Practice Business July 2011

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july 2011

Chairs of the board

What makes a good CCG board

The customer’s always right

The importance of patient relations in commissioning

Skilling up

The best practice management qualifications

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Editor’s letter EXECUTIVE EDITOR roy lilley www.roylilley.co.uk EDITOR julia dennison julia.dennison@intelligentmedia.co.uk FEATURES WRITER allie anderson allie.anderson@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER george petrou george.petrou@intelligentmedia.co.uk PUBLISHER david collingbourne david.collingbourne@intelligentmedia.co.uk DIGITAL MANAGER dan price dan.price@intelligentmedia.co.uk DESIGNERS jo wilkins jo@b-creativedesign.co.uk sarah chivers sarah.chivers@intelligentmedia.co.uk PRODUCTION ASSISTANT sinead coffey production@intelligentmedia.co.uk CIRCULATION MANAGER natalia johnston natalia.johnston@intelligentmedia.co.uk

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

Even change can change

These last few weeks have proved a challenge for journalists working on a monthly health title – what with all the changes to the changes, nothing seems to stay put for longer than a minute when it comes to the NHS, let alone in good time to publish a timely edition of this magazine. There were more last minute changes at proofing stage than usual this month, for it was as we prepared to go to press that the phrase ‘GP-led commissioning consortia’ became ‘clinically-led commissioning groups’ and the CQC deadline looks to be bumped forward. Much of what I spoke about in my last edit comment will be different now.

The bottom line is, despite the change in name, GPs will still be leading the way (hence Cameron’s quote in his speech about the reforms: “And when GPs are in control of their budgets, they can decide the best possible care for their patients and design health strategies that suit their local area.”), it just means that secondary clinicians will join consortium boards (which is already happening in some places already). The commissioning groups already exist as pathfinders in most part of the country and are likely to keep on carrying on, with a few adjustments. One thing is clear, practice managers sit on a fair few of these boards (see the article on the subject on page 18) As for CQC, although the deadline has moved, practices will undoubtedly have to register at some point (now looking to be April 2013), since it already exists for social care and dentists. If anything, the BBC’s Panorama exposé of shocking conditions and abuse in a residential care home will only make the government keener to have quality standards across the board in the health service.

The truth is, the good practice managers I’ve been speaking to don’t feel all that alarmed by the CQC registration. Yes, it means a one-off fee and paperwork, but they seem keen to prove they’ve already been doing the work to make their practice meet a certain standard of quality for their patients, so for many it may not actually mean that much extra work. More than likely, it will be something practice managers will be able to do with flying colours.

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SEE INSIDE FOR YOUR GUIDE TO MANAGING COMMISSIONING

P.10

Contents SECTOR 06

news Top news for practice managers this month

08

executive editor comment The latest from columnist Roy Lilley

COMMISSIONING 10

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

12

comment Customers serviced Roger Hymas meets Jose Tarnowski to talk patients

18

analysis Chairs of the board Should PMs sit on the board of a CCG?

22

interview Sitting on the Bay PM lead for Baywide CCG, Mark Thomas

PEOPLE 28

interview Still waters run deep Freezywater’s Anita Boulter prepares for change

MANAGEMENT 32

technology The great dictator Efficiency through dictation technology

36

clinical QOF This month: A run-down of what’s new for the QOF 2011/12

39

legal Let’s talk business Succession planning and partnership agreements

WORK/LIFE 40

cpd Accredit to the practice manager An update on PM qualifications

42

diary Tim Maslin of the Woottons Surgery in King’s Lynn discusses patient satisfaction practicebusiness.co.uk | july 2011

sector

06

CQC deadline set to be extended

The Department of Health has put forward a proposal to extend the deadline for GP practice registration with the Care Quality Commission to April 2013, one year after the original deadline.

The government has launched a six-week consultation on the registration of primary medical services providers. The aim of the delay is to try to improve the process for GPs, give the CQC more opportunity to embed compliance monitoring in the sectors they already regulate, and to ensure registration is more closely aligned with accreditation schemes.

“The CQC wants to learn from its work to date to register providers and wants to make further changes to its regulatory systems and methodology,” the consultation document reads. “This would help to provide an improved service and greater assurance to patients and service users.”

There is also set to be a more streamlined process of registration for GP practices.

The CQC is working with the DH and stakeholders to ensure any changes are clear and will be writing to all affected providers.

Providers whose sole purpose is NHS GP out-of-hours services or walk-in centres will still need to register by 1 April 2012. Registration will open in October 2011 as planned.

There are no plans to change the scope of regulation – all NHS primary care medical services will have to register, but the Key Facts timing of that registration for  The date of registration of GP GP practices may change. practices to the CQC is set to be To take part in the extended from April 2012 to consultation on GP registration, April 2013 which ends 29 July, visit  Out-of-hours providers and NHS the DH website at www. walk-in centres will still go ahead dh.gov.uk/en/Consultations/ with the April 2012 deadline Liveconsultations/DH_127174.

QOF consequences

your monthly industry lowdown

news

july 2011 | practicebusiness.co.uk

Improvements in quality of care associated with the Quality and Outcomes Framework (QOF) appear to have been achieved at the expense of non-incentivised aspects of care, finds a bmj.com study.

Since 2004, the NHS has commited £1bn annually in funding to the programme, which links around one quarter of UK general practitioner income to performance on a range of quality indicators.

Using data from the General Practice Research Database (GPRD), a team of researchers examined trends in quality of care for 42 activities (23 incentivised and 19 non-incentivised) before and after QOF was introduced.

For all activities, there was a improvement in quality prior to the introduction of QOF. For incentivised activities, quality of care improved significantly in the first year of the scheme, but reached a plateau in the second and third years. For non-incentivised activities, there was no overall effect on the rate of improvement in the first year of the scheme. However, by the third year, quality was worse than projected from pre-incentive trends. The authors blame a focus on patients for whom rewards applied.

practice Email risk

GPs risk a fine and GMC censure if they fail to protect patients’ personal information when sending emails, a union has warned.

Medical defence organisation MDDUS is reminding practices to be aware of the pitfalls when sending patient data electronically after a decision last month by the Information Commissioner’s Office (ICO) saw Surrey County Council fined £120,000 for a serious breach of the Data Protection Act when sensitive personal information was emailed to the wrong recipients on three occasions.

MDDUS senior medical adviser, Dr Anthea Martin commented: “Doctors who fail to protect patient information risk incurring a fine from the ICO. But, in addition, they could also face professional difficulties with the GMC as their guidance clearly states that personal patient information must be effectively protected at all times against improper disclosure.”

