Practice Business January 2012 by Intelligent Media Solutions

PRACTICEBUSINESS + inspiring business solutions for practice managers

january 2012

YOU COMMISSIONING PERSON OF THE YEARâ&#x20AC;Ś

Why the NHS needs practice managers for clinical commissioning to succeed

Practice Business is an approved partner with...

e c in s d re e v li e d e ’v e w s e in c The length of all the ﬂu vac e ic tw d rl o w e th le c ir c ld u 1968, laid end to end, wo 1

Over a billion flu vaccine doses produced in over 40 years, backed by the reliability, customer service and support you expect: that’s Sanofi Pasteur MSD 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. 1. Sanofi Pasteur MSD. Data on file 2010, UK14392

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. UK15223 II 09/11

Editor’s letter EXECUTIVE EDITOR roy lilley www.roylilley.co.uk EDITOR julia dennison julia.dennison@intelligentmedia.co.uk ASSISTANT EDITOR carrie service carrie.service@intelligentmedia.co.uk REPORTER jonathan hills jonathan.hills@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 production@intelligentmedia.co.uk CIRCULATION MANAGER natalia johnston natalia.johnston@intelligentmedia.co.uk

Now this is just getting silly…

Welcome back – how has 2012 been for you so far? Any unexpected patient cleansing? Is your brand new diary already chock-a-block with PCT appointments and CCG meetings? As we enter this New Year, it seems to me there are more questions than answers – particularly when it comes to clinical commissioning group size. Before we broke up for Christmas, the GPC and the RCGP called for a restructure of the CCGs to ensure they cover a population of at least one million patients – five million ideally. This is quite the increase from previous estimates of 500,000 patient minimums – not to mention the tiny pathfinders out there of less than 50,000 patients. Of course, our resident columnist Roger Hymas has been predicting all of this for some time – but it’s finally becoming clear, not only does size matter, but the idea of small, localised CCGs focused on a customised patient population is beginning to feel like a pipe dream. Even after the simplest of maths equations, it quickly becomes clear that with five million patients each, we’re looking at 10 CCGs. Which makes me wonder, are we not right back where we were before with SHAs – let alone PCTs? Where are the freedoms for practices? Cue GP and their practice manager loss of interest. I don’t think we’re there quite yet, thank goodness. When I visited Val Denton, the recent recipient of a practice manager of the year award and CCG shadow board member, her commissioning group in Somerset of 200,000 patients was newly formed and had had no pressure to conglomerate with nearby groups…yet (read her story on page 20). Let’s hope, for the sake of GP-led commissioning, practices will still be given some power to lead, otherwise what’s the point? Anyway, rant over. I have a good feeling about 2012 – after all, it’s the practice manager’s time to shine (hence Roger Hymas’ dubbing this the Year of the Practice Manager on page 12). Let’s welcome it with open arms.

editor

see inside for our guide to managing commissioning

P.10

Contents sector 06 news Top news for practice managers this month 08 executive editor comment The latest from controversial columnist Roy Lilley

COMMISSIONING 10 12

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

comment Commissioning Person of the year 2012 You. Roger Hymas explains why this is the practice manager’s time to shine

PEOPLE 20 interview Award for the wise Val Denton of Tudor Lodge Surgery, Somerset, nabs

coveted manager and practice awards

24 interview Community leader Star practice manager Nick Nurden reaches out to his

community over customised clinics and coffee

MANAGEMENT 28 advice Rest secured How to keep your staff safe and patients close 32 clinical QOF This month: Learning difficulties 34 legal In search of partners How to recruit the best practice partners

Work/life 36 38 40

premises Sound advice How to make your practice deaf aware

power relations GPs vs. practice managers How to win in a fight

top tips Staying optimistic As the New Year kicks off, we bring you advice on staying happy in your job and life in general

42 diary Barnsley’s Mike Robinson takes a unique approach to care

sector

Lansley launches new patient outcome measures Health Secretary Andrew Lansley has outlined new measurements that are to replace the existing targetled system of assessing NHS performance, designed to give patients better informed choice over which GP they want to see, including user-friendly maps provided on the NHS choices website to determine the area of expertise for GPs in their region. Data on hospital death rates, individual GP performance and patients’ experiences under their care are to be published in an attempt to improve standards. The new plans are also intended to help patients with long-term illnesses so that they can opt to choose a GP who is a specialist in their condition or illness. “The NHS is about one ambition and one ambition alone, improving results for patients,” said Lansley, commenting on the changes in the NHS Outcomes Framework. “It sets the direction for the whole NHS, orienting the NHS back towards the people who really matter, its patients.”

Government U-turn Lansley has been reproached as a result of the measurements, as critics say they conflict with his previous promise to scrap NHS targets. Shadow Health Secretary Andy Burnham commented: “Doctors and nurses will roll their eyes in sheer disbelief at this news. “The government that promised to scrap NHS targets now loads 60 new targets on an NHS already under severe pressure. It will add red tape and bureaucracy just as the NHS is struggling to cope with the financial challenge and the biggest reorganisation in its history.” Dr Stephanie Bown, director of policy and communications at MPS, agreed the new measurements would be a challenge: “The tsunami of unfocussed guidelines and protocols received each month is undermining. There is an expectation of doctors to have local knowledge about every subject, and this is a wholly unrealistic and unnecessary source of pressure.” However, Mike Farrar, chief executive of the NHS Confederation, was more optimistic about the reform, stating that “the plans present the NHS with a genuine opportunity to deliver better healthcare for patients”.

your monthly industry lowdown

news

‘We have to work together to survive’ Practice managers and GPs need to work together in the future if they are to survive. This was the message from leading PM Jose Tarnowsk (pictured) speaking at Veale Wasbrough Vizards’s Managing Change in General Practice conference last month. On the back of this point she argued for practices to work together. “We have to prepare to work in a federated way if we are to retain what is best about general practice, and also survive,” she said.

january 2012 | practicebusiness.co.uk

“There is nothing in the NHS bill about the future of provision in terms of general practice,” she continued, contemplating whether this was an accidental or deliberate oversight when the bill was drawn up. Like Practice Business columnist Roy Lilley, who presented before her at the conference, Tarnowski spoke about the difficulties that may arise from the next generation of long-term health sufferers and the need for a higher skilled staff in primary care. Touching on telehealth and health education, she called for a greater level of education for patients with these conditions to remove strain on GPs and practice staff, though retained the importance for the familiarity associated with the traditional GP practice.

SECTOR | news

clinical news Most patients are happy with their current GP practice Eighty-eight per cent of patients rate their overall experience with their GP practice as good, according to the most recent GP Patient Survey, covering July to September 2011. According to the study, carried out on behalf of the Department of Health by Ipsos-Mori, national performance on primary care services is high. Nearly three quarters (71%) of patients have seen or spoken to their GP in the last six months and over half (56%) have a preferred GP. For most patients (78%) it is easy to get through to someone at their GP surgery and most patients (89%) find the receptionists at their GP surgery helpful. Over four in five patients (83%) voiced concern that other patients can overhear what they say to the surgery’s receptionist, however, the majority of patients (90%) usually book their appointments by phone, while just under a third (30%) book their appointments in person. Few patients (less than three per cent) book their appointments online, or by fax. The majority of patients (88%) were able to get an appointment to see or speak to someone. Of the patients who were not able to get an appointment, or unable to get a convenient appointment, the issue for nearly half (49%) of them was that there weren’t any appointments Over half of patients have a long-standing available for the day they required. health condition A quarter of patients made an (Source: Ipsos Mori) appointment for another day, while 13% decided to contact the surgery another time. A minority of patients went to A&E (eight per cent); had a consultation over the phone (four per cent); or saw a pharmacist (three per cent). The majority of patients (58%) usually wait between five and 15 minutes after their appointment time to be seen, and a quarter (24%) wait over 15 minutes. One in ten (10%) have to wait less than five minutes. Most patients are satisfied with the opening hours of their GP surgery (81%). Patients who do not feel their GP surgery is currently open at convenient times were most likely to say that Saturday opening or after 6.30pm would make it easier for them.

53%

Telehealth More telehealth and telecare is to be rolled out across the country, after a Department of Health study found it reduced death rates by 45% and emergency hospital admissions by 20%. The study found that, when implemented properly, telehealth could reduce death rates in patients with long-term conditions (LTCs) by 45%; reduce A&E visits by 15%; emergency admissions by 20%; bed days by 14%; and reduce tariff costs for patients with LTCs by eight per cent. As a result of the successful trial, the government plans to roll out the use of telehealth and telecare technologies to the homes of three million people over the next five years as part of a campaign to help patients and reduce costs called ‘3 Million Lives’.

NICE Providers and commissioners are to be fined if they fail to implement National Institute for Health and Clinical Excellence (NICE) rules on drugs and practice, according to a Department of Health report. NHS chief executive Sir David Nicholson stated that providers would lose the entire 2.5% Commissioning for Quality and Innovation payment if they did not comply with nationally specified “high impact innovations”.

