had three receptionists who were doing the front desk and telephones and it seemed that everything was always so busy and everybody was really stressed. Everyone thought i was slightly mad when i took two [people] off the front and left one, but we never needed three. We’re a relatively small practice, we don’t have that big a through-put of actual people, and by taking the two off, they were able to go away and answer the phone, so it improved the confidentiality and took the pressure off the reception area. other than that, we looked at the balance of the staffing, just to see if we could adjust the split of part-time staff coming in on a morning or afternoon, to try and meet demand a bit better, because although our patient numbers have remained fairly static over the years, demand has gone up 20-30%. How are your patient satisfaction levels? We get very few real complaints – but you do get an undercurrent of grumbling around the same issues: appointments, telephones and parking. We’ve improved our appointment system and a lot of things, but if a patient can’t get through or get an appointment on one particular day, we’re kind of tarred with that regardless of what else we do. We’re going to spend the next 12 to 18 months on perception and communicating with the patients because i think it’s something we’ve not done particularly well in the past and still don’t do particularly well. The prime element of one of the support staff’s roles is trying to look at things from a patient’s point of view. So if we come up [with an] idea, she’ll look at how it impacts the patient and how we would communicate it to them. Do you have a patient participation group? Yes, we have a great patient participation group, which we work very well with. Actually, a person in the group and i have been helping other practices set up patient participation groups. The PCT set up a committee in Bradford to advise different practices

» practicebusiness.co.uk | december 2011

PEOPLE | interview

You get grumbling around the same issues: appointments, telephones and parking on good practice, which we’re a part of. We’re very big on trying to promote health education and selfcare and we use our patient participation group to do up the boards in the reception with that focus. We bought them a telly so we could run health education dVds in the practice. They also come into the practice for various health education sessions, generally related to the illnesses they perhaps have, so they have a personal interest, but also therefore have a personal insight. We’ve found we have a really good bond with them now. Keighley is quite a parochial town and it has a strong voluntary sector, so we’ve registered the patient participation group with the local community association and we’ve also been involved in building a local directory of community and voluntary services. Would you agree a large part of a practice manager’s role is to help the GP do his or her job better? Yes, absolutely. i’m quite lucky because i like to work off my own initiative and the gPs here pretty much leave me alone to get on with it. i perhaps see my role as such that if a gP or partner has a strategic role to play in their business, i’m doing that bit for them, rather than just the day-to-day managing, which other people are doing for me. Strategy, general planning and implementation are what i’m about. A lot of that is involved in trying to make best use of clinical time. Can you tell me about your letter-reading team? our gPs don’t see their letters at all now unless it’s something we think they need to see. Three people open the post; read it; scan it in; do all the coding; respond to it; book appointments; send letters and whatever else, and then they’ll shred it. it’s literally a complete process, it’s freed up a load of clinician time and it’s pretty much all dealt with on the same day it’s received. one of the gPs does a regular check on it to make sure everything is being dealt with as it should be and the team has a manager who keeps an eye on it and checks work all the time. one of the things it’s designed to do is to reduce the number of telephone calls we are getting in, because a lot of the calls are as a result of delays in dealing with paperwork. We keep in control of our time by doing that too.

december 2011 | practicebusiness.co.uk

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PEOPLE | interview

You have a unique care-planning approach to longterm conditions. Can you tell me about it? When i came in, we had a system for dealing with people with long-term conditions whereby if you had three long-term conditions, then we called you into the practice three times – so you’d come in, we’d do your height/weight/blood pressure for your heart disease and depending on the luck of the draw of our patient recall system, you might get called in a week later for your asthma. We got quite a lot of non-attended appointments, so it was clear that people didn’t really value it. i knew we needed to do something about it – it was madness. i heard a local Bradford gP named dr Shahid Ali speak about a care-planning approach, which meant creating a one-stop-shop for long-term conditions. We took it on-board from June, so the patient is now invited in once and the number of illnesses they have determines how long they’re seen for – so if they’ve got two illnesses they’ll get a half-hour appointment, if they’ve got three or more, an hour. We’ve invested quite a lot of time in it but the idea is we’ll get economies of scale back because we’re only doing weights and measures the once and we’ll get a saving in gP appointments once it really takes off. Patients are now getting the conditions dealt with in context – whereas before we could have been sending someone away with diabetes lifestyle advice to go running when they have asthma. now we look at all their conditions altogether and at the end of the appointment, the patient leaves with a professionally-produced folder with a print-out of