07

SECTOR

| news

clinical news Practice boundaries to change The Department of Health has confirmed it will be changing the practice boundary system from April 2012 to give patients a wider choice of GP. However, reports say it is unclear whether boundaries will be removed altogether or regulations just relaxed.

A ‘GEOGRAPHICAL STRAITJACKET’ The Patients Association has been campaigning for the DH to abolish GP practice boundaries and allow patients to register with any practice.

Vanessa Bourne from the Patients Association told the BBC: “Here we have something that is nothing to do with the patient, only to do with their address. It’s a geographical straitjacket…Giving patients a proper choice would help them take more interest in what they actually require from a GP.” However, the Patients Association does not expect the removal of practice boundaries to lead to a huge uprooting of patients changing practices. “We hear from many patients who really value their relationship with their GP – a relationship which they have built up over many years – and are happy with the practice they are in,” commented interim chair Celia Grandison-Markey.

She adds that many patients are unable to change GPs – for example, patients who live in a rural community and have only one GP practice in their area, or older patients and those with mobility issues who can’t physically access a GP practice in a location that is not close to their home.

IN DEFENCE OF LOCAL GPS The Royal College of General Practitioners (RCGP) has defended practice boundaries, saying that abolishing practice boundaries could affect the safety of vulnerable patients, rural practices could close, and home visiting could become very difficult.

Practice boundaries, they say, also enable GPs to determine how many patients they have on their lists and assess the health needs of those patients so that local services can be planned most effectively and make it easier for children to be on the same list as the rest of their family.

The RCGP says patients who would like to access a GP close to their work could be accommodated through greater access to walk-in centres, or telephone and electronic consultations with a GP.

They said…

“” fact

“The days of the ‘traditional family doctor’ may be over, thanks to societal and professional developments – including an increasingly mobile population – but the need for relationship and management continuity is more important than ever...

Management of...chronic conditions depends on joined-up care that general practice, with support from our specialist colleagues, is uniquely placed to provide.”

Dr Clare Gerada , chair of the RCGP, after a report on continuity of care

Practice managers use buying groups. More than a third of practices are expected to form buying groups with a leading medical supplies firm by next year in a bid to meet government efficiency targets. A surge of 2,000 practices have already formed 25 buying groups with Williams Medical Supplies, which predicts 130 buying groups by the end of 2012.

Measles There have been 496 cases of measles in England and Wales up to the end of May 2011, according to the Health Protection Agency, surpassing the 2010 total of 374 cases. However, immunisation data shows that uptake rates for the MMR vaccine in children aged two reached 90% in the first quarter of this year – the highest level for 13 years. Dr Mary Ramsay of the HPA said: “Anyone who missed out on MMR as a child will continue to be at risk of measles, which explains why we are seeing these new cases in a broad age range.”

Diabetes Practices are letting down young diabetic patients. Children and young adults are less likely to receive the basic care checks required to monitor their condition than older ones; leading to concerns that they will require substantial hospital care in a matter of years. The National Diabetes Audit 2010 identified substantial regional variation in both the prevalence and treatment of complications.

Men’s health The Men’s Health Forum (MHF) is calling on the NHS to develop a range of internet services to improve the health of men, including male-targeted health information, and the ability to make GP appointments and have consultations online. According to the MHF, digital technologies provide a significant opportunity to reach men who often find it difficult to use traditional health services because they are too embarrassed. One in five has not been to a doctor in years.

Get the latest news in your inbox Want to be bang-upto-date on your health sector news? Sign up to the PB Weekly e-newsletter and receive the latest practice manager news and views straight to your inbox. To sign up, email subscriptions@intelligentmedia. co.uk with the subject line “PB Weekly” or visit www.practicebusiness.co.uk. practicebusiness.co.uk | july 2011

08

SECTOR | comment

Roy Lilley Roy Lilley is executive editor of Practice Business.

He is an independent health and policy analyst, writer and broadcaster and commentator on health and social issues.

july 2011 | practicebusiness.co.uk

Pause, replay, rewind

A year on from ‘Equity and Excellence’, its radical proposals remain shrouded in uncertainty. ROY LILLEY asks, is there a light at the end of the stop-start tunnel?

When I first wrote this editorial we were ‘paused’. Becalmed is probably better – well, in the dark, at least! Prof Field’s listening exercise drew to a close and all the cognoscenti were telling us it’s a done deal. The government will accept all the recommendations.

It’s wasn’t rocket science. The prime minister let the cat out of the bag when he did his Five Pledges speech at the University College Hospital FT in London.

Number Ten was in full retreat, stung by the depth and persistence of resistance to the reform package set out in Andrew Lansley’s ‘Liberating the NHS’.

The rumour mill was in full grind; consortia boards will not be the ‘boy’s clubs’ first thought. They will be opened up, their membership to include nurses, hospital doctors and others commissioning in a collegiate and cooperative way.

Next, ‘we are going to press on regardless’ is dumped in favour of consortia being allowed to form at their own pace. To provide an overarching strategic view, support the slower groups and keep a leash on the fast movers, senates will be formed from the old SHAs and PCT-lite organisations will stay.

Of all the proposed changes it was Monitor that has panicked people the most.

The original powers for Monitor included the right it impose competition on the NHS, threatening local health economies and the delicate clinical linkages that hold services together. The extent to which Monitor’s powers would be cut was the key issue.

Competition has been central to the Lansley reforms and it is unthinkable that it will be dumped completely. Indeed, we all know that competition plays a central role in everyday life, leveraging up quality and choice and keeping a handle on costs.

Should the NHS be any different? Probably not. However, introducing competition in a managed way with a soft landing is an entirely different thing to allowing a regulator to impose it from on high.

If you stood back, took a deep breath and looked at the whole picture, what might you have guessed the outcome to be? The Department of Health, a commissioning board, commissioning board out-posts of some sort, senates, consortia, health and wellbeing boards and HealthWatch… all to replace SHAs and PCTs and in pursuit of lower management costs and cuts in bureaucracy!

That was then, this is now. We have had the Future Forum report and the government’s response. The gossip was right and we can expect something like 500-plus organisations replacing under 200. But, we are still no further forward!

The 180-plus amendments to the 360-plus page bill leave us with a conundrum.

The bill has to be unpicked, line by line.

The complexity of rewriting the bill is enormous and no one has had the time to do it. So, we are still waiting for someone to shed some light on the future of the NHS.

The gossip was right and we can expect something like 500plus organisations replacing under 200

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Empowering practice managers in consortia

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commissioning

10

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

commissioning in context

Collaboration, collaboration, collaboration The future of clinical commissioning was under the microscope at the inaugural Commissioning show last month, as GPs, practice managers and commissioners gathered to discuss the conundrum of commissioning a better national healthcare service under higher patient expectations and with less money – the key to which seems to be collaboration.