They said…

“”

“The current combination of constrained finances and structural change in the NHS offer[s] an opportunity to cut waste and streamline services. Patients often applaud the care and compassion of staff whilst lamenting the inefficiency of systems. NHS professionals often express their frustration at the waste of systems that hinder the delivery of care” Dr Jagdeesh Dhaliwal, GP clinical lead of Productive General Practice, a new programme from NHS Institute for Innovation and Improvement aims to help clinicians increase the time they spend with patients by upping efficiency

diary Delivering quality in practice

Aston Villa Football Club, Birmingham 19 January

47%

Nearly half of registrations by the Care Quality Commission had not been completed on time, according to a report by the National Audit Office indicating that the CQC has not been entirely successful in its regulation of care in the NHS

A NEW STRATEGY FOR NHS PROCUREMENT: SECURING THE FUTURE OF NHS SERVICES

Manchester Conference Centre 17 April

practicebusiness.co.uk | january 2012

SECTOR | news

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

Paradox found

What does the future hold for GP-led commissioning? Not a whole lot, finds ROY LILLEY

So what is the future of GP commissioning? To be frank; it has no future january 2012 | practicebusiness.co.uk

There is a bit of a paradox going on. In fact there is probably more than one. What’s the plural of paradox? Paraduple? Paradie? No idea! OK, let’s start again; I think we’re getting ourselves into a muddle. Where to start? Well, it was universally acknowledged that PCTs weren’t handing commissioning very well. Actually it’s not true. The last results for World Class Commissioning scores showed us that PCTs were actually improving in all areas. Second, because PCTs struggled with commissioning, I don’t think that is an immediate indicator that people running and working in PCTs were all idiots. On the contrary, there were some really smart people, many of whom, incidentally, have left the NHS and we will miss them. The fact is commissioning is very, very tricky, complex and intricate. GPs are finding this out. In a recent poll for a GP trade magazine we discovered that a good number of GP consortia bosses had stepped down citing ‘complexity’ and ‘time required’ as their principle reasons. Even NAPC frontrunner GP Johnny Marshall has thrown in the towel as the chair of his local CCG. He says he can’t do it all. He’s right. I think the doctoring profession is coming to realise that commissioning is a different sort of profession and they can’t do it. I think GPs can work on commissioning at the margins. They can tidy-up local care pathways for this and that, but real commissioning? Boutique stuff, yes. Industrial buying? No. A combination of a per capita management allowance of around a third less than PCTs enjoyed and the realisation that risk pooling doesn’t work under about 500,000 people means consortia are being bashed and crashed into bigger and bigger configurations. Another survey, this time for the NHS Alliance, made it clear; GPs thought they were being forced into bigger organisational structures. The spirit of local decisionmaking, no decision without me and doctor knows best is long gone in the pursuit of making ends meet. So what is the future of GP commissioning? To be frank; it has no future. Commissioning groups are being shoe-horned into PCT-like configurations. The Health and Social Care Bill makes it clear; GPs have to be on the board but they have power to delegate each, all and every function to sub-committees at which GPs do not have to be present. New plans revealed last week make it clear ‘commissioning support’ will come from private sector companies, or the rump of PCT staff who might form companies or social enterprises, who will provide the data mashing and bashing that is the essential ingredient of commissioning. They will design care pathways and also provide back-office functions. Will GPs commission healthcare? No. There will be 50 or so PCT-like organisations with four or five GPs on each of the boards. Do the maths; no more than 300 GP will be involved in the business of commissioning. By the way; it’s paradoxes.

Meet your new personal assistant New Directrec fixed microphones from Olympus Ideal for professional and multi-user environments with fixed cable to avoid loss and hard wearing for daily use. With dedicated support for our professional range, ergonomic design and ease of use you can rest assured your dictation is in safe hands. There are four models to choose from, all delivering improved cost savings and efficiency benefits: DR-1200, DR-2100, DR-2200 and DR-2300.

Across the range benefits 3 colour, programmable LEDs for ease of use Non-detachable USB cable to prevent loss Quality recording with uni-directional microphone Hard wearing for cost savings and reliability Highest Dragon speech recognition rating for efficiency.

For a demonstration, quote or product brochure email dictation@olympus.co.uk

COMMISSIONING

EMPOWERING PRACTICE MANAGERS IN CCGS

CommiSSioNiNG GRouPS to CoVeR at leaSt oNe millioN The GPC and the RCGP have called on the restructure of clinical commissioning groups (CCGs) to ensure they cover a population from one to five million patients. The move marks a shift in policy from the GPC, which has previously encouraged a minimum population size of 500,000. The intent is to try and prevent CCGs from losing the power to commission independently and make their jobs easier following the announcement of £25 per head management fee for commissioning groups. SHAs have been given until March 2012 by the NHS Operating Framework to ensure that they have sorted any outstanding configuration issues, indicating that CCGs are to merge within the next few months. RCGP chair Dr Clare Gerada told Pulse: “One to five million population…is the only way.

Then you can start to have sensible people on your commissioning, then you can start to have population base, you can start to be employing the right people. “The move is also intended to give CCGs an easier time in the new NHS following the recent announcement of a £25 per head management fee for commissioning groups.” Meanwhile, GPC chair Dr Laurence Buckman wrote a letter to the medical profession, stating: “Adequate funding is essential to allow the CCG to be able to function effectively. We do not consider the proposed £25 per head to be sufficient and will be seeking a substantial increase in that sum. “We have previously advised that CCGs should have a minimum population of 500,000, but with strong local structures to ensure they can be truly representative and sensitive to local needs.”

SmootHiNG oVeR tHe CRaCKS The future of commissioning lies in “smoothing over the cracks” and “consolidating roles” within the new infrastructure. This was the prominent prediction among speakers at last month’s NHS Alliance Conference. “What we are trying to do here is build a clinical commissioning system, not a clinical commissioning organisation or a series of organisations,” said Sir David Nicholson, chief executive of the NHS Commissioning Board in his keynote speech. “Building a clinical commissioning group is not about drawing lines on a map,” he said. “It’s about working with practices and building commitment and understanding and knowledge to build something better than the individual practice.”

commissioning in context

PRACTICE MANAGER VIEW The view of practice managers attending the conference however, was mainly focused around the tightening ﬁnancial situation in primary care and the impending spending cuts set to hit GP practices. The PM stream presentations made it obvious that practice managers were concerned with reducing costs, lowering staff numbers and streamlining the organisation of their practices in preparation for the impact of the health bill. Issues such as staff redundancy, reducing patient did-not-attends and how to deal with changing staff roles resulting from commissioning featured prominently. There was, however, also a poignant call from speakers for practices to work together for mutual beneﬁt and that practices need to start grouping together for information allocation, staff sharing roles and procurement if they are to survive when, and if, the health bill passes.

january 2012 | practicebusiness.co.uk

Practice insight

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

CCGs singled out in awards ceremony Clinical commissioning groups were applauded by the NHS Alliance for their hard work in the annual Acorn Awards. Taking place at the organisation’s annual conference last month, the awards were given to primary health professionals who excelled in efforts to improve services for patients. This year’s awards had six categories: GP consortia; urgent care; QIPP; patient and public involvement; consortia manager; and leader (see box out for winners). Notable among the winners was David Thorne, leader of Newcastle Bridges CCG, one of the most foremost and well-established groups of its kind in the country. Also to be acknowledged was the Health Works practice in the Black Country comprising of 22 GP practices that use an innovative ‘experience-led commissioning’ approach. ACORN AWARD WINNERS 2011 The Gateshead GP Consortia: Care Home Programme Winner – Bassetlaw Commissioning from Gateshead’s Organisation Runner up – NHS Nottingham City Clinical GP commissioning Commissioning Group consortia was also Urgent Care: awarded the prize for Winner – Gateshead Care Home urgent care following Programme their year-long pilot Runner up – Mastercall Healthcare QIPP: project to support the Winner – Corby Healthcare care home setting to Runner up – Newcastle Bridges reduce emergency PPI: admissions. Winner – Health Works Dr Stephen Runner up – Monitoring and Advisory Richards won the Board Consortia manager: ‘leader’ category as a Winner – David Thorne. result of his influence in Runner up – Alan Webb making GPs recognise Leader: the benefits of a single Winner – Dr Stephen Richards commissioning group Runner up – Dr Sam Barrell for the county.

Data reporting transformed “The speed with which we can turn round data reports is quite dramatic”

Neil Ryder This month we talk to Neil Ryder, data quality manager with NHS Stoke on Trent, about how data searches with EMIS Web can help improve patient care and save practices time

They said…

“”

“It is absolutely fundamental that CCGs are free to make their own decisions. It is not up to any particular organisation to dictate what CCGs should look like and the coalition is totally committed to supporting CCGs’ independence and helping their leaders to work through any challenges that may arise.” Dr Michael Dixon, a leading member of the Clinical Commissioning Coalition

www.emis-online.com

EMIS Web has transformed data searching and reporting for 45 GP practices within NHS Stoke on Trent. The PCT’s data quality manager Neil Ryder is now able to produce data reports from his desktop in 24 hours, subject to data-sharing agreements with local practices, thanks to EMIS Web’s state-of-the-art search functionality. It means the data quality team no longer has to spend weeks travelling around individual practices to collect data. “We went live with the system about 10 months ago, and the speed with which we can now turn round reports is quite dramatic,” he said. “For example, we have to collect data every three months for NHS Health Checks. It used to take a day to get round, on average, just five practices; now we can get results from one practice in five to 10 minutes. I would estimate that it has saved our data collection time across the PCT by about 90%, and we no longer have to trouble individual practices with visits.” Ryder is particularly impressed by EMIS Web’s reporting element. “It’s a lot more powerful than anything else on the market. For example, all systems let you run a search for patients with diabetes, but EMIS Web also allows you to extract and report on their latest blood pressure reading or smoking status much more easily than any other clinical system I have used. It eliminates the need to go into the record and make manual notes. You can also break down reports by elements such as age range, medications, or dosages.” Ryder has plans for a number of data searches in future that will help improve patient care – and make life easier for practice managers. For example, with agreement from individual practices, he hopes to carry out centralised searches for enhanced services data – with the potential to save each PM up to four hours a month on producing data reports.

COMMISSIONING | analysis

commissioning person oF the Year:

roger hymas roger hymas is a former md of Bupa and director of commissioning for hampshire pct. he is the founder of the commissioning community website, www. commissioningcommunity. co.uk and a regular columnist on commissioning for Practice Business. You can contact him to clarify any issue at rogerhymas@btinternet.com

It will be up to the PMs to micro-manage practice commissioning budgets to steer the NHS away from a potential train crash. ROGER HYMAS explains why 2012 is the practice manager’s year to shine I had hoped to start the year on an upbeat note, but all around me I see warning signs for the future of GP-led commissioning. NHS politicking seems to be reaching new highs and some of the language is becoming, shall we say, a little less than parliamentary. The factions – the government, the DH, the NHS Commissioning Board, SHAs, PCTs, GPs, pressure groups and trade bodies – are digging in for what could be a long winter. This means that progress with CCG development across the country is patchy. In many localities GPs january 2012 | practicebusiness.co.uk

don’t yet seem to be assuming the role as clinical commissioning leaders, while in others they are roaring ahead. Whatever the picture is locally, thankfully, practice managers are taking a ‘business as usual’ stance and just getting on with it. You know, there really is a lot to be said for ‘keep calm and carry on’. My view is that looking back from January 2013, we’ll find that among all the upheaval, it will be the practice manager who steadied the ship and got us through the year.

fOR hEAlthiER figuRES: thE pREScRiptiOn-REAdy

hEAlthcARE pRintER

With budgets constantly under pressure, small costs soon add up. Reducing the cost of routine activities like printing can release funds to protect vital healthcare services. So next time you buy a printer, consider Kyocera. Our long-life consumables system means fewer components to replace, so every page costs less to print. Our unique Ecosys technology increases reliability whilst reducing energy use and waste. And because our healthcare model is shipped prescription-ready, switching couldn’t be easier.