their results and an explanation of what they mean, as well as an action plan with their goal for the next few months and a contact number for the nurse – the idea being that if they feel it isn’t working, rather than book a doctor’s appointment, they’ll ring the nurse. Hopefully they understand their illness and how it affects their lifestyle better too. We have people to help with that, like a diabetes champion and someone from Age Concern who does social prescribing and deals with the underlying issues. How have you been promoting it? We got professionally-printed leaﬂets and posters to outline what was involved – all the marketing support we could imagine to really make it look like a private service we were giving for free through the nHS. What’s the reaction been? The feedback’s all been good. i think the nurses have got a little bit bored with it because it is the same thing over and over again, and because we’ve allocated so much time, they have to do it a lot. But we expected that in the first year, and we’ll get through it. our initial target was that we would deal with the same number of people we dealt with last year on long-term conditions, and we will do that by the end of the year. We’ve not really measured anything beyond that because we know if we get the same number through, they’ve had a better service and we’ve done well. next year we’ll start to measure outcomes but at this point we’re just happy to get people in and used to the service.

FACT BOX PRACTICE Holycroft Surgery PATIENTS 9,800 PARTNERS Six CLINICAL STAFF Nine SUPPORT STAFF 23 (four full-time) PCT Bradford and Airedale CCG Airedale, Wharfedale and Craven PRACTICE MANAGER Andy Haigh TIME IN ROLE Two years BACKGROUND Andy Haigh has been helping small businesses in one way or another for years. He started out in ﬁnance and business planning, working for private schools. Tired of ad hoc jobs and not being able to see the full fruition of his work, he looked for a full-time position. Practice management appealed, so when the job as practice manager at Holycroft Surgery came around he took it.

december 2011 | practicebusiness.co.uk

business intelligence and management sense for practice managers

management

Practice makes perfect A CQC registration update Although the requirement for GPs to register with the CQC has been delayed until April 2013, it seems it’s never too early to ensure your practice is meeting best practice. As we move into 2012, Julia Dennison speaks to managers of healthcare organisations who have gone through the registration process before to find out just what it entails and what surgeries can do now to prepare

The Care Quality Commission registration system was brought into effect under the 2008 Health and Social Care Act as a way to ensure by law that this country’s healthcare providers meet an essential standard of quality. Primary care is the final part of a large exercise by the CQC to get health and social care providers registered – and 22,000 of them, including independent ambulance and dental care providers – are already registered. Now it’s the GPs’ turn. By April 2013, practices will have to show they are legally compliant with 28 standards of quality and safety – or if not compliant, well on their way (visit cqc.org.uk for details) – and will be required to pay an annual registration fee once registered. After an initial deadline of April 2012, the registration process for providers of NHS general practice and other primary medical services was pushed back a year due to the sheer complexity of

december 2011 | practicebusiness.co.uk

primary medical services. Before the deadline was moved, there was a distinct buzz and momentum about the primary care sector and it’s fair to say that with the delay, some of that has died down a bit. Other tasks around commissioning, enhanced services and QOF have risen to the top of practice manager to-do lists. However, with the New Year upon us, there is no better time to pick up the process. Working towards the greater goal of CQC registration does not necessarily mean ticking the boxes yet. At this stage, a practice is well-advised to ensure it is operating to the best of its ability. “Ignore CQC for moment,” recommends Bharat Patel of software firm X-Genics. “What I would do is get my practice into shape. Do a practice run until March and what you need to do for CQC, do on QOF. Don’t waste time trying to do things that don’t need to be compliant until 2013; there are some things you need