No to local consultants To start off the show, Health Secretary Andrew Lansley addressed the audience of 2,000 healthcare professionals, underlining his commitment to extend patient choice of any qualified provider.

Lansley also caused controversy in the hall when he revealed that local consultants will not be able to sit on GP commissioning boards, “to avoid any potential conflict of interest”.

july 2011 | practicebusiness.co.uk

The hall applauded Dr Roger Pinnock, a GP from Kent, when he asked the health secretary: “Where on earth do you think this consultant is going to come from?”

Dr Johnny Marshall from the National Association of Primary Care (NAPC) said: “GPs are very concerned about this. They’re telling me that the point of having consultants on the commissioning boards is to look at local needs. So it makes no sense to insist consultants aren’t local – they simply won’t understand local issues.”

Speaking later at the show, Dr Marshall challenged GPs to “put our own house in order” and “better align” clinical and financial responsibility.

He said unwarranted variation should be regarded as “a system failure” and warned against the risk of “recreating PCTs”.

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.

Don’t be a hero Meanwhile, in his presentation to the delegates, commissioning pioneer Dr Paul Zollinger-Read spoke about a change in leadership style that will be required under commissioning.

Where traditionally, healthcare organisations have operated under the control of “hero leaders”, which involves “appointing a leader, putting them on a pedestal then everyone doing as they are told”, with groups of independent practices working together in commissioning groups, that style won’t work if they wish to remain their individual identities.

“The new consortia are totally different to anything the NHS has seen before and the traditional ‘hero style’ of NHS leadership simply will not work,” the director of GP commissioning at NHS East of England said.

In the absence of any corporate identity, the new bodies will need to adopt “a more distributed style of leadership” – a notion Dr Zollinger-Read coins “followership”.

This notion of collaboration was one that ran throughout the conference. In her address on the changing face of practice management under commissioning, Jose Tarnowski, practice manager at Wrington Vale Medical Practice and chair of the ‘Commissioning Business’ stream of presentations at the show, spoke about the benefits of working collaboratively with other practice managers to “share the load” of tasks like CQC registration and commissioning.

“I think the next stage for practice management is working in federated groups, so we don’t all carry the same burden,” she said, referencing federations of schools as an example to emulate. “If practices work together they can learn from each other and [we can] skill ourselves up.”

Streets ahead “EMIS Web is the hub system for the entire polyclinic”

Prash Thurairatnam This month we talk to Prash Thurairatnam, practice manager at Tudor Lodge Health Centre in Wandsworth, south London about EMIS Web’s potential for providing joined up care

A brave new world In his key-note address on the final day of the show, Sir David Nicholson, chief executive of the NHS and head of the NHS Commissioning Board, told delegates that the government pause had produced a “much stronger set of proposals for change than we had before” but GPs would have to change if they were to be successful under the new NHS. He said that a whole generation of NHS management – including Nicholson himself – had defined success as “increased activity and hitting government targets” and that was going to change; in the future the NHS would incentivise “outcomes rather than activity”.

Sir David told the conference that the coalition government had been “incredibly brave”, in seeking to allow GPs to run the NHS. He described the white paper as a “radical response” that was “challenging” for the NHS and that GPs now need to step up to “the opportunity to shape the service Sir David Nicholson, chief executive of the NHS as never before”.

www.emis-online.com

A GP practice in Wandsworth, south London is set to share its patient records with the majority of departments in two local hospitals, thanks to EMIS Web. The surgery already gives other community healthcare staff at the health centre access to its patients’ recent medical history, including medication details, to help them provide more efficient care.

Soon, clinicians at nearby Queen Mary’s Hospital and the St George’s Healthcare NHS Trust, caring for thousands of patients a year, will also be able to view the records, without having to first phone up the GP or ask for information to be faxed over.

Prash Thurairatnam, the surgery’s practice manager, says the strength of EMIS Web is that “it is not just there for GPs, but for other healthcare professionals too.

“Because of its ability to offer joined-up care through secure recordsharing, EMIS Web is the hub system for the entire polyclinic,” he says. “As part of a GP commissioning consortium, we are currently piloting access to patients’ records via EMIS Web for the hospital diabetes service, and also for the out-ofhours doctors. In future, the majority of departments at the two local hospitals will be able to see vital clinical information in the GP records, subject to secure record sharing agreements. It will mean a quicker, safer service for patients.”

Tudor Lodge Health Centre Surgery was the first GP practice in Wandsworth to go live with EMIS Web, last November.

Since then, staff have seen the benefits.

“It is modern and user-friendly for this generation, which is used to Windowsbased systems. And in terms of GP2GP transfer, electronic prescribing and integration with other third party products and with pharmacy systems, EMIS Web is streets ahead of other systems,” Thurairatnam adds.

12

COMMISSIONING | news analysis

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

july 2011 | practicebusiness.co.uk

Facing the customer

Under commissioning, the customer (read patient) should always be right. Roger Hymas visits practice manager Jose Tarnowski to find out why, at her practice, every patient interaction matters and how it’s important not to neglect the moments of truth in commissioning “You should get out more often,” said the editor.

“Why don’t you go and talk to some real live practice managers?”

Well, at that precise moment a letter arrives from a reader. I don’t get many, so every one I receive is cherished. And the letter I’d just got was something else. It was full of seriously challenging, degree-level questions. However am I going to frame a half decent reply?

I panic. I can’t bluff my way out of this. I’ll volunteer to go and visit the revered reader and see if I can deal with some of the issues on the spot. I tell the editor I’m going out. “It’s a bit off the beaten track,” she says. So, I jump in the car and three hours later, I find myself in a delightful spot in the North Somerset hills.

I’ve not met many of you practice managers, but if you’re anything like Jose Tarnowski, the future of primary care is in safe hands. Jose’s career does make her rather special, stretching all the way back to the Bath Health Authority in 1990; a hospital contracts manager during GP fundholding; senior positions in PCGs and PCTs and now back to her first love as practice manager in a practice with 9,000 souls spread across a wide rural area. Job satisfaction exudes from every pore. “In general practice, you go home in the evening and you feel you’ve done something,” says Jose. You’ve also got the enormous scope of the job – customer service, compliance, supplies management, finance, logistics, technology, HR, patient choice, alongside the everyday managing and scheduling of general practice. There are so many skills that have to be mastered.