Call us on 08457 103 104 to find out more. KYOCERA. COUNT ON US.

KYOCERA MITA UK Ltd – www.kyoceramita.co.uk/healthcare

COMMISSIONING | analysis

We’re in the middle of the awards season right now, everything from the Emmys to Employee of the Year. So I’ve decided – with the editor’s approval – that PB should make its own award and proclaim that, for 2012, the Commissioning Person of the Year will be – pause for the opening of gold envelope – the practice manager. I’m being genuinely serious about this and in the next thousand words or so I’ll tell you why.

Leader in the pack We can all feel that the NHS is moving into crisis again. Often, as it’s been in the past, it’s about the money and the prospect of it running out. As I’ve said before in previous articles, the real reason – and what comes down to the last chance saloon reason – for the government to move to GP-led commissioning is because it’s only GP practices that have any chance of controlling NHS finances and balancing the budgets. Every commissioning decision starts in the surgery as doctor and patient eyeball each other. On average, within seven to 10 minutes, a decision is made to refer, prescribe or do nothing, based on the GP’s judgement of the patient’s condition. Often, a care plan is initiated at this point and the short-term financial consequences of the patient encounter are often determined. Nowadays, with a tariff in place, there’s already a good idea of the likely financial outlay for the episode of care. Certainly, the practice managers I’ve met since I started writing this column a year or so ago have all seemed to me to have a clear understanding of where the money is being spent across the healthcare system. Controlling cost and regulating demand, always within a determined risk profile, will be the most important factor in how the NHS will be able to balance its budgets over the next few years. It will be GPs working with their practice managers who will have the most influence over how their share of the CCG budget is going to be spent.

Data management What I see as absolutely inevitable within the next 16 months in the run-up to CCG commissioning is a significant improvement in the management process and, for example, the information made available to practices. Using this data, practices will start contributing to the process of re-engineering the provision of care, commissioning new solutions and designing out what’s wrong. Also, if quality doesn’t improve, they will have the right, for the first time as the commissioners, to find a better solution for their patients. We can also expect to see a lot of january 2012 | practicebusiness.co.uk

CCG initiated tenders seeking different or new care arrangements. Doesn’t that sound exciting? What I’m also really looking forward to – beyond the current raw numbers of commissioning – is the improvement in care quality that practices will begin to drive, this time based on new information about outcomes and patient satisfaction. PMs already know where care provision doesn’t cut the mustard. All the time you see the patients and they let you and the GP know where the experience is less than good. Also, soon you will collect actionable data that begins to take you towards realising the promise of ‘no decision about me without me’.

Micro-commissioning PCTs never sought this kind of feedback and as a consequence were never empowered to drive real commissioning improvement. Not only did they have any impact on what I call micro-commissioning – patient level engagement – but arguably, it meant that some even missed the real disasters in the system, right up to hospitals whose practices have rightfully been condemned over the past few years. History will show that PCTs were dealt a bad set of cards. They were never able to get down to any level of granularity with their reporting systems. They were only able to do commissioning at a macro level. This meant it wasn’t very distinguished; witness the House of Commons Health Committee report on commissioning, published in March. ‘Weaknesses,’ they identified, were ‘due to PCTs’ lack of skills, notably poor analysis of data and lack of clinical knowledge. They need to be able to analyse and use data better to commission services. PCTs will need more power in dealing with providers.’ Every day practice managers do microcommissioning. They know their patients and they know their local providers. What they will also get to understand is exactly what care costs and how much is spent on whom. The reports are already accessible in

My plea for 2012 is for PMs to get more involved in the management of commissioning. The way to get close to this objective is to make the practice manager the Commissioning Person of the Year

advertorial

SUBSCRIBE TODAY AND GET 3 MONTHS FREE

practicebupsrinaecsts icebusiness ers

ns for Practice Manag

+ Inspiring Business Solutio

october 201

november 2011

+ Inspiring Bus

iness Sol

utions for

Practice Ma

nagers

1 YOUR GUI tO manaG DE InG cOmmIs sIOnInG !

sed Negative expo es and in surgery premis Negative equity rs for retiring partne the issues it raises

strengt

at the gates CommissioNiNg e manager leads at

Are small h in numbers CCGs eve n possibl e?

The three practic their story Gateshead CCG tell

A guide

We find out to the p pAt pA Ati tie ien en ntt p practice A pA Arti tic managers’ pAr cipA Ati tio on n opinions ipA on the enh des commiss anced serv A West Cou ioning And ice clo ntry view of the Hea tted creAm lth Bill

the flu? did you CatCh ign the 2011 flu campa We take a look at minute techniques and share some last

Practice Business

is an approved partner

with...

Practice

Business

is an app

roved part

ner with...

SUBSCRIBE TODAY AND RECEIVE...

+ SECTOR NEWS + BEST PRACTICE INTERVIEWS + CLINICAL INFO + MANAGEMENT ADVICE CALL: 020 7288 6833 EMAIL: subscriptions@intelligentmedia.co.uk WEB: www.practicebusiness.co.uk/subscribe/ *TERMS & CONDITIONS In order to qualify for a free subscription, the recipient must be a first time subscriber and be a finance, practice and/or business manager with purchasing authority at surgeries and practices in the UK or

Understanding medical terminology Substantial time commitments are often associated with continued professional development (CPD) and training GP practice staff. This need not always be the case with a new online training course from Mediterm Training, the largest provider of training in medical terminology in the UK. To take the pressure off, Mediterm Training is offering the Level 2 AMSPAR course to medical secretaries, summarisers and reception staff, to study in their own time, with the option of sitting the final exam at the practice under invigilation. This Level 2 qualification is structured around a 12-week online course, covering six modules. Each module covers terminology relating to a particular body system, together with roots, prefixes and suffixes (the nuts and bolts of medical terminology), prescription abbreviations and medical specialities/departments. Full mentoring support is available from the experts at Mediterm Training, along with feedback and on-going assessment through marked revision tests after each module and completion/ feedback of past papers. On completion, trainees have the option of upgrading to the Level 3 Certificate. Courses start in March, August and October of 2012. Courses cost £245 plus £55 exam and registration fees.

Ireland. For those who do not qualify log on to our website to subscibe for half price. For details or to subscribe contact Natalia Johnston on subscriptions@intelligentmedia.co.uk, +44 (0)20 7288 6833 or visit www. practicebusiness.co.uk/subscribe/

For more information, or to book, visit www.meditermtraining.co.uk or contact Gill Critchley on 01625 266610 or Gill@meditermtraining.co.uk.

COMMISSIONING | analysis

the commissioning support marketplace, enabling the PM and the CCG management to mount appropriate challenges to providers. Hopefully, PMs who are comfortable with this aspect of the commissioning process will help develop and introduce more of the required reporting systems. This year will also see the introduction of practice risk reports – identifying the individual opportunities and threats for practices – to help guide managers to where corrective action needs to be taken.

Your country needs you So my plea for 2012 is for PMs to get much more involved in the management of commissioning. Let’s make sure that we break out of the top-down approach to commissioning that we saw with PCTs and move to a bottom-up, practice-led initiative. All practices will not be large enough or sufficiently resourced to do the job, so the CCG role should be organising support for the smaller practices, maybe by doubling up parts of the admin process with the larger practices in the locality. Certainly on a regular basis, CCG analysts should sit beside GPs and PMs in their practices and discuss their commissioning results with them. When executed properly, commissioning does become a genuinely scientific management activity. Effective commissioning means directing patients on to the care pathway, which will create the best outcome and deliver the best value for money for the payer. With so many care pathway options, the patient experience isn’t always optimised. The health destination can be a return visit to the practice, a trip to the pharmacy, a care worker calling at the patient’s home, a community care location, or if the prognosis looks serious enough, a referral to the local DGH. But for many encounters, how often is the hospital consultation the default decision? The real phenomenon of the English NHS is that despite all initiatives to keep patients out of hospital, hospital attendances just keep on growing. Would you like to take a guess about how many hospital outpatient appointments are scheduled every year in the NHS? One million, five million, 10 million? The answer for the year ending 2009/10 was a staggering 87.6 million. Left unchecked, we’re pushing towards 100 million a year by 2015. That’s nearly two appointments a year for every member of the population of England.

Reducing referrals Many of these, of course, start with first hospital referral. Attendances for these went up by two million from 18.7 million to 20.8 million between 2009 and 2010. january 2012 | practicebusiness.co.uk

Around 30% of them resulted in the patient being discharged from the consultant’s care back to the GP without any further need for hospital care. As I’ve said before, across the NHS in England, there are an average of eight hospital referrals a week. Reduce outpatient attendances by one a week and you eliminate about six million hospital visits a year: I reckon that’s at least £750m, maybe as much as £1bn worth of savings for the NHS, with no risk to the patient. Being a lifetime member of the disruption school of management, I’m itching for some originality to be brought to the referral process. The DGH visit needs to be a more considered choice. I totally agree with Clayton Christensen when he wrote in The Innovator’s Prescription (the textbook on radical solutions for healthcare): ‘Hospitals need to be disrupted. We need them to cede market share to disruptive business models, patient by patient, disease by disease, starting at the simplest end of the spectrum of disorders that they now serve.’ But this will also mean more innovation in care pathway design and a genuine movement to creating more OOH alternatives. The challenge for commissioning in 2012 will be breaking out of the top-down, macro commissioning behaviours that have been the mainstay of PCTs. CCGs need to keep their organisation structures flat and lean, just as practices do. They should automate data collection and report generation and, wherever possible, take the load off the GP. Behind the scenes sophisticated algorithms can begin to do the checking and validation (they’re out there). The CCGs should hold practices to account. Believe me, most will relish the challenge. So, what I’m getting at is that for 2012, the only way to get close to delivering these objectives is to make the practice manager the Commissioning Person of the Year. His or her ability to identify the costs associated with their care – and particularly hospital care – will be the make or break factor for NHS finances. Doing it any other way will result in failure. On that note, I’ll wish you a happy, and (hopefully) prosperous, New Year.