management | CQC

to do now for QOF anyway – like IG Toolkit, training and staff appraisals – so practise on that as if you were going to do CQC and then your time isn’t wasted.” Arif Ladha is eight weeks into his role as business development and operations manager at Fairhill Medical Practice in Kingston upon Thames, overseeing a network of three different sites with individual deputy managers. His previous job was with a private healthcare provider that had to register with the CQC last year. Because he’s already gone through the process, he knows what it takes and with this in mind he started work on getting his new practice fully compliant from his first day. “What I’m doing is making sure that all our processes are in-line with CQC and consistent across the practice,” he explains. “I’ve already had the discussions with my staff and planted the seeds about CQC and what it means.” Meanwhile, the Blue Dyke Surgery in Chesterfield, Derbyshire was one of 20 practices to pilot the CQC registration process, and practice manager Verity Shelton has confirmed that it was “not as

script file

Increasing patient choice “It’s great to give more choice to patients on repeat medication – Pharmacy2U provides a flexible service that’s available to all”

Sue Coleman Practice manager The Whitfield Practice

delivering health

A Yorkshire practice has found that offering a wider choice of pharmacy options has benefitted both patients and the practice. The Whitfield Practice in Leeds decided to introduce an NHS mail order prescription service to offer a flexible alternative to local chemists, for patients who require regular medication. The service, from leading mail-order pharmacy, Pharmacy2U, takes prescription requests direct from the patient – either by phone or online. It then contacts the practice electronically to gain authorisation, before dispatching the medications direct to the patient’s home, workplace or another address. Simple for patients and the practice The service is easy to set up and can make life easier for patients by streamlining the repeat script process. Sue Coleman, practice manager at The Whitfield

Practice, commented: “We were keen to offer more choice to patients who require regular medication. Pharmacy2U provides a flexible service, which has been particularly popular with the elderly and those with work commitments, who can often find it difficult to collect prescriptions.” The service has benefitted the practice too, Sue said: “We receive the prescription requests electronically and these go direct to the doctors’ inboxes for authorisation. It’s very straight-forward. “Patients can also sign-up for its free reminder service, so they don’t forget to order important mediations – helping to reduce the number of last minute requests we receive.” The service achieves very high levels of patient satisfaction and is currently being used by 300 GP practices. It is free for practices and patients. www.pharmacy2u.co.uk/practice

management | CQC

If you’re not careful and you’re a medium-tolarge practice, you’re going to end up employing someone just to do the CQC

challenging” as she feared. The amount of paperwork was a challenge, however. “There was a considerable amount of work involved in the initial formcompleting process for the pilot,” she told Pulse. “This workload was compounded by trying to navigate around the paperwork and identify which parts needed to be completed.” She said that while the registration system was “not straightforward”, the CQC has confirmed they’re working on making it easier.

Will non-compliance shut you down? There have been a number of misconceptions the CQC has been quick to debunk. One of them is the concern that if you do not meet essential standards you will have your registration refused and your practice will be shut down. Under the new system of regulation, a GP practice can declare ‘non-compliance’, but will be required to show the CQC how they plan to become compliant and when. Only in extreme circumstances, or if a practice does not do what it says it will when an inspector calls later, could it be shut down. “I can tell you this is extremely unlikely and we would only take this action where we find extreme cases of very poor care,” confirmed Professor David Haslam, professional adviser to the CQC, in the organisation’s latest guidance document.

Do I need to hire more staff? The CQC does not require practices to hire additional staff to meet the standards or submit an application. However, the regulations state that a GP practice must designate a manager who is responsible for the day-to-day regulated activities and ensuring the provider meets necessary standards. This is more than likely the practice manager. While this sounds daunting, much of what is required for compliance is part of the practice manager’s role anyway, so it might not mean much work above and beyond the call of duty. december 2011 | practicebusiness.co.uk