And now the focus is moving on to clinically-led commissioning – 26 practices in her PCT PBC group, merging into a single consortium. Already, there’s the feeling that even with a population of well over 200,000, the scope of commissioning might be too small and an arrangement with neighbouring South Gloucestershire and Bristol may be necessary to get the right size and quality of commissioning staff and maybe help to manage financial risk.

Then we got into a long discussion about commissioning and the differences that emanated from the focus being either ‘front-of-house’ or ‘back-office’.

I’ve always seen commissioning as a pretty sterile set of business processes for achieving the best outcomes within a defined financial budget. Because I’ve always worked at the population level, I’ve found it impossible to see how commissioning affects individual people. I’ve lived all my time in the comfort zone of the back-office. Front-of-house is all about the experience from the moment the patient picks up the phone, gets an appointment, checks in at reception, waits, sees the GP, gets a hospital appointment or prescription, a follow-up meeting with a practice or community health worker – exactly how the patient really sees what commissioning delivers.

Now this was when my visit to Jose became a big light bulb moment for me. Not a new light bulb, just an old one coming out of a dark recess of my

»

14

COMMISSIONING | news analysis

It’s the moments of truth of the customer experience that should be the essence of commissioning. You just have to get it right for each patient, every time. Nothing else is acceptable mind. I’ve worked in many large customer service organisations during my life – the AA, American Express and Bupa, to name but three. All were, and I’m pleased to say still are, pretty obsessive about customer experience.

The very week I’m in North Somerset, I read this in the Financial Times about American Express: “As the battle for customer loyalty in the card industry became increasingly fierce, Amex recognised that its core competitive advantage had to be something that would be difficult to replicate: superior everyday customer service.

The challenge: The company became concerned that [it] was focusing too much on managing service as a cost centre – rather than as an opportunity to build customer relationships.

The response: Amex shed its traditional call-centre approach, which included monitoring whether customer care professionals (CCPs) adhered to a script. Instead it focused on whether customers would recommend Amex to their friends based on each interaction they had with the company. It also took its CCPs off the clock – letting the customer decide how long to spend on each call.

The result: Amex can now link a customer’s satisfaction with a specific call to the CCP who took that call. It provides constant feedback so each CCP can improve.

Amex now selects, trains and incentivises staff to get customers more engaged, creating an emotional connection and discussing the ways customers can benefit from their relationship with Amex.

Did it work?

Customers increased their spending on Amex products by approximately eight to 10% as CCPs reinforced product benefits through relationship care.

Customer satisfaction improved substantially too.

Amex also saw its CCPs become more efficient: they were able to reduce the average time of a call because they resolved issues more effectively.

Service quality improved as a result.”

The Financial Times, 18 May 2011 This took my conversation with Jose on to talk about those little things that happen to every patient at some time or another as they are interacting with the health care system. Jose is a stickler about these: if there’s a system malfunction in the practice, she starts with the viewpoint that it’s the practice’s problem, not the patient’s, and she fixes it. I was lapping all of this up and we got into a long discussion about the applicability and relevance of the work of one of my heroes, a man called Jan Carlzon, author of a famous book from the 1980s called Moments of Truth. I’ve adapted the next bit about Carlzon from Wikipedia: Carlzon took over Scandinavian Airlines (SAS) when the company was facing large financial difficulties and had an international reputation for always being late. A 1981 survey showed that SAS was ranked number 14 of 17 airlines in Europe when it came to punctuality. Furthermore, the company had a reputation for being a very centralised organisation, where decisions were hard to come by to the detriment of the customers, the

»

july 2011 | practicebusiness.co.uk

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Enhance your professional development today The General Practice Foundation is an exciting initiative inviting practice managers, practice nurses and physician assistants to become a part of the Royal College of GPs. Membership of the Foundation provides practice managers with:

Education · A tailored programme of events created by the UK’s leading practice managers · Access to the RCGP Online Learning Environment and e-GP · Significantly reduced rate to attend the RCGP Annual Conference 2011, 20-22 October, Liverpool

Information · Dedicated quarterly newsletter, monthly profession specific update and a daily digest · Access to BJGP and RCGP News

Networking · Discussion forums facilitating communication within professional groups and cross-professionally with other users

Policy Consultation · The chance to contribute to policy shaping general practice in the future

www.rcgp-foundation.org.uk

16

COMMISSIONING | news analysis

If there’s a system malfunction in the practice, Jose starts with the viewpoint that it’s the practice’s problem, not the patient’s, and she fixes it

shareholders and the staff. He revolutionised the airline industry through an unrelenting focus on customer service quality.

Within one year of taking over, SAS had become the most punctual airline in Europe and had started an ongoing training programme called ‘Putting People First’. The programme was focused on delegating responsibility away from management and allowing customer-facing staff to make decisions to resolve any issues on the spot. Jan Carlzon said at the time: “Problems are solved on the spot, as soon as they arise. No front-line employee has to wait for a supervisor’s permission.”

Does large ‘very centralised organisation’ ring any bells? Does this sound like the NHS, particularly as represented by its largest institutions?

Googling on, I found someone’s blog on Moments of Truth at the website 1001waystowowyourcustomers.blogspot.com: “Carlzon defines the moment of truth in business as this: “Anytime a customer comes into contact with any aspect of a business, however remote, is an opportunity to form an impression.”

Some examples of moments of truth in Jan Carlzon’s airline business are:  when you call to make a reservation to take a flight  when you arrive at the airport and check your bags curbside  when you go inside and pick up your ticket at the ticket counter  when you are greeted at the gate  when you are taken care of by the flight attendants on board the aircraft  and when you are greeted at your destination.

All of these are main moments of truth, and notice that they are all controlled by people. These are the points of contact that our customers and clients have directly with us and our organisation.

The Disney organisation has taken the small moments of truth to an even higher level. They understand the importance that these small moments of truth have on their customers. They train their cast members (Disney’s term for employees) to acknowledge the guest (Disney’s term for a customer) with a smile or facial expression if within 10 feet. If the cast member gets within five feet of the guest, they are to acknowledge them verbally. All of the little moments of truth, combined with the major ones, with the addition of the product or service your organisation is selling, add up to the overall level of a customer’s satisfaction.

Sometimes a customer may have a legitimate complaint. We not only need to fix problems and complaints, we also need to give customers a reason to want to come back and continue to do business with us again and again.

So, manage your moments of truth. Seize every one of them, even if they are moments of misery, as opportunities to show how good you and your organisation are. This will go a long way in building long-term customer loyalty and total customer satisfaction.” july 2011 | practicebusiness.co.uk

Up to now with my articles for Practice Business, I’ve generally focused on how improving the back office of the GP practice and consortium will deliver better, more effectively designed solutions for commissioning.