Save thousands on skin cancer referrals Malignant melanoma is the second most common cancer in young adults â&#x20AC;&#x201C; and can be deadly if not diagnosed quickly enough. Using technology, practices can instantly reduce referral rates With the continuing popularity of sun beds and beach holidays, skin cancer is on the rise in Britain. There are two main types of skin cancer: malignant melanoma, which is less common but more serious; and non-melanoma skin cancer, which is very common but not so serious. Malignant melanoma incidence rates in the UK have more than quadrupled over the last 30 years. Around 11,770 cases of malignant melanoma were diagnosed in 2008 in the UK and more than two young adults (aged 15-34) are diagnosed with malignant melanoma every day in the UK, as it is the second most common cancer in this age group. Over the last twenty-five years, rates of malignant melanoma in Britain have risen faster than any of the top 10 cancers in males and females. This is no thanks to Britainâ&#x20AC;&#x2122;s love of tanned skin and warm holidays, as sun exposure is the main cause of malignant melanoma and non-melanoma skin cancers. Other factors that influence the risk of skin cancer include: having light eyes or hair and being susceptible to sunburn; having lots of moles or freckles; and using sunbeds. The most common site for men to develop a malignant melanoma is on the chest or back. For women, it is on the legs. A pocket-sized solution With skin cancer on the increase, the onus has fallen on general practice to provide some of the solution. As part of this, NICE published guidelines last year to help the NHS, local authorities and other organisations in their work to prevent skin cancer. With patients becoming better educated about getting moles and concerning lesions checked out, GPs without adequate equipment have to make many more referrals to secondary care as a result. Encouragingly, these referrals can be reduced by at least a quarter using MoleMate 2.0 from Schuco, a portable examination device available from Williams Medical Supplies which also offers aftersales technical support. MoleMate is a non-invasive, rapid, and painless melanoma screening device that has been designed with GPs in mind. By assisting and accelerating the diagnostic process, MoleMate Dr James, QLD enables the clinician to make a decision to refer a patient; excise

We chose MoleMate 2.0 because it provides clear imagery, is easy to show patients and explain and allows us to keep a record

a lesion or assure them that their lesion is not suspicious in a matter of minutes, reducing the need for referrals to dermatology clinics by as much as 27%. THe BUsiness cAse in July 2007, dr Russell cherry purchased a MoleMate device. With 6,750 patients on the practice’s books, dr cherry wanted to minimise unnecessary referrals and patient anxiety, while at the same time avoiding missed diagnoses and ensuring that any potentially dangerous moles were referred immediately for further, specialist attention. An audit was carried out in April 2008 to determine how effective the device had been both in the context of two week-wait referrals, and overall for the practice. it found using the MoleMate saved the practice £7,600 in the first year (based on a cost per referral of £200) – more than 2 and a half times the price of the Molemate itself.

pATienT BeneFiTs •

76% reduction in the two-week wait dermatology referral rate

•

27% reduction in referral rate to dermatology clinics overall

•

no missed diagnoses (false negatives) revealed to date

•

patients appreciate speed of diagnosis and are hugely reassured.

To order the schuco W5173 MoleMate 2.0 for £2,999, contact Williams Medical supplies on 01685 846666 or visit www.wms.co.uk.

people

Winning one for the team Val Denton, practice manager of Tudor Lodge Surgery in Weston-super-Mare, is on a winning streak, taking home a top award for herself, her practice and a grant to use for training. Julia Dennison pays the champion a visit january 2012 | practicebusiness.co.uk

people | interview

When I visit her, she is still very clearly stunned. “We went thinking we wouldn’t win anything,” she says modestly, but there’s no question it’s well-deserved and thanks very much to Denton’s hard work improving patient care pathways, educating patients, rallying her staff and saving the NHS money as a result. This is no easy challenge when faced with 10,200 patients.

Reducing referrals

When I visit Tudor Lodge Surgery in Weston-superMare, the waiting room is filled to the brim, yet the patients (some of whom are nearly falling out the door for space to wait), seem happy. There is a sense that they know that when they are seen, they will be well looked after. And I can’t help but think this has something to do with the busy practice’s ability to communicate well with its patients. For as you walk in, there is a sign clearly stating that the receptionist is in training; two windows to greet patients – one for prescriptions, one for appointments; a plasma screen displaying a plethora of helpful messages; and a sign on the wall boasting of the practice’s recent award streak. Indeed, Val Denton, Tudor Lodge’s practice manager, was recently hailed the ‘hero of primary care’ when she took home the Williams Medical Supplies’ Practice Manager of the Year Award 2011 at a ceremony in London last November. If this wasn’t enough, Tudor Lodge itself was named Practice of the Year and was also one of four winners to receive a share of the BMI Medical £10,000 bursary award at the recent event.

You can’t do anything in a practice if the partners don’t communicate

One of the major initiatives for which Denton and her practice were praised was their successful attempt to reduce unnecessary referral appointments. As part of a practice-based commissioning enhanced service, all practices in the area were encouraged to look at their referrals. Tudor Lodge decided to tackle this by having the GPs meet as a group and scrutinise each other’s referrals. As part of this, they decided to work to reduce the excessive follow-up appointments taking place at the practice, with little or no outcome. The result was a 30% reduction in the first week and much more in the last 18 months and the model has since been taken up by North Somerset PCT for use in practices across the region. Three years ago, Tudor Lodge had one of the highest patient admittance rates to the local hospital walk-in centres during the day of any local practice, but the team has since worked hard to reduce those rates to one of the lowest in the area, by proactively targeting inappropriate admissions and educating patients. The team does this by calling patients who use the walk-in clinic, to ask them why, see if the GP could have helped, and educate them on how by not going to Tudor Lodge, they cost the taxpayer money. “If it’s proven that they just went because it was convenient for them, we actually tell the patient how much it costs,” explains Denton. “If you put it in context, that could pay for part of a special care baby cot or somebody’s hip, patients will think twice about going and will always ring us first.” Tudor Lodge is now open five days a week from 8am to 8pm, so there really is little reason for patients to visit the walk-in centre within that time. The receptionists also administratively triage the patients when they ring up to ensure they get seen by the best person. “The patients hated it at first, thinking they were only receptionists, but they accept it now,” she says. “Nine times out of 10 we can filter them through to the right people.” The receptionists also have a protocol to follow for conditions like UTIs and conjunctivitis, so the patient doesn’t even need to come in. Denton believes it’s a waste of time to have doctors doing the triage when there are skilled receptionists who can do it instead.

practicebusiness.co.uk | january 2012

people | interview

at home all day and wait for the nurse to visit, and many more patients can be seen each week as a result. another one of Denton’s successful ideas was bringing in a clinical pharmacist prescriber to replace a GP partner who left. tudor lodge is one of very few practices in the country to have a pharmacist prescriber, which has proven very helpful. “She can do diabetes; she does all our medication reviews; she does insulin initiation; she does a minor illness clinic; she’s a real valuable source of skills,” says Denton. “Most practices are under pressure to be efficient prescribers, keep within budget, but also not compromise patient care, because it’s not all about money,” she continues. “With prescriptions, you get a lot of queries. Patients should have a medication review at

caRing aPPROacH the team phones elderly patients, those recently bereaved or those who have been in hospital to check on them. this takes little time, and allows staff to keep tabs on the practice’s more vulnerable patients. Furthermore, different team members are allocated to different conditions, and stay in touch with the patients with those conditions to ensure they have everything they need. “it’s more personal care here,” explains Denton, who herself has a list of patients to call each week. “i think we just go that extra mile but we do it because this is what we do – it’s not that we’ve sat down and said this is our plan. it’s just our culture.” as part of this culture, unsurprisingly, the practice has a thriving patient participation group, (which was responsible for putting the congratulatory poster for the winning practice up in the reception area). “it used to be a mouthpiece for the patients to complain but now it’s changed completely, we really work closely together and talk about what services patients want, what they can do for us,” says Denton, who will invite speakers in to educate the PPG about things like commissioning, to keep them abreast of the changes to the nHS, and even has had them sit behind reception to get an idea of what it’s like from the practice staff’s point of view. “they’re much more clued up about what’s going on and that really helps,” she adds. this results in a very strong relationship between the practice and its patients – which is evident in the room full of waiting patients when i visit.

clinical iMPROVeMenTs the practice has worked hard to bring more traditionally secondary care services to the practice, for example one of the GPs acts as a diabetes lead. Denton has also brought in a district nurse catheter clinic to the practice. Patients have pre-arranged appointment times so they don’t have to stay january 2012 | practicebusiness.co.uk

least once a year, which means a face-to-face consultation with a doctor to make sure they’re on the right quantities, and a lot of the GPs’ time was being taken up by these when they could be seeing sick people.” the pharmacist prescriber can take on many of these clinics, freeing up the GPs’ time, and is also able to advise doctors on what they should be prescribing.