Shelton recommends having more than one person responsible, as she felt the amount of paperwork could not be completed by one member of staff alone. “At this stage it is important to ensure that those responsible are aware of the potential workload and are happy to take on their roles in the registration process,” she wrote last June in Pulse. This can sometimes mean a culture change among practice staff. As Patel says, “the problem is not the legislation, but the people”. “The problem is, when you actually go to speak to staff, the excuses they come up with tend to be: ‘I’ll do it if you’ll pay me another pound an hour’ or ‘I’m not going to do it because for the last 20 years I’ve never had to do it,’” he warns. “What practice managers need to do now is to start talking to staff now and saying we really need to pull together on this.” GPs will need to be on-board too and, according to Patel, there are still many who have not yet cottoned on to what is required. “They don’t always understand that the practice manager’s workload has almost quadrupled over the last five or six years and is going to increase by another 30-40% over the two years because of commissioning and CQC,” he comments. “If the GP is not behind the practice manager on this, the practice manager is really going to struggle – they’re just not going to be able to do it.” It’s easy to think this level of extra work warrants an extra pair of hands. “If you’re not careful and you’re a medium-to-large practice, you’re going to end up employing someone just to do the CQC,” continues Patel, which could cost as much as £50,000 a year. This can be avoided by working with other practices in your area or CCG to undertake the registration process together, assigning a different area of expertise to each practice. “If you have 28 practices in a CCG and each practice manager took on one outcome, then as long as they can share the information across the practices, they can absolutely cut their work load,” agrees Valentine.

management | CQC

Do I need to buy external auditing or compliance systems? The CQC is very quick to make it clear that a certain software system is not required for registration, as many practices already have good monitoring and back office systems in place, however, there are products out there that will help you organise your information to prove you meet the standards should you so wish to invest in them. “In most of the areas they probably are already compliant,” says Peter Valentine of IT firm PinBellCom. “Where they have real issues is proving that they’re compliant and gathering the evidence is the important thing.” Documentation control is a big issue, he adds, particularly around versions of documents and access. “What most practices seem to be concentrating on at the moment is they think all they need is a document to say: ‘This is what my process is’,” he says. “Actually the correct way to approach this is not just to have a document to say what your process is, but to be able to prove how you adhere to that process on a day to day basis.”

Will I need to upgrade my premises – old carpets, toys etc.? While the CQC requires patients to be cared for in safe, accessible settings, there are no strict building standards for practices to meet. “We always take a proportionate approach, and care provided in carpeted premises (or those with toys and books in their waiting rooms) is not likely to cause us concern,” reads the CQC guidance. “We just need to be assured that you have identified any risks and have taken reasonable steps to manage them.” The registration process is online and the CQC says it is working hard to make it as straightforward and easy to understand as possible. Once the application is started, there is no pressure to finish it there and then. Registering practices will be able to complete the form over a number of sessions and print it out to take away and consider. The last thing to bear in mind is that you need only register once. Although compliance is a daily duty, the actual registration process is a one-off, which means after it’s done, all practices will have to do is ensure they maintain a certain standard. For Patel, CQC registration is the opportunity of a lifetime for GP practices: “All the bad practices of the last 20 years can now be put right.” With registration over a year away, and the application process not starting until summer of next year, is it too early to embark on the process? “Gosh, no,” exclaims Ladha. “Embark on it now.” practicebusiness.co.uk | december 2011

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

december 2011 | practicebusiness.co.uk

Pneumonia

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: pneumonia As winter draws on, our thoughts inevitably turn to consideration of all the winter ailments that afflict us: colds, coughs, flu and chest infections. Among the most serious of them is pneumonia, which affects about one person in every 100 each winter. Pneumonia is a disease in which one or both lungs become inflamed as a result of infection, which may be viral, bacterial or, less commonly, due to a fungus. Sometimes the inhalation of toxic smoke or corrosive chemicals can result in pneumonia. The disease is serious at any age but can be fatal, particularly in vulnerable sufferers such as the elderly and the infirm. About five per cent of patients who contract the illness die from it. Infection of the lungs usually occurs because of inhalation of infecting organisms or because infection elsewhere in the body reaches the lungs via the circulation. It is also possible to produce a chemical pneumonia, which may also carry with it micro-organisms, following the inhalation of vomit, such as may occur in drunken states and in conditions where the protective reflex is diminished. Pneumonia is most common in the weak and elderly, those who have preexisting illnesses, asthma sufferers and smokers, diabetics (who have resistance to infection in general), alcoholics, patients who have had their spleen removed and those who have a compromised immune system. However, anyone can develop pneumonia. A vaccine to protect against pneumonia due to infection by pneumococcus is available for patients over 65, those with asthma or other chronic lung disease, chronic heart disease and diabetes and those patients who have lost their spleen. It is also wise to ensure that all vulnerable adults have an annual vaccination against influenza. Pneumonia usually presents with the typical symptoms and signs of an acute infection, a high fever, shivering, chest pains, breathlessness and a troublesome, often relentless, cough. The cough is initially dry but it subsequently becomes productive and might be thick, pus-like, yellow or green in colour. The breathlessness might become quite severe, shallow and gasping. The patient might also develop a stabbing pain on inspiration. This is called pleurisy and occurs because the infection in the lung has spread to involve the pleura, which lines the lung and is