But what I’m sure Jose is saying is that it’s the moments of truth of the customer experience that should be the essence of commissioning. You just have to get it right for each patient, every time.

Nothing else is acceptable. Which also means that as consortia work on the contract, commissioning and choice initiatives, they have to get down to the human level, looking at the patients’ needs one by one. It’s relatively easy for general practice to do this (they do it every day), but what about the bigger delivery points in the system; the large foundation trusts, for example? The only way you’ll find out is asking the patient about how it was for them. Consumer organisations like the AA, American Express and Bupa survey their customers all the time. And so should the NHS. How else would you know if the services you are commissioning on behalf of patients are any good?

One survey methodology I can commend to you is the SF36, a patient survey technique I introduced at Bupa in the 1990s. They have now had feedback from hundreds of thousands of patients. I know that an awful lot of care commissioning has changed as a result. Google “SF36, Bupa, Vallance-Owen” and see what you get.

Here’s one last suggestion for consortium and practice managers: why don’t you have patient satisfaction scoring written into next year’s provider contracts? I promise you it will have a major impact on what they deliver.

Thank you, Jose it was a real joy to spend a couple of hours with you. Good luck with the North Somerset commissioning challenge. But stay close to your instincts and the patients will continue to love what you’re doing for them.

Now, I like this going out and meeting people thing.Would anyone else like a visit?

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COMMISSIONING | analysis

Musical chairs

As the executive boards of commissioning groups are being formed, Julia Dennison finds out what makes a good one and how much of an involvement practice managers should have

As the pathfinders find their way, with little guidance from central government, there’s an unsurprising Wild West approach when it comes to forming clinical commissioning group executive boards. The variation in clinical/manager/layperson ratios on these boards is wide. While most are led by a team of GPs, the decision to include practice managers on the team remains disputed. In some cases, the board comprises mostly GPs; in others it can include one or more practice manager representatives alongside anything from practice nurses to pharmacists or patients (see box case study for an example of a board structure in north London). As we went to press, a speech from Prime Minister David Cameron confirmed that GPs would have to share commissioning responsibility with doctors and nurses in secondary care, meaning everyone will have to make room for them too.

Take a seat While many boards will already exist, happy to use their formations leftover from practicebased commissioning (PBC), where do the others looking for a fresh start turn? Of course, even in commissioning there can be such a thing as too many cooks. While lots of people may want a seat at the table, that doesn’t necessarily mean they deserve one; july 2011 | practicebusiness.co.uk

after all, the clinical commissioning group (CCG) is an accountable body. “While we appreciate people’s desire to have a voice, whether it’s always appropriate to represent people in that formal structure is quite a different question,” comments Julian Patterson of NHS supporting body Primary Care Commissioning.

“The people you’re going to need there are those member practices and they’re the people the buck stops with.” It’s therefore important to be inclusive without involving too many unnecessary people.

And just because you’re not a clincian, it doesn’t mean you’re unnecesary. Practice managers, of course, are very useful on the team. “It makes absolute sense that practice managers are included on boards because they are sometimes the only people in a practice who have a real handle on the business,” Patterson confirms.

After all, some see the ability to involve the practice manager in commissioning as a benefit CCGs have over PCTs. “PCTs weren’t very good at listening to practice managers who often know how things are going to work practically,” agrees Barbara Craddock, business manager for Alexandra & Crestview Surgeries in Lowestoft and practice manager director for pathfinder HealthEast CIC (Great Yarmouth and Waveney). “GPs have very good clinical ideas but they’re not necessarily sufficient on their own without a little bit of management support.”

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COMMISSIONING | analysis

While many pathfinders see the benefit of including practice managers on the board, others remain unconvinced, confident that GPs’ knowledge of primary care will be sufficient to lead this proposed NHS reform. However, the smart ones see these frontline managers as experts in running the business of general practice. For PMs not already on the board who want to see their profession represented, now is the time to speak up. Even those CCG boards that remain as unchanged versions of their PBC predecessors, many are open to change.

Craddock got involved as a director for Waveney PBC group before it merged with Great Yarmouth to form HealthEast. “I’m one of those people who always likes to know what’s going on,” she explains of why she put herself forward in the first place.

When we spoke, Craddock had come from having a discussion with her fellow leaders at the pathfinder about the merit of practice managers on the board after one of her PM colleagues had to step down due to moving jobs. “The problem for us was when we were just Waveney we were four clinicians and three practice managers [on the board],” she explains. “When Yarmouth joined us, we felt that doubling that was too much. However, we didn’t want to lose the continuity of the existing directors.

So that means we have 14 [clinical and manager

It makes absolute sense that practice managers are included on boards because they are sometimes the only people in a practice who have a real handle on the business directors] and two lay directors as well. As time goes by we have to consider whether we need a nurse or secondary care representative too.” Of course, since Cameron’s changes to the reforms, it is looking like she will.

Selection/election process The government’s policy of non-interference means there is a bit of a free-for-all when it comes to selecting the individuals to sit on consortia boards.

Whether the process takes place in a fair and open fashion to ensure the best people are appointed is up to the pathfinder. However, with transparency the name of the game, it seems a democratic approach is welcomed by most. This can be a minefield, though, as it raises questions on how wide you should cast the electorate net – for example, do you involve

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practicebusiness.co.uk | july 2011

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commissioning | analysis

patients in the voting? While there are few answers now, they will undoubtedly come out of good practice.

It’s worth noting, however, that the individuals who establish the pathfinder may not always be the best people to run it. “In lots of young organisations you would expect to see the leadership that creates the organisation give way to the leadership that needs to run it,” concedes Patterson. “In private organisations the structure of the board will change quite dramatically through its early years. You would hope for the sake of consistency and stability that that doesn’t happen too much in [clinical] commissioning.”

Indeed, Michael Wright, a practice manager at Whyburn Medical Practice and one of three practice managers on the Nottingham North and East Consortium’s executive board, is seeing the practice management representation on the board change in the next few months. “We’re still really in transition,” he admits. “We still have the board that we’ve had for the last four years or so [under PBC], but in September we’re changing so there’s going to be elections and a selection/election process.” This will be an open application process for representatives from each member practice to apply. The new structure will not only keep the three practice manager representatives, but it will see their roles “beefed up” to cover three defined management areas: practice/primary care; information management; and quality and governance. Wright expects this will result in up to four extra hours of work a week for the managers. And even though he’s a practice manager lead on the board now, it’s not a given that he’ll keep the job come September (though he’s clearly a likely candidate). “We’ve been on the board for years; there might be people out there that really want to get involved,” he admits.