TeaM MORale Faced with such tough nHS budget cuts, Denton believes efficiency is fundamental, however, to do this, she understands how essential it is to maintain staff morale. “We’re very much a family here; we’re very supportive of each other,” she comments. as part of this, all the support staff are trained on each other’s role, so they can crosscover different shifts. although she’s the manager, Denton still spends an hour on reception every day to keep herself hands-on and in-touch with the patients. the partners also meet every morning for coffee. “You can’t do anything in a practice if the partners don’t communicate,” she explains. Denton believes wholeheartedly in skilling up her staff, which is why she will be using her £2,500 share of the bursary the practice won towards training and education. She trains the healthcare assistants to do as much as they can and one of the nurses recently went on a prescribing course. it’s also a training practice, taking on medical students from year two, right up to registrars. “although that costs us something, in time, it actually keeps the doctors on their toes clinically,” says Denton. “it’s actually cost neutral in as much as the time the doctors spend training, the trainees are seeing patients anyway and i think it’s been a real benefit to us.” as i leave the practice, the staff are preparing to have their annual Christmas comedy play, which Denton writes. this, along with regular meals and quiz nights, is evidence of an admirable effort by an award-winning team to work closer together in order to improve the health and wellbeing of a local population.

facT BOX PRACTICE Tudor lodge Surgery PATIENTS 10,200 PARTNERS 5 GPs 6 STAFF 22 CCG North Somerset PCT North Somerset PRACTICE MANAGER Val Denton TIME IN ROLE Four years BACKGROUND After starting a family, Denton’s primary care career began as a medical receptionist in a small rural practice. She soon outgrew the role, self-funding a practice management course and passing with distinction. She became a deputy practice manager at a university health centre in essex, before being promoted to practice manager and moving to Tudor lodge.

people | interview

One for the money

Itâ&#x20AC;&#x2122;s financially tough times for GP practices. Nick Nurden, partner and practice manager at The Ridge Medical Practice, is one businessman with a good head for the bottom line. Julia Dennison visits him at his new ÂŁ11m Bradford premises to find out how he is maintaining and developing further revenue streams january 2012 | practicebusiness.co.uk

people | interview

As you approach The Ridge Medical Practice in central Bradford, its impressive façade has an air of a community centre. An interweaving complex of new and old buildings, the GP surgery boasts a café, an education centre, pharmacy, open-plan reception (with plasma screens to boot) and smiling staff to greet you from behind a desk that feels vaguely reminiscent of a hotel. All this is thanks, in part, to the hard work of one man: Nick Nurden, the practice’s business manager. Now five years into his role, he oversaw the recent building project that brought a number of different primary care services under one roof. While the practice’s efforts to reach out to the deprived nearby community seems altruistic in nature, Nurden is a businessman through and through. Every decision he makes as the business manager of The Ridge Medical Practice is one he does with the bottom line in mind. Lucky for him, much of what helps patients stay healthy, saves the practice and the wider NHS money in the long run. For this reason, budget spent on bringing services into the community, he feels is money well spent. As a result of his forward-thinking approach to general practice, Nurden has overseen an organic growth of 40% in patient numbers since he joined the practice and has successfully tendered for two local GP practice contracts – bringing the total number of surgeries the practice is operating to four: two PMS and two APMS.

Building for the future When Nurden first joined the practice as a partner, one of the first things he did was commission a new building. This was long overdue as the previous premises were not fit for purpose, as back office and clinical functions were divided between two different buildings. The partners bought the land The Ridge currently occupies in 2007 and spent the next year designing a building and getting it through planning. Nurden considered a third-party developer, but opted against it in the end to ensure full control over the end result. So he appointed the architect, who worked closely with the practice to see the project through. “The architect came in and met with our nursing team, GPs and staff so the design of the building reflected the culture of the practice and the way in which we wanted to work,” he explains. The end-result is a uniquely curving building that Nurden is happy with, despite it costing £11m to build and leaving the practice with a £9.5m mortgage. Natural light features heavily throughout the openplan reception. This, coupled with the surgery’s colour scheme and surgery’s branding, give a friendly and professional impression. “I wanted people to feel they

were in a clinical space because it felt clean, but I wanted to get away from that hospital feel and [for it] to feel like a family doctor,” Nurden explains. The practice has now been smoothly running out of the new building for the last two years.

Community outreach programme When the partners bought the land, the terms of their planning permission included refurbishing the derelict building across the way. Despite it not being an ideal space to hold clinics, the partners decided to keep the Yorkshire stone edifice and use it as a community health education centre. “If we are going to meet the challenges of the NHS going forward, we need to be educating our patients,” Nurden explains of the thought process behind the centre. Now completely renovated, the education centre includes a lounge, classroom, café, which promotes healthy eating, and office space that the practice is hoping to turn into a place to address the needs of the local youth population. “It’s linked with the health centre, but it’s a different space,” he explains of the building. “When you’re having a weight loss [clinic], to sit in a consulting room is too clinical and actually we want to break that down.” It’s an ideal space for patient involvement and one of the practice’s receptionists has recently been promoted to patient services manager and now runs a patient involvement group out of it. One of the health care assistants, for whom the practice recently sponsored a health and social studies degree, also works out of the centre as health promotional manager, who is on hand to speak to patients who make unnecessary appointments, in order to prevent them in future. Other projects the practice runs out of the building next door include a ‘cook and eat programme’, which teaches young mothers from the local estate how to cook. “It frightens me, but we get mothers in their mid-20s who have never peeled a carrot in their life,” comments Nurden, who also understands the need to work with more local services, including the pharmacy, schools and local community and voluntary groups to get a deeper handle on the various problems in the community. “We have a number of patients who are creating a lot of demand on us and their needs are probably more social than medical,” he explains. “So if we can, we take those people out to local groups that can give them that support better than we can.” The practice gets no extra funding for this project, but this doesn’t deter Nurden. “At the moment we’re under financial pressure, but actually, we need to get a blend between taking a short-term view that says

FACT BOX Practice The Ridge Medical Practice Sites Four PCT NHS Bradford and Airedale Patients 25,000 Partners Seven GPs, one nurse practitioner and the business manager GPs 22 Nurses 9 HCAs 6 CCG Bradford Contracts PMS and two APMS Practice manager Nick Nurden Time in role Five years Background Previous to his role as business manager at The Ridge, Nick Nurden worked as a recruitment consultant, facilities manager and as an operations manager for Orange.

practicebusiness.co.uk | january 2012

people | interview

we’ll stop spending on everything and we’ll retract and developing things for the future.” He says this with his commissioning hat on – as the practice is active in the local Bradford clinical commissioning group.

Financial pressures There is no doubt, however, that finances are in a pinch for practices. “Partner profits are challenged; we know NHS funding is tight and is only getting tighter in the coming years,” says Nurden, who points out that the fact that GP practices are run as private businesses puts them at risk. “If you look at a GP practice, the way it’s structured as a partnership, it’s a unique strength of general practice in that the dedication you get is a huge strength, that if you got rid of it, and went to a completely salaried service, you wouldn’t get,” he says, “but it’s a huge risk as well because if you look at your average GP practice running as a business.” He gives the example of a Warfarin clinic the practice is running that is receiving less funding from the PCT than it used to. “This means that people who are working the hardest are working harder than they ever have done are taking a year on year pay cut.” The majority of Nurden’s costs are fixed costs that aren’t easily reduced – like the electricity bill or staff salaries. “If you’re getting a hit to your income, which we are because they’re making it harder to earn the same money through QOF, incentive schemes coming to an end or enhanced services we’re not able to deliver, unless I do something differently, then partners’ profits fall,” he adds. The responsibility thus falls on the practice manager to keep revenue at a healthy level in other ways. Apart from the long-term investments in health promotion and the community, Nurden is also looking at the shortterm – and it is not in petty savings. “Most people, when they need to save money, shop around and look at things like stationery and medical supplies, but actually, that’s tinkering around the edges,” he says. “Most practices are buying fairly economically, they’re getting into buying groups to save a bit of money. We’re a big practice but my spend on medical consumables is about £35,000 a year. Now I could put quite a lot of effort into shopping around further, and save 20p here and there and I might wipe five per cent off it, which would probably cost me more in staff time to do it.” One area of focus is appointments. As a result, Nurden focuses on helping his staff identify the patients who need to be seen, rather than those who want to be seen by prioritising and tagging patients on the software system. “There’s a real risk that the patients who ring up and shout the loudest are the ones who get seen,” he explains. He has also been working with the january 2012 | practicebusiness.co.uk

people | interview

practice nurses to take a holistic approach to patients with long-term conditions, helping them work with the whole patient rather than getting them in for a different appointment for each condition. All in all, it’s about working more efficiently. “I still don’t think we’re quite perfect on that,” he admits. “We need to look closely at all our processes to make sure we’re doing the most important things and it really comes down to skill mix.”

Staff shuffle Indeed, the real money to be saved is in the work force, believes Nurden, but not in the support staff – where the impact of one less receptionist could be huge. Rather it’s in reducing the number of unnecessary salaried GPs. “If I’m going to protect partner profits from falling any further I’ve got to look at the workforce – and what you’ve really got to look at is the clinical workforce.” Nurden uses his business acumen to consider the value of the clinical staff. He estimates the average salaried GP costs £90k, nurse practitioner £60k, and nurse £30k, endeavouring to use the cheapest labour possible to meet the patients’ needs. “Why have a nurse do it if I can have a healthcare assistant do it? Why have a nurse practitioner do it if a nurse can do it? Why have a doctor do it if a nurse practitioner can do it? It’s getting the skill mix right in the team,” he explains. For example, he feels nurse practitioners are better suited to deal with coughs, colds and flu than doctors. These clinicians’ value is evidenced when you consider that when Nurden started, The Ridge had one nurse practitioner and by March it will have eight. In his experience, nurse practitioners work best as part of a clinical team and with this in mind, The Ridge has launched what it calls the ‘same-day assessment clinic’, which is led by a GP who works with nurse practitioners to work down a list of around 80 patients. As a result, the people who need to be seen get seen in an efficient manner. “The GP sees less patients, but deals with emergencies and more complex things that really do need to be seen the same day,” explains Nurden. As part of this, the GP also works through a list of general enquiries – “so it’s more like a secondary care outpatients’ clinic where the consultant leads, with his registrars doing the work around him.” While this move to nurse practioners saves the practice money, it’s not the sole reason for the shift. Nurden has found that GPs are harder to come by.