practicebusiness management | MFM

extremely sensitive. Elderly patients can become confused as a result of the development of an acute confusional state. During an episode of pneumonia it is common for sufferers to develop cold sores round the mouth. The diagnosis of pneumonia is usually made by clinical history and examination. The symptoms are usually suggestive of the diagnosis and listening to the chest with a stethoscope will generally elicit typical added lung sounds. The diagnosis is usually confirmed by chest X-ray and the identity of the infecting organism can often be made by culturing a specimen of sputum in the laboratory. Management of pneumonia is important and in the most severe cases hospitalisation is necessary. The mainstay of treatment is antibiotic, usually orally but intravenously in more serious cases. It is also important to lower the temperature by the use of medicines such as paracetamol and patients might also need stronger pain relief if they have pleurisy. Those patients treated in hospital might also need chest physiotherapy and sometimes oxygen. Pneumonia should be resolvable with early and effective diagnosis, appropriate treatment and the necessary support. Prevention is also important and the appropriate management of any pre-existing lung conditions is crucial. There are no QOF points specifically for pneumonia but there is a large number for asthma, COPD, ensuring that vulnerable groups have flu vaccinations and the provision of pneumococcal pneumonia vaccination. With such an approach the risk of acquiring the disease is much reduced.

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WorK/LifE

A natural taught leader

advice for busy lives

Being a â&#x20AC;&#x2DC;leaderâ&#x20AC;&#x2122; is not a natural state for many people. Few of us are likely to become the ideal mix of Nelson Mandela and Lord Nelson; instead we need practical advice to guide us through this minefield. JO OWEN, author of How to Lead,, explains the skills and behaviours to succeed as a leader Airport bookshops are awash with books telling us how we can be great leaders. We are urged to be an implausible combination of Churchill, Genghis Khan and Mother Theresa. We cannot succeed by trying to be someone else: we can only succeed by being the best of who we are. Here are some tips on how any of us can lead, whatever we do. We do not have to be a CEO to be a leader. This is about leadership as it is, not as it should be: it is leadership we can all learn, and we can all aspire to achieve.

december 2011 | practicebusiness.co.uk

work/life | leadership

Top 10 characteristics of leadership in practice 1

Everyone can learn to lead

You do not need to be born to lead. Leadership is based on skills that everyone can and must learn: delegating, directing, influencing, motivating, decision-making. Most of us learn from role models and experience, both good and bad. Never stop learning; never stop improving.

No leader is perfect

You can lead at any level

Leadership is about performance, not position. An effective leader is someone who takes people where they would not have got by themselves. That means you have to make a real difference: be brave, be bold.

Build on your strengths

All leaders have a signature strength that lets them succeed in the right context. Build on your strengths and work around your weaknesses. Hire people into your team who are strong in the areas where you are weak.

Leadership is a team sport

Don’t try to be the lone hero. You cannot do it all yourself. Work with others who have strengths that are different from yours and will compensate for any gaps you might have. Weak and defensive leaders hire clones of themselves, and get weak performance as a result. Confident leaders gather the best possible talent.

Make a difference

Leaders do not manage the status quo. They make a difference. Leaders push themselves and others to go beyond their comfort zone, to develop themselves and their organisation. Be ready to challenge. Don’t accept excuses, because once you accept excuses you accept failure. Be selectively unreasonable in stretching and pushing people. We all remember Alexander the Great: who remembers his cousin Alexander the Reasonable?

Find your context

Leaders who succeed in one context can fail in another. Think of Churchill: a great hero in the war. Before the war he was a maverick and when he was PM after the war he was forgettable. Context is everything.