With six PMs to the eight GPs around the table, HealthEast on the other hand, is actually considering reducing the number of practice managers in favour of more clinicians. “We feel very strongly that clinicians must be in the majority,” Craddock explained. Six practice managers is the largest number of PM representation this editor has seen on any consortium board, and she agrees it’s too much.

Where pathfinders don’t have a practice manager on the board, there is still room for representation with the help of a PM networking group running alongside. In Richmond & Twickenham’s CCG, each member practice is required to nominate a GP clinical lead, who is then supported by a practice manager. Together they are responsible for disseminating information to immediate colleagues and for soliciting the views of the practice in formal decision-making. Practice managers also meet separately to take forward planning, implement initiatives and share information borough-wide.

“Whether you’re on the board or not, there are so many ways now that [practice managers] can get involved,” comments Wright. “Being on the board is important because you can get your voice heard and you can reflect the views of your colleagues if you do it skilfully, but also, just playing some part and getting engaged with the whole agenda is really what this is about. You don’t have to be on the board.” Indeed, whatever the outcome of the CCG boards and no matter how many secondary clinicians sit on them, there is no question practice managers will have their fair share of commissioning ahead. july 2011 | practicebusiness.co.uk

CASE STUDY In a letter published last month, Nancy Padwick, local commissioning coordinator for NHS North Central London – a partnership of Barnet, Camden, Enfield, Haringey and Islington Primary Care Trusts – shared the process by which The NHS Islington Shadow GP Commissioning Consortium formed its board despite what she calls “very little guidance from the DH”. The result is a board that is one of the most comprehensive in terms of groups represented, fitting for a pathfinder covering 210,076 patients. The proposed board includes:  chair – GP  vice chair – GP  locality representation – One GP per 50,000 patients, hence one GP representative each from north and central locality and two GP representatives from south locality  sessional/salaried GP  practice manager  practice nurse  lay representative  LMC observer  HealthWatch observer  senior NCL officer co-opted on to the board, which will include: - borough director - borough local finance lead - GP commissioning programme manager - local authority representative.

From the above it was proposed that only the GPs, practice nurse, practice manager and lay representatives will have voting rights. This list is also likely to extend to include secondary clinicians after Cameron’s reforms.

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COMMISSIONING | interview

The hot seat Mark Thomas is practice manager of three practices in Torbay. He is chair of the PM group associated with Baywide GP Commissioning Consortium, for which he is also the PM lead. Julia Dennison speaks to him about his experience on the board of a CCG and of commissioning to date

Running a conglomerate of organisations is nothing new to Mark Thomas. A background of managing a major retail chain at an operational level, as well as his eight years of experience as a manager of three GP practices in the southwest, puts him in good stead for a future of clinical commissioning, something he’s taken on in full force as the practice manager lead for the pathfinder – Baywide GP Commissioning Consortium (GPCC). july 2011 | practicebusiness.co.uk

Clearly a busy man, Thomas has responsibility for the management of Chelston Hall Surgery, Old Mill Surgery, and Abbey Road/Shiphay Manor Surgeries. Apart from Abbey Road Surgery, all are housed at Chelston Hall in Torbay. Despite being in such close proximity to each other, the three practices work as completely separate businesses – “but we benefit from the [associated] economies of scale and the clinicians now work much closer together for training, and importantly, commissioning activity”, Thomas confirms.

This is where his background in multiple retail store management comes in handy. Prior to becoming a practice manager, when he moved back to his hometown of Torbay, Thomas worked as a regional manager for several retail companies in the northwest, including Mothercare, John Menzies and Stationery Box. He uses the skills he learned in the private sector to run his GP surgeries. “The core for me is about customer service, and making sure patients are getting the service they need,” he explains. “Then there’s obviously the people skills required for managing. In one of my Mothercare stores in Manchester I had 400 staff under one roof; here I only have about 20 to 25 staff in each surgery, but the management of them is the same – it’s about getting the best you can out of them.”

Fact box Practice manager: Mark Thomas Time in role: Eight years Background and training: He has a background in retail, at regional and operations levels for big UK companies. He became a practice manager after moving back to his hometown of Torbay Practice: Chelston Hall Surgery, Old Mill Surgery and Abbey Road Surgery Patients: 5,500; 2,500; and 6,000 respectively PCT: Torbay Pathfinder: Baywide GP Commissioning Consortium Pathfinder patient number: 150,000

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COMMISSIONING

After moving from his role in the private sector to that in a GP practice, the pace of Thomas’s job initially took a turn for the slower as he became aware of life within the NHS. However, as he took responsibility for more practices, he found himself busier than ever. “In my retail world, if decisions were made they would come down pretty quickly,” he explains. “There was a step change in coming to the NHS; things do seem to take longer.” However, if anything is set to change under commissioning, it will hopefully be this.

“The difference that I suggest may be what’s changing now is the speed of things,” Thomas admits.

One voice It’s no surprise therefore that when the 21 practices that form Baywide GPCC came together to become a practice-based commissioning group, Thomas led the way as practice manager lead on the executive board and head of the associated practice manager group. When Baywide became a pathfinder under the coalition government’s new scheme, Thomas kept his place as one of 10 directors on the board, which comprises eight GPs from different practices, one nurse practitioner and one practice manager in the shape of Thomas and meets every six weeks alongside three sub-committees – performance

| interview

and finance; business development; and corporate governance. On top of this, co-opted members include a pharmacist and layperson. “We are looking to bring in as much resource and skill from the community as we can,” Thomas comments.

There are three towns that make up Torbay – Torquay, Paignton and Brixham. Each town has a locality group for the practices in the town and they meet regularly to discuss issues relating to commissioning, performance data, the commissioning group, and share information.

“We’d had commissioning in the bay for a good few years, but we’d come together as one organisation two or three years ago now,” remembers Thomas. “We were frustrated with the direction of travel and agreed to form one organisation.

Historically we were split into five localities in Torbay and, for example, Brixham would never really know what Torquay was doing. There may have been fantastic programmes going on in Brixham, but as a practice we were based in the locality of Torquay South so we were working on our own things. While there may have been better options out there, we didn’t know about them. It was unsatisfactory and we felt as if we were in silos, so Baywide PBC group came along as one organisation working for the patients of Torbay.”

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practicebusiness.co.uk | july 2011

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COMMISSIONING

| interview

As chair of the managers’ group, Thomas recognises the need for the 21 practices in the bay area to work together, and clinically-led commissioning will only solidify this further. “We can now start to see things that are working elsewhere and we can then pilot those quickly,” he says. One such example is providing pulse checks for atrial fibrillation. “That is the kind of thing that’s exciting to me, because we know if we can find irregular pulses it may stop people going on to have a stroke,” Thomas adds. “For a relatively small amount of money to get 21 practices all at the same level, I think the impact on our patient services will be fantastic.”