He advertised recently for GPs and nurse practitioners and only had two GP responses – and many more for the nurse practitioner role. “Historically, the route of a GP was you qualified, did a bit of locum work, maybe a bit of salaried work and then you got a partnership somewhere, and that was your career progression,” he explains. “Now, the doors are shutting on those partnership options because that’s another way to save money if you’re a GP partnership – if a partner leaves, replace him with a salaried GP and it gives you all £10k boost in profits. So we’re finding most GPs who join us actually want a portfolioed career – they don’t want to work full-time as a GP.” Furthermore, Nurden feels working as a full-time salaried GP, working nine sessions a week, for example, seeing two and a half hour booked surgeries is too stressful and instead encourages his GPs to find specialisms. This focus on specialisms also fits nicely into the commissioning agenda and provides the practice with additional streams of income. For example, specialist GPs run neurology, dermatology, MSK, sexual health, women’s health, blood pressure and anti-coagulation clinics, as well as vasectomies, minor surgeries, and ECGs – on all of which the practice can earn a tariff. Nurden sums up his key efforts of a business manager in a modern practice: “It’s about developing the right team; looking at processes and procedures; managing the money carefully; educating the patient; and continuously adapting access.” He believes primary care and the NHS has a lot to learn from the private sector and that the future of general practice will lie in bigger practices, which can take advantage of much of the same back office infrastructure to smaller practices. He believes this will only work, however, if practices work smarter to improve the level of service they give patients, while getting away from the one-size fits all approach to general practice. This is made possible by having a range of appointment types and times and making efficient use of the staff. Doing all this will continue to keep partner profits at an acceptable level and allow a smart practice and its manager to keep their eyes on the long-term future.

Why have a nurse do it if a healthcare assistant can do it? Why have a nurse practitioner do it if a nurse can do it? Why have a doctor do it if a nurse practitioner can do it? practicebusiness.co.uk | january 2012

business intelligence and management sense for practice managers

management

Rest secured Threats to security should be at the forefront of any practice manger’s mind – though not to the detriment of patient relations. Julia Dennison looks at things practices can do to protect their premises The number of break-ins and patient attacks on staff has been on the rise in general practice, to such an extent that last month, a poster campaign was launched in Wales to highlight the issue. The NHS’s zero tolerance policy on aggressive and abusive patients who target doctors, healthcare workers and staff has been a success, with 200 prosecutions since April 2010 in Wales alone. However, GP practices have to take their own precautions. Staff safety is paramount, yet this is also a time where a grassroots focus on healthcare means surgeries must also maintain a good relationship with their patients. “The need to provide a truly accessible service is increasingly a requirement rather than an aspiration, following the implementation of disability discrimination legislation and the compulsory registration of all GP practices with the Care Quality Commission by 2013, which will involve compliance with essential standards, some of which relate to the suitability of premises,” warns Bryan Wootten of Wootten Dean Chartered Surveyors, who sees the issue of premises security in two parts: maintaining a fully secure building when the premises are not in use and securing the practice when it is open. “A balance needs to be struck between creating a pleasant environment for patients and staff, whilst ensuring that they, and the premises and contents, are protected,” agrees Martyn Hayward, senior director and head of DTZ Facilities Management. However, it’s important to remember that GP practices are public spaces that make prime targets for criminals and the insurance industry generally categorises GP practices’ crime risk as ‘high’, due to the desirability of its drugs and equipment. “Reduction or prevention of crime

january 2012 | practicebusiness.co.uk

against the person can be dealt with by undertaking a detailed risk assessment,” he explains. This risk assessment should cover the property, contents and its people and it’s important to get a recognised health and safety expert to do it. “If a claim is brought against the practice, it can very probably defend itself by demonstrating that the partners have recognised their duty to protect all those on the premises and have discharged this duty by following professional advice,” says Andrew Lockhart-Mirams, senior partner at Lockharts Solicitors.

Heart of glass Once a risk assessment has been undertaken, practices can begin to get an idea of what they need to do to keep themselves secure. “There are simple things that can be done to improve security of staff, such as assessing the layout of rooms in order to allow ease of escape for any member of staff who feels threatened or finds themselves in a situation with an irate patients,” comments Daniel Dickinson, building manager at One Medical. “Person safety extends not only for example to adequate lighting both inside and outside the premises, but also to proper door locking systems and very possibly to some form of security barrier between the reception area, which will always be under the surveillance of reception staff, and the corridor to clinical areas which, for most of the time, will not have practice personnel present,” says Lockhart-Mirams. Larger practices may wish to consider a security gate, particularly if they share a waiting room. When it comes to the reception desk, there are a few things to consider. The Disability Discrimination Act requires a low level front desk area for wheelchair

management | premises

users, which could present a security issue. “This can be addressed by good design, such as increasing the depth of the desk or incorporating appropriate and welcoming protective screens,” says Wootten. Installing glass windows in reception is sometimes an unpopular option among patients. “Only a few patients complained about how terrible the screens were when they were installed and how the place looked like a bank, but I personally feel that more and more practices do have to be more professional and looking like a bank is not a bad thing,” says Debbie Gladwell, practice manager at West Hampstead Medical Centre who recently installed security screens. “We seem to be having less problems face-to-face with patients, although I do get called in now and then to deal with an angry patient. Sometimes you have to be quite frank and stern with patients.” Jeremy Syree, a partner at accountancy firm Ballard Dale Syree Watson LLP, recently advised a large GP practice in the West Midlands on several development areas – one of them being a large state-ofthe-art conference room and suite. When the practice manager was concerned about the premises being left over night, Syree helped his client to think carefully about security options – in this case, dissuading them from security screens. “When I recently read about companies offering GP practices thickened, bullet proof glass fronts to the reception desk, I felt this would separate staff and patients and, thank goodness, [is] currently unnecessary,” he comments. He did feel the practice needed to bolster its security, however, and helped the manager consider a number of options, including a door buzzer entry and CCTV system around the perimeter. Any CCTV system should be fitted and maintained by an installer registered with a nationally recognised installation body, such as the National Security Inspectorate. Even if you don’t install CCTV cameras, you should be seen to be doing so. “Simply displaying signs highlighting that security measures are in place can go a long way towards preventing criminal activity and dummy CCTV cameras are another great deterrent,” recommends Dominic Slingsby, MD of Slingsby. Motion detection lights is another option for protecting the building, so is grilles over windows. “All accessible opening windows should be fitted with key-operated locks, but protect secluded windows and roof-lights with grilles or shutters,

A few patients complained about how terrible the screens were and how the place looked like a bank, but I feel that practices have to be more professional and looking like a bank is not a bad thing practicebusiness.co.uk | january 2012

management | premises

which will be hidden from view of the patients,” says Hayward, who recommends practices install shutters over the door, which can be rolled up and hidden during opening times, together with bollards to deter ram raiders – which will need planning permission. Protecting drugs on site is paramount, particularly for dispensing practices. Managers should ensure medicine and medical supplies are protected to the standards required by their relevant professional body. Furthermore, patient records could also be targeted by identity thieves, so it is essential you give those your full attention, this includes security checking contractors, such as cleaners. However, no security measures are completely crime-proof. “Given time, almost any physical security can be overcome, so consider fitting an intruder alarm system which will act as a deterrent and limit the time an intruder will have on your premises,” says Hayward. Also, while the practice is closed, lock away any portable electronic devices in a secure cabinet and security mark anything valuable. “Bold marking of equipment, such as engraving the surgery name or post code greatly reduces the ‘pay off’ if a stolen item is to be sold,” he adds.

safetY fIrst It’s important when installing any physical security device to ensure it is not in breach of any fire safety regulations. “A safe means of escape should not be hindered by security devices,” agrees Hayward, who explains that locks on external doors should carry the British Standards Kitemark and comply with BS3621. Staff should also be protected by accessible panic buttons in all the rooms, or by agreeing on a verbal code they can use over the telephone if they are in an unsafe situation. However, there are even subtler ways of doing this. “Overt panic buttons are gradually being replaced by alarm systems which allow staff to type in an alert phrase into their computer keyboard, which will notify other staff of the need for assistance in a particular room without communicating the alarm call to the patient,” explains Wootten. Mirrors can also help staff keep a close watch on possible unsavoury behaviour. “Wherever possible, steps should be taken to reduce blind-spots, which is often just a case of installing convex mirrors,” says Slingsby. Lastly, it’s important to keep up appearances. “As well as giving patients a good first impression, burglars know that a well-maintained site is more likely to be secure, so look after the appearance of your premises,” recommends Slingsby. “Think about how january 2012 | practicebusiness.co.uk

a criminal would get into your building and look at every opening, including air vents and roof access to see how they can be made more secure. Finally make sure that all areas outside a building are well-lit and often this can simply be a case of using brighter bulbs in existing lights.”

tIMINg Is eVerYtHINg Practices considering security investments may want to act quickly to get the most out of the Annual Investment Allowance (AIA). The AIA is a type of capital allowance, which offers tax relief at 100% on qualifying expenditure in the year of purchase. The maximum you can deduct from your taxable profits is £100,000 – however this will reduce to £25,000 from 6 April 2012. “Due to this reduction, we felt it tax efficient to make this investment into security before the changes took place next year,” Syree said of his client’s security purchases. Once new equipment or procedures are put in place, it’s imperative staff are trained to use them. This includes making them all aware of what to do in an emergency. It’s also important to form a good working relationship with the local police, specifically their Crime Prevention Office or Safer Neighbourhood team. Furthermore, practices should ensure they have sufficient occupiers liability insurance and third party insurance cover in force – “insurances which safety tips Practice manager Debbie gladwell shares her tips should cover any liability if accidents happen not 1. listen to your staff and look at ways in which to withstanding following the improve security steps set out in an audit,” 2. Be realistic about your budgets and what can be done says Lockhart-Mirams. 3. Involve the reception team and allow them to offer their This, alongside the right opinions on improvements protection equipment and 4. ensure the security measures fit with the existing procedures, will ensure practice settings (to enhance the existing working happy staff and patients. relations with the patient) To which Wootten adds: 5. ensure installations cause minimal disturbance to “The truth is that there practice consultations/day to day running’s 6. Do not be afraid to receive negative feedback following are no absolute guarantees the installation (from patients or staff) of safety for all within 7. allow for further improvements to be made – we recently the patient environment received feedback from staff and patients that they but there is a need for found it difficult to hear through the glass panels, so an understanding of we have purchased a microphone to test out and if this the balance between works we will purchase two more to rectify this issue. accessibility and security 8. If you have a patient reference group, involve them in within the practice the process environment.” All a practice 9. tell patients about all the improvements made – I am manager can do is try hoping to do this very soon with a leaflet for patients. their hardest.