No leader ticks all the boxes. As your career progresses, you live increasingly in a goldfish bowl where everyone will examine and comment on all you do: weaknesses become more visible over time. But do not strive for perfection; strive for improvement and build on your strengths. No one succeeded by building on weaknesses. Find the context in which your strengths will flourish.

People skills become more important

The more senior you become, the more your job becomes about people and politics. Leaders only succeed by making things happen through other people, so you have to learn the arts of influence, managing conflicts and crises, aligning agendas, building trust, doing deals and knowing which battles to fight. As one CEO put it: “I hire most people for their technical skills and fire most for their (lack of) personal skills.”

The rules of survival change

The technical skills you learned at the start of your career are likely to be more or less irrelevant by they time you become CEO. The only way to avoid career altitude sickness is to learn and adapt.

You are responsible

Many leaders like to be responsible for successes, not for setbacks. You can delegate away most things, but you cannot delegate away your accountability: you are accountable for the performance of your team. The big question all of this raises is: “How can we learn to lead?” People usually choose two from the following: • Bosses (good and bad) • Peers • Role models (inside and outside work) • Books • Courses • Experience. Virtually no one chooses books or courses. We all learn from experience. This makes sense in the real world. But it also means that many careers are a random walk. We bump into good bosses and experiences and we accelerate. We have bad bosses and experiences and we head straight into a dead end. Books offer a way of taking the randomness out of the random walk and to make sense of the nonsense we encounter day to day. How to Lead (Prentice Hall), £12.99, is available now practicebusiness.co.uk | december 2011

WORK/LIFE | top tips

Reaching hard-to-reach patients With recent reports of practices taking a zerotolerance approach to difficult and awkward patients by striking them off patents lists, leading to a six per cent rise in complaints to the Health Service Ombudsman last year, never has there been a better time to reach out to your most hard-to-reach and difficult patients, rather than taking the drastic measure of removing them from your list. There are, of course, other reasons to reach out to patients, namely to help your practice hit QOF targets, like flu vaccine uptake, for example. Below are a few pointers to bear in mind when dealing with your elusive patients (with thanks to Steve Martin, MD of Influence at Work).

advice for busy

COMPARE LIKE FOR LIKE. When trying to reach a certain target group to come into the practice, it’s useful to mention a statistic that shows to them that other people in a similar situation are doing what you need them to do. For example: ‘X per cent of patients with diabetes came in for their flu jab last year.’ This has a high success rate for getting them to do what you need them to do.

GIVE THEM A SINGLE CALL TO ACTION. Once you’ve told them what they could lose not doing what you need them to do, give them one single thing they could do to mitigate that loss. For example, attend the flu vaccine on Saturday (be sure to include a map and directions on how to get there) or opt-in to a virtual patient participation group via a web link.

GET INTO THEIR SUBCONSCIOUS. A recent government study looked into what GP practices can do to reduce did-not-attends – when patients don’t go to their allotted appointment. The study, led by Influence at Work, found that a combined effort of getting patients to confirm their appointment by verbally repeating the details to the receptionist; getting patients to write the appointment down themselves (rather than a receptionist doing it for them); and placing positive messages around the GP practices confirming that attending appointments is the ‘social norm’ could help reduce DNAs by a third.

POINT OUT WHAT THEY HAVE TO LOSE. Telling a patient what stands to be lost if they fail to, say, get vaccinated (they could get the flu) or join a patient participation group (they could lose a chance to have their say), is a great way to get patients to sit up and listen. This works better than pointing out the gains.

december 2011 | practicebusiness.co.uk

DON’T SAY ‘YOU’RE WELCOME’. An individual is most likely to pay attention and respond to a request immediately after they’ve said thank you to someone. Martin explains: “If a patient rings up for an appointment, a piece of advice, or a repeat prescription and after that service has been provided they say ‘thank you’. That’s the point when you need to be saying: ‘By the way, have you done X?’”