Working together As part of its goal to bring the 21 local practices closer together, Baywide has an annual incentive scheme that rewards practice engagement in commissioning work.

The group also performs quarterly peer review audits of referrals and reviews monthly performance data, public health targets and additional audits, such as unscheduled admissions.

The GP practices in Baywide have been doing quarterly audits of referrals as part of this incentive scheme since November 2009. Practices are also sent monthly referral data packs from the commissioning group so they can look at their referrals by specialty and

by GP, alongside doing the audits. This enables them to review where they are outliers compared with the other practices and between GPs in their own practice. As part of the scheme, they are rewarded for reviewing the data in their practice meetings and producing a quarterly action plan to address outlying areas.

PMs to the rescue The practice manager group that Thomas chairs meets monthly and all 21 practice managers in the Baywide GPCC are represented. They open each meeting with a round-table discussion, open to the community, which provides a popular and lively sessioon. The PM group also invites guest speakers to talk on a variety of topics and ends the meeting with a closed-doors business session for practice managers only. Lately, the main topic on everyone’s minds at these meetings is commissioning.

The general feeling towards clinically-led commissioning among the Torbay practice managers is positive. “They can see the benefits – it’s understanding that it’s now about patient services and the knowledge we possess in terms of designing the services we know our patients need, and I think that’s where we will focus. We need to understand how we can benefit our patients, what we need and what we can afford.

We’re also looking at what we can commission locally, whether we can work with our current providers, or if there are other models out there. Certainly we’re all energised by commissioning because there are 21 of us and we’re not isolated anymore. Now we’re one team and we’re pulling in resource where we need it.” july 2011 | practicebusiness.co.uk

Certainly we’re all energised by commissioning because there are 21 of us and we’re not isolated anymore.

Now we’re one team and we’re pulling in resource where we need it For Thomas, it’s important the practice managers are there to support the GPs as they lead in commissioning: “I want the GPs to be clinicians; for me it’s about the management: what can I do to make their life easier and improve? For commissioning it’s the same: there are areas where GPs lead but when they need that management resource it’s there.” Thomas comments on the changing face of practice management and adds that there are just as many talented managers within GP practices as PCTs. “There are a lot of ex-bank managers and managers with experience of the private sector coming into the world of primary care now who weren’t there before,” he explains. “Certainly in Torbay there is a lot of management skill and we’re starting to explore and use that now.”

Thomas is also looking to the wider world, networking with practices in Plymouth and South Devon and beyond. “My background says don’t reinvent the wheel, if there is somebody that has a certain skill use them,” explains Thomas. “Critically, for me, it’s about what is the best that’s out there? And why start from scratch if there are skills and resources and experience out there?” He relates this back to his day job: “If I have someone working in one of my practices who is good at IT and likes getting involved in spreadsheets and reports, then I use them. Why should I sit there scratching my head? For our GPCC, as we grow, it will be a question of: do we start from scratch, use what’s already out there, or is there an alternative we haven’t thought of? That’s the excitement for me.”

Excitement or not, clinically-led commissioning will take time, and Thomas’s roles on the Baywide GPCC and PM committee take him away from the practice. “I am very lucky to have an exceptional team of people behind me that allows me to get involved in all of the other work streams.” His three practices work independently of each other, but they come together for year-end activity, such as QOF work. Where before, Thomas would have done all of this himself, with his new role under commissioning, he has had to hand a lot of detailed work to his teams. “Of course, I’m not a million miles away, I’m still here to help and support them,” he adds quickly, still clearly getting used to not being as hands-on. “I’m not a one-man-band; I stand or fall by them.” As commissioning takes off, this motto will undoubtedly be put to the test time and again.

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vendor profile | pelican

In quality we trust

Pelican Feminine Healthcare is a name GP practices trust. Practice Business finds out more about the company and just what makes it such a trustworthy name in the world of disposable feminine health supplies

Quality has always been a priority for buyers of healthcare products. Purchasing high-calibre clinical supplies is instrumental to the health and wellbeing of patients and with the onset of increased patient choice of GP practice, never has this been more important. A debate at the BMA’s annual conference last month further reiterated the importance of the subject when it called on the NHS to take a firmer stance on procuring products from trustworthy sources.

One company that has always prided itself on Contact details the trustworthiness and reliability of its products Pelican Feminine Healthcare is Pelican Healthcare. Under the mission statement ‘quality, service, trust, innovation and value’, 02920 747400 gill.sims@pelicanhealthcare.co.uk Pelican has a loyal fan-base of GPs, nurses and practice managers who are confident in the fact its www.pelicanfh.co.uk disposable medical products will not let them or the patient down.

Pelican started life in 1994 and from the outset manufactured disposable products for stoma care and feminine healthcare. The following year, the company july 2011 | practicebusiness.co.uk

acquired Nightingale Limited which has since become the Pelican Home Delivery Service that supplies its stoma customers and serves all parts of the UK. In 2007, the company was bought by TG Eakin Limited, a world-renowned producer of specialist medical adhesives and wound care products, and is now part of the Eakin Group of companies. Its stoma care products are now available in the UK under the Pelican brand with an increasing number of international customers served by Eakin under the Eakin brand.

This year Eakin went on to further acquire Clinical Innovations Europe Limited, which extensively added to Pelican’s obstetric and gynaecological product range. One of the more popular products brought on board was the Kiwi Vacuum Delivery System, essentially a single-use ventouse that works with an integral hand-held pump.

Since the acquisition, the feminine health division of Pelican Healthcare has become its own entity.

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vendor profile | pelican

Pelican Feminine Healthcare Limited underwent a rebranding; separating from the stoma care side of the business, and further emphasising its speciality in gynaecological and obstetric products.

Pelican has also embarked on an ambitious development plan intended to transform its spacious premises in Cardiff to a state-of-the-art manufacturing and distribution centre and shares a joint research and development facility, based in Northern Ireland, with its sister company, committed to bringing innovative, quality products to market for the benefit of its customers.

Products you can trust Pelican’s primary care customers are particularly loyal to its gynaecological products. One of Pelican’s most popular and well-known products is its PELIspec disposable vaginal speculum, which is the leading product of its kind with 70% market share and is available on NHS contracts.

Pelican’s newest addition to the PELIspec range is the PELIspec with Light Source, which uses an attached light source to visualise the cervix, ensuring maximum visibility for the professional to carry out any gynaecological procedure.