UNCOMPLICATED, RELIABLE AND COMPATIBLE PRESCRIPTION PRINTING

For more information contact your usual supplier or visit www.brother.co.uk/healthcare

management | qof

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

january 2012 | practicebusiness.co.uk

Learning difficulties

Learning difficulties is often an overlooked and little understood side of healthcare but seven QOF points are available for its management. Dr Paul Lambden explains the different conditions to look out for Learning difficulties is a poorly understood area of medicine that includes a variety of disabilities affecting an individual’s abilities to understand information and communicate. It is caused by a disturbance in brain development during pregnancy, associated with anoxia during delivery; through illnesses such as meningitis; or head injury during childhood. It may also be the result of the presence of certain genes, either through inheritance or by transmutation. The condition affects over 1.5 million people in the UK. Approximately 20 in 1,000 people have mild learning disability and three to four out of 1,000 have severe and profound learning disabilities. The difficulty may affect the use of words, the ability to write, use figures, concentrate, or behaviour and social communication. It may be mild, moderate or severe and the nature of the difficulty will vary and there is no consistency between groups of people with the same diagnostic label. The problem may affect the person’s ability to learn or their ability to undertake particular types of work. Some adults can live independently, while others need assistance with everyday tasks. The disorder may present in a variety of ways. • Dyslexia sufferers may encounter difficulty with both the spoken and the written word. The mechanism is complex and is believed to be associated with the perception of visual and auditory information. There may also be difficulty with some aspects of short-term memory. Concentration and the ability to organise may also be affected. Dyslexic people may, however, be very talented and may display considerable skill in managing the area of difficulty. • Dysgraphia is a difficulty in writing and may present in a variety of ways. Letters may be irregular in size or shape or mixed upper and lower case, spelling may be poor and the result may be text which is illegible. The degree to which written communication is affected may exist in varying degrees and the person’s intelligence may be above average but there may be a lack of co-ordination and fine motor skills. • Dyspraxia is a condition affecting coordination. It is developmental and can affect movement, perception and thought with the result that physical activities such as speech, fine motor movement, bodily activity and hand-eye coordination are disturbed. There may also be disturbances in the application of logic and the ability to organise. • Dyscalculia affects mathematical skills but affected people have normal language ability and have no difficulties with the printed word. They struggle with addition, subtraction, multiplication, division and mental arithmetic calculations. They have difficulty remembering mathematical formulae, mastering arithmetic facts and they may transpose, omit or reverse numbers when doing calculations. The problem spills over in to normal everyday living because they may confuse left and right, may not keep track of time and miss meetings, etc., may have problems with banking and other financial accounting. Some people may have problems

Normally diagnosed in childhood, once identified, the GP can refer for specialist diagnosis, advice and management

management | QOF

reading music. They may also have a poor sense of direction. • Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are non-psychiatric disruptive disorders. Affected individuals struggle to maintain attention and may have a pattern of unpredictable difficult behaviour including hyperactivity, impulsiveness, mood swings and social ineptitude. Patients with the condition may also experience anxiety and depression. • Autism is a developmental disorder characterised by impairment of social skills, language and behaviour. More severely affected individuals may be unable to communicate verbally or make eye contact. It is a neurological disorder, genetically determined and affecting over half a million families in the UK. • Asperger’s syndrome, sometimes called high functioning autism, presents with variable features including inappropriate or unexpected responses to particular situations, difficulties with social interactions and particular difficulties such as problems with reading. Obsessive actions are often a characteristic. This may be a problem but can be an asset resulting in punctuality, reliability and attention to detail. The syndrome is neurologically based. However, intelligence may be unaffected. Seven QOF points are available in connection with patients with learning disabilities. Four points are available for maintaining a register of patients over age 18 with LD and up to a further three points can be obtained for measuring thyroid function (TSH) in up to 70% of adults with Down’s syndrome every 15 months. Normally diagnosed in childhood, once identified, the GP can refer for specialist diagnosis, advice and management. Healthcare professionals involved may include paediatricians, speech and language therapists, physiotherapists, psychotherapists and educational and clinical psychologists. The approach is multiprofessional and treatment will be directed towards helping individuals to live independent lives and making them as normal as possible. Support for people with learning difficulties has improved over recent years. Virtually everyone with learning difficulties now lives in the community.

management | legal

How to attract new partners Recruiting new partners to join a partnership can be a challenge, particularly for GP practices. Victoria Patterson, a solicitor at law firm Veale Wasbrough Vizards, gives her tips on how to attract, recruit and retain new partners Recent surveys indicate that many GPs, particularly those over the age of 55, are contemplating early retirement from partnership. Although in many cases, this is of the ‘24 hour’ variety, the causes for this exodus are obvious: uncertainty about the future, the new contract, the new ‘structure’, increasing performance monitoring (CQC and revalidation) and the impact of the new pension arrangements. The effect of these uncertainties may also encourage incoming GPs to prefer salaried status over partnership. The consequences of this could mean that there will be too many practices looking for too few applicants.

Interviews are a two-way process so make sure you are well prepared and familiar with the application. Set aside plenty of time for the interview and be prepared to answer questions and ‘sell’ the practice. If interviewing a number of applicants, it is desirable to use a standard assessment form on which you individually assess each applicant. To avoid any allegations of discrimination, make sure you can justify any particular choice. After you have held the interviews, make a timely decision. Once the successful applicant has accepted the role, offer feedback to unsuccessful applicants. Be cautious that any feedback given does not give rise to any allegations of discrimination.

Recruiting the applicant

Retaining the applicant

Where is the best place to advertise to attract the right applicants? Think carefully about the content and placement of the advertisement. While it must grab attention, think about the legal constraints. What is being said about the contract? Is there a risk it could be construed as discriminatory? Have you complied with advertising codes? To attract the right applicant for the role, you need to adopt a good recruitment procedure. Consider using an application form to obtain information about specific topics, making it easier to compare candidates. There is no second chance to make a first impression, so make that first point of contact count. Once an application is received, personalise the response and define the recruitment process timetable.

Use a probationary period effectively to ensure you have found the best match for the practice. Implement an induction programme and training process so the new partner settles in quickly. The key to retaining staff is to maintain a good working environment, so make sure the new partner feels part of the team from day one. This could mean having a welcome lunch or regular one-to-one meetings. Building the foundations for a strong future partnership is always time well spent. After all, any business partnership is often considered to be a relationship closer than marriage and even more difficult to unravel!

Legal update sponsored by Veale Wasbrough Vizards

january 2012 | practicebusiness.co.uk To receive some examples of recruitment policies and procedures, please contact Victoria Patterson on 0117 314 5387 or at vpatterson@vwv.co.uk.

There will be too many practices looking for too few applicants

practicebusiness.co.uk | january 2012

management | premises

Sound advice One in six people are deaf â&#x20AC;&#x201C; of those, 800,000 are severely or profoundly deaf. These difficulties result in problems including misdiagnosis, missed appointments, wrong prescriptions and a poor patient experience. Dr Mandy Basi provides advice and guidance on making your practice more deaf accessible

january 2012 | practicebusiness.co.uk

management | premises

There are more deaf people accessing healthcare services than ever before. Ten million people in the UK (one in six) now have a hearing loss. However the service experienced by deaf patients varies considerably, with many, unfortunately, being very poor. So how does deafness affect the patient experience? Ultimately, deafness throws up many obstacles that affect both the deaf patient and the hearing healthcare provider. Poor deaf patient experiences are due largely to a lack of knowledge, understanding and appropriate skills of staff. Healthcare is not alone, indeed in many sectors when asked: “Is your organisation deaf aware?” it is not uncommon to hear a reply of: “We’ve never really thought of that.” “As a deaf person I experience day to day difficulties with communicating with some hearing people,” says Lucy Clark, cofounder of DeafWise, a deaf awareness training organisation. “There have been many times when I have been sat in a waiting room at the doctors and my name has been called out over the loud speaker, but being deaf I don’t hear it. I always tell the receptionist that I am deaf so they can let me know when it’s my turn, but this doesn’t always happen, I have been left there and missed my appointment, to both the doctor’s and my frustration.” In this case Clark took the responsibility of being a deaf patient to let the hearing receptionist know she was deaf. Often the problems start when a hearing person doesn’t actually realise the person is deaf (not all deaf people have a recognisable sign such as wearing hearing aids).

Tips on how to recognise if a person may be deaf (if they don’t tell you): • • • • • • •

They may be wearing hearing aids They may not react to sounds They may watch the speaker’s mouth or face They may not react to someone speaking to them They ask you to repeat something They have a hearing guide dog They have an unusual speech pattern and tone.

So having been made aware of the patient’s deafness, common sense would have suggested that Clark would need to be attracted in a non-audible way – simply walking over to her and getting her attention would have done it, but either someone forgot or was too busy or just didn’t think. Clark’s dental practice realised that she was going to be a regular patient and providing great customer service to all patients is a primary aim of the practice. The receptionists are often the first point of contact and so along with the dental nurses they attended deaf awareness training delivered to understand the obstacles that they would face when communicating with Lucy and other deaf patients. By understanding their patient’s needs, adopting an inclusive attitude and having the ability to adapt their communication

Word of mouth is strong in the deaf community for recommending organisations that are deaf aware style, the team now demonstrates how simple it is to make a big difference to the deaf patient’s experience. The result is a practice that is more aware of their diverse customer base and what is needed to engage better, not only on a face to face level but at all points throughout the patient journey. Perhaps more importantly they have a happy patient who is made to feel welcomed and valued and return time after time.