Work/life | diary

Practice diary Debbie Gladwell Debbie Gladwell is practice manager at West Hampstead Medical Centre in London

If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk december 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: Debbie Gladwell discusses why she chose to implement security screens at her practice Due to the many changes the NHS has had to face in recent times, patients are finding it difficult to gain an understanding of how the NHS system works and therefore are beginning to take their frustration out on general practices and the way in which care is delivered. Scenario one: The hospital issues medications and tells the patient to go to their GP practice to get them, only to be told when they come to their GP that we have not received the hospital’s request and we do not prescribe that particular medication. The patient gets angry and feels it’s all about money. Well, in part it is; the hospital tells the patient to get the medication at the practice in order that it does not come from their budget. The hospital has not liaised with the health authority’s medicine management team and no shared care agreement made, no license was given for the medication to be issued safely in primary care and it is not on the practice’s formulary. This then becomes a safety issue. Now, try telling this to a patient. Scenario two: Another patient has run out of their non-urgent tablets and screams when told this takes 48 hours as they have a plane to catch today and need their medication as they will be away for weeks. When I get involved with verbal complaints, it is because reception has tried everything to reason with the patient and this has been unsuccessful. I empathise with the patient, walk in their shoes, see the bigger picture and try to find some resolve.

We have a practice zero-tolerance on aggressive and rude behaviour (both physical and verbal) and I certainly would not tolerate aggressive or rude behaviour from any patient or staff member, so why should I expect my team to do so? We all have responsibilities and work/life pressures; however, many patients forget that we are human too. Is it right that we should allow patients to be bullish and aggressive? Had the patent discharged from hospital waited at the hospital pharmacy they would have received the medications issued. Had the patient who needed their medication organised themselves and requested their medications in time then there would have been no reason to act out an Oscarwinning performance. As a result of on-going abuse to practice staff, we recently took the action of fitting security screens in our reception area, which has encouraged patients in turn to treat staff more professionally and courteously. While there is always an emphasis on patient engagement and customer service, we have to remember that dealing with difficult patients is all part of the service we have to tolerate, especially since patients cannot be expected to keep up to date with all the ins and outs of the NHS. While this is not an excuse, we ensure the patient is gently reminded of our practice policies, which they must work with. Lest we forget, without patients we would not be here.

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postponed in patients with febrile illness or acute infection. Warnings & precautions: Due to the risk of high fever, consideration should be given to the use of alternative seasonal influenza vaccines in children under the age of 5 years. In case it is used in children, parents should be advised to monitor for fever for 2–3 days following vaccination. As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of an anaphylactic event following the administration of the vaccine. Viroflu® should under no circumstances be administered intravascularly. Antibody response in patients with endogenous or iatrogenic immunosuppression may be insufficient. Interactions with other medicinal products and other forms of interaction: Viroflu® may be given at the same time as other vaccines. Immunisations should be carried out on separate limbs. It should be noted that the adverse reactions may be intensified. The immunological response may be diminished if the patient is undergoing immunosuppressant treatment. Following influenza vaccination, false-positive results in serology tests using the ELISA method to detect antibodies against HIV1, Hepatitis C and especially HTLV1 have been observed. The Western Blot technique disproves the false-positive ELISA test results. The transient false positive reactions could be due to the IgM response by the vaccine. Pregnancy & lactation: The limited data from vaccinations in pregnant women do not indicate that adverse fetal and maternal outcomes were VIR/078/180811/P. 10/11

attributable to the vaccine. The use of this vaccine may be considered from the second trimester of pregnancy. For pregnant women with medical conditions that increase their risk of complications from influenza, administration of the vaccine is recommended, irrespective of their stage of pregnancy. Viroflu® may be used during lactation. Undesirable effects: The most common reactions locally are redness, swelling, pain, ecchymosis and induration, and systemically are fever, malaise, shivering, fatigue, headache, sweating, myalgia and arthralgia. These usually disappear within 1 to 2 days. In one clinical trial fever of 39–40°C was found in children. Special precautions for storage: Store in a refrigerator (2°C to 8°C). Do not freeze: the vaccine must not be used if it is inadvertently frozen. Protect from the light. Package quantities and basic NHS cost: Single dose pre-filled syringes, basic NHS cost £6.59. Legal category: POM. Marketing authorisation number: PL 15747/0005. Marketing authorisation holder: Crucell Italy S.r.l., Via Zambeletti 25, 20021 Baranzate (MI), Italy. Date of last revision of prescribing information: October 2011.