Tips for face-to-face communicating with a deaf patient: • Keep a good distance – three to six feet is sufficient for a deaf person to see your face and arms/hands • Make sure there is no bright light behind you – this casts a shadow on the face and makes it harder to lip read. • Keep face-to-face contact when speaking – if a deaf person can’t see you face, they can’t understand what you are saying so try to not look away mid-sentence. • Do not use long and complicated sentences – try and keep it simple. • Do not exaggerate your mouth too much – it’s harder to lip read someone who is not speaking with a natural rhythm. • Please do not be dismissive with ‘oh never mind’ – have a little patience and include the deaf person in your conversation. • If at first you are not understood – repeat, then rephrase. Don’t continue to repeat the same sentence over and over. If it’s still not working, use a pen and paper. Non-face-to-face communication throws up more challenges when it comes to access by deaf patients. Having explored the whole customer journey and identified obstacles to their deaf patients, Clark’s dentist also now send text messages with appointment details and allow her to reply by SMS. The great thing is that this simple inclusive solution benefits both hearing and deaf patients. Word of mouth is strong in the deaf community for recommending organisations that are deaf aware, and equally for those that aren’t. If a business demonstrates a positive attitude towards deaf people, improved perception and increased custom will most certainly result from this currently under catered for audience, likewise with the likes of Twitter and Facebook, tales of bad experiences are soon spread. practicebusiness.co.uk | january 2012

work/life

Friends for life advice for busy lives

The relationship between doctors and managers has changed considerably in recent years, and itâ&#x20AC;&#x2122;s set to change even more. Practice partner and manager Debbie Bodhanya gives her advice on coping with the GP/PM divide Working within a busy practice and constantly changing NHS presents many challenges, none more critical than that key relationship between the partners and the practice manager. In any industry the ability of the senior management team to establish effective and efficient working relationships influences the ultimate success of the organisation. The philosophy and culture is created by the leadership and the team dynamics.

january 2012 | practicebusiness.co.uk

Practices vary in their style and approach to senior management. Some are doctor-led and the practice manager is the linking pin between the GPs and staff. Other practices have a flatter structure and the practice manager is integral in the strategy and direction of the practice. Whatever the style of the practice, effective communication is vital. We all have busy roles. GPs are balancing their clinical sessions, path results, paperwork, telephone

work/life | relationships

calls, homes visits etc. The practice manager is juggling staff issues, rotas, finance, premises issues, PCT demands, and the list goes on. This means that making time to develop that key relationship is hard. It’s sometimes physically impossible to find five minutes in a day to speak with the particular GP that you need to help with a management issue. So what can we do to help in a practical way to develop this all important relationship?

Understand the communication style of your GPs No two people are the same but time and research has shown that there are ways in which we can develop techniques to understand each other’s communication style. There are many techniques out there, but in a sense it’s about finding out more about each other and what is important to us. Are we someone who likes detail? Are we motivated by what makes the team feel good? Are we action orientated? Do we function best if actions feel fun? If you are meeting with a GP who likes detail and needs to know why, then arriving poorly prepared to a meeting with no documentation and no logical explanation probably won’t give you the best outcome. Speaking with a GP who is concerned about the team and not having considered the impact of your suggested plan on the feelings of others may also not get the outcome that you had hoped for or needed for the organisation. So taking time to think about your partnership team and the styles that are within may help you to create an optimal environment for discussion.

Understand your communication style Insight is a wonderful thing. Knowledge of how we communicate can be such a powerful tool if with that knowledge we can adapt to suit a situation or person. When communication goes wrong, is it because of us or the receiver? How do I like people to communicate with me and how do they perceive my communication style? Do I like to get straight to the point? Do I ask how someone is feeling before launching into my thoughts and plans? Do I explain what the benefits of a project are to those in the team? Reflection on how we communicate can help us, not only with our relationships with GPs, but our whole team, patients and other organisations.

Set meeting times Acknowledging that we all have busy and

demanding roles, we need to allocate appropriate time to meet and discuss strategy and operations. Ad hoc meetings can lead to frustration and resentment by both parties so agreeing what times are good to meet is really important. Is an early morning meeting better before surgery starts to allow a GP to think of management issues ahead of a busy clinical day? Is lunchtime better with a coffee and a sandwich? Whichever it is, setting the time in the diary ahead of crisis situations occurring is crucial.

Clear goal setting Having a clearly agreed set of goals and expectations may enable both parties, not only to evaluate outcome, but also to measure it. If we don’t know what we both want to get out of a project or situation, we will never be able to see if we have achieved what we set out to do. Formalising these goals by email or in writing is often helpful when we are busy as an aide memoire or as a way of looking back to see what we actually agreed.

Planning In our busy days and weeks what is it that together we need to achieve? Once we have set this how are we going to get there? We need a plan that we can refer to as we move along. If we have a plan to refer to this will help both GPs and managers to know where we have got to and where we still need to go. A written or visual plan, e.g. a Gantt chart, is helpful as we can look at it at different times to suit our own schedules, hence reducing unnecessary meetings or any misunderstanding.

Communicating outcomes Many GPs and practice managers have great working relationships and often this is because they have shared goals, clear plans, regular reviews, structured meetings and also they share the successful outcome. Make sure that there is a time to actually acknowledge and share success, whether that is a clinical or management success. This will always help to strengthen the relationship. In these changing times, when clinical and management functions are so intertwined, the relationship between the practice manager and GP is crucial. It can be an extremely rewarding relationship, as together we can achieve great things for our teams and our patients.

Debbie Bodhanya is a managing partner at The Limes Medical Centre, Epping, Essex

practicebusiness.co.uk | january 2012

Work/life | top tips

Positivity in practice Start the New Year in good spirits. Work/life balance expert Sheri Riley shares her five tips on how to stay optimistic and calm when the going gets tough

Reflect on positive past events

Many accomplished people never pause to revel in or acknowledge their past successes. They are constantly striving for what’s next. While not entirely a bad thing, when your desire to achieve and earn becomes bigger than your desire to be, your existence will be likened to a hamster running in an endless circle, never at peace and never at a point of rest.

give to receive Most know that giving back to society and those in need is one of the most meaningful activities we can engage in – making us feel happy and optimistic about life. In fact, many very successful people also believe that giving is directly tied to their luck and success up ahead. Giving back not only creates more opportunities for you to provide for others, but doing so allows more opportunities for your continued success to manifest in your life, and others: what impacts one impacts us all. Achievement, earnings and accomplishments come from the hard work, but true success comes from giving. Not just donating your time through charitable work or financial donations, but also allocating time to family and friends.

january 2012 | practicebusiness.co.uk

Tap your inner courage

Sometimes we are so busy with the work of life that we don’t sit still and take the time to listen to what it is we want from it. Being courageous means not allowing life to stifle your dreams, hopes, aspirations, and plans but living in the now. It takes courage to be honest with yourself, acknowledge your personal goals, and be present in your quest to live those goals. Living in the fullness of who you are – and want to be – takes true grit.

Live exponentially Exponential living is achieved through excellence in your personal and emotional health, and balance in all aspects of your life – with yourself and others. It is achieved by loving and caring for yourself (hobbies, exercise, “me” time); spending quality time with and appreciating yourself and your family; and recognising your successes. When living exponentially you are comfortable with who you are, separate from what you do. It’s when you live in a state of true contentment, being present with yourself and others while also pursuing and maintaining excellence in all aspects of your life.

Happy is a choice; contentment and joy are lifestyles One of the definitions of the word overwhelmed is “to give too much of a thing”. When you truly desire to live a life that is fulfilled in all areas, you are destined to have more to do than you have the time, energy, and ability or help to accomplish or complete. The feeling of being overwhelmed is when you have what you need and are overflowing with what you want. When you have so much success, opportunity, potential, projects, options, prosperity that you can’t handle or manage everything, your reaction is to feel overwhelmed. So what about those times when you’re overwhelmed with challenges, struggles, health issues, and other life concerns? Know the plan for your life and the struggles won’t defeat you, but to make you stronger.

Sheri Riley is the founder of GLUE, Inc. and creator of the Exponential Living programme (www.exponentialliving.com)

Work/life | diary

Practice diary Mike Robinson Mike Robinson is a practice manager and consortium management lead in Barnsley

If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk january 2012 | 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: Mike Robinson takes a ‘unique’ approach to primary care in the community In 2009 I was attending a commissioners’ course and came across an article by Dr David Lyons about his Unique Care System for reducing hospital admissions. This came in the shape of an early warning system for potential admissions to secondary care in the over 65s, highlighting those at risk of admission whether from clinical need or anxiety. It was achieved through patient surveys and an algorithm. Following an offer of support by the PCT, we embarked on our own pilot of the system in 2010. Bringing together an extended primary healthcare team was a challenge we met with pragmatism, using a core group of regular attendees from community nursing, social care and secondary care, supplemented by specialist nurses and others as the need arose. The group initially met every three weeks, but it soon became obvious that we could extend its remit to include other areas of concern, such as palliative care, special needs patients and social care. This has enabled us to reduce the number of meetings held, while fulfilling the requirements of QOF and clinical governance criteria; it also gives us the opportunity to discuss more wide-ranging issues concerning patients. Thus Unique Care Plus was created. This collaborative approach to primary care was possible because we are a small practice

(4,500 patients) with a tight practice area and dedicated community resources, such as district nursing, so day to day communication with all the team is possible. From an administrative point of view, we have been able to access services and support that otherwise would have taken a great deal of time trawling through services support to find. Now that direct involvement is there, it is very often the service that instigates the solution. For the patient, we now offer a fully joinedup service that is aware of all the needs and the problems they present. We are able to adjust schedules to meet the needs of the patient and provide extra support when needed. The reduction of patients needing nonelective admissions has fallen and our frequent flyers’ appointments have been drastically reduced. This has been done by early intervention through Unique Care contracts with patients who were regular attenders, alongside direct contact to discuss patient need and give them reassurance about their health. Unique Care gives us a connection to patients, promoting those values at the heart of community care and putting the patient at the centre of decisions about their health and care. We have become facilitators of solutions to patient needs.

Sweet

sixteen For more details on the Plinth 2000 range of plinths, couches & podiatry chairs, please contact us at:

Plinth 2000 Ltd. Wetheringsett Manor Wetheringsett Stowmarket Suffolk IP14 5PP t: 01449 767887 f: 01449 766122 e: sales@plinth2000.com

www.plinth2000.com

Sixteen is the average life expectancy of a Plinth 2000 couch, guaranteed built to lastâ&#x20AC;Ś you canâ&#x20AC;&#x2122;t get much sweeter than that!