The PELIspec with Light Source was mainly created using feedback from nurses and doctors, who complained of awkwardness when using separate, unwieldy light devices and, in some cases, the inability to see the cervix, which resulted in expensive hospital referrals. Ensuring everything runs smoothly is imperative when patients undergo what can be such a sensitive procedure, but it can save money too. The ability for a clinician to see what they’re doing can cut down on time, reduce the need to have another person in the room and also reduce repeat referrals.

of its products, and a dedicated customer services team, helps to explain why some of Pelican’s customers have been buying from them for all 18 years it’s been in business. Particularly for practice managers who are not doing the actual clinical procedures but are buying the products, having the support of a company they can trust is priceless.

So while going for a smear test is probably last on the list of pleasant experiences for female patients, high quality products from companies like Pelican are there to ensure it’s as comfortable and efficient a procedure as possible, which not only helps the patients but the practice too.

For practice managers who are not doing the actual clinical procedures but are buying the products, having the support of a company they can trust is priceless

Standing by their values Ensuring quality of product, particularly in the field of gynaecology, is so important to patient relations. One bad experience can put a patient off from returning to that practice or going for a future smear test altogether. With this in mind, Pelican also supports Jo’s Cervical Cancer Trust, by donating 5p to the cause from every box of speculums sold.

Jo’s Trust offers information and support to help women understand the importance of cervical screening and encourage them to attend their smear test appointment.

Pelican offers free delivery to its customers and is also the only company in its market to manufacture its products in the UK, which not only ensures a certain quality standard, but also reduces the risk of damage to the product en route. This, the reliability practicebusiness.co.uk | july 2011

one to ones with the people who matter

people

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Still waters run deep At Enfield’s Freezywater Primary Care Centre, improving systems and processes was essential for practice manager ANITA BOULTER to prepare for CQC regulation and commissioning, as she explained to ALLIE ANDERSON How did you come into practice management?

I’ve been in this role for two years, but I’ve been a PM for 15 years. Before that, I had an interim role at Newham PCT in commissioning and did some work in the practice support unit there for about a year.

I’ve been involved in practice management and PCT

july 2011 | practicebusiness.co.uk

work on and off for the last seven to eight years. Prior to that I was a PM in Waterloo, which is Lambeth PCT, and I also worked in City and Hackney PCT for a while. That’s a very innovative PCT and they’re frontrunners – one of the best PCTs I’ve worked in. I was really impressed with their foresight.

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people | interview

You spent about a year at Newham. What sort of things did you get involved in with commissioning?

It was early days for me on that side, so I don’t have a great deal of direct experience with commissioning. I worked mainly supporting the practices that came under Newham PCT. So you moved over to manage this practice two years ago. What sort of things do you do?

As well as the day-to-day running of the practice, I do a lot of consultancy work in other practices, helping them to get organised with different things.

What does that involve?

I go into a practice, look at their QOF points and their organisational skills, assess their HR policies and those sorts of things, and bring it all up to date.

Then I develop an action plan and advise them on the sorts of things they need to be doing in three or six months, and up to two years’ time.

Is that just in London?

I get recommended, so it’s word of mouth and mainly in London and Hertfordshire and the surrounding area. I do that one day a week and I’m here at the practice four days a week. I’m spreading myself a bit thinly now, so I’m having to reign everything back a little, especially with the demands of CQC regulation and making sure the practice is at the standard it needs to be.

Do you think Freezywater is ready for the CQC changes?

No, and I don’t think many are. Practices, in general, have been ticking away nicely. QOF came up and we dealt with it like we always do, by mucking in. But practices have to realise this is an open market and the government is trying to push us onto the same level playing field as private companies, and we have to be responsible for the day-to-day running of the practice including policies and procedures. Many practices aren’t geared up for that. What we’re seeing now is a great deal of PM posts coming up, where a partner retires and his wife, who was the PM, goes as well. So the practice has to put a new team in place, all because of this [CQC and commissioning] panic.

Some PCTs in other London boroughs aren’t phased by it. They’re saying: “It’s just another one of these measures that we’re going to have to do, but it’ll fall by the wayside.” But we have to be clear that practices need to be accountable for everything they do. It may have another name but it’s something important that we have to do on a daily basis, and everyone must realise that.

Do you have an action plan or a strategy?

Yes, I need to automate as much as I can. I’m just one person and I can’t do everything. I’d love to be superwoman but I’m not, so I have to be realistic

about what I want to achieve for the practice, and recognise where I can get help. PMs in the past have basically done everything, but now it’s becoming overwhelming. There’s HR, health and safety, and all the day-to-day things you would normally do, but now you also have to write reports and action plans that never used to be required. Most PMs don’t have time to do all of that, because if you’ve got Joe Bloggs kicking off downstairs, you’re the one who has to go and deal with that, which knocks everything else out for the rest of your day. If you’d planned to focus on health and safety, for example, that gets sidelined if a problem arises in the practice. An automated support network is essential to make sure things get done – it’s taken a whole heap of work off me.

What kinds of things will automation do for you and the practice?

I’m looking to implement the whole lot – everything to do with risk assessment, health and safety and HR. I’m still managing it, but I’m doing it in a way that’s easier for me, using a process that doesn’t take forever. It also involves retraining a lot of the team, because again, they’ve spent years saying to themselves: “We don’t have to bother with that, we’re just a doctors’ practice.” But it’s more than that – we’re part of a community and we’re serving that community, and the feedback we’re getting from patients is that we need to provide a service they can access easily.

One person trying to coordinate all of this places too much stress on that person. Many GPs think if

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Fact Box Name: Anita Boulter Time in profession: 15 years Practice: Freezywater Primary Care Centre Patients: Circa 11,000 Clinical staff: Seven GPs including three partners, three part-time practice nurses and one HCA Non-clinical staff: Small team of admin and reception staff PCT: NHS Enfield Consortium: Enfield GP Consortium practicebusiness.co.uk | july 2011

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people | interview

I want to focus on looking at and building on the services we provide for patients rather than dealing with the mundane stuff that eats into our time.

That makes us a viable business.

they’ve got a PM, it’s all fine. But they often don’t realise the pressure PMs are under because we’ve always just got on and dealt with it.

Do you think this change in mindset driven by all the reforms on the horizon is difficult to instil to GPs and admin staff?

Certainly, in this area, there is a ‘stick your head in the sand’ attitude that it will all bypass us, but there are ripples of realisation that this is big and things have to change. It’s sinking in slowly, but if practices of this size aren’t seen to be going in the right direction, or certainly organising ourselves, what chance have the smaller practices got? Automation is going to help me a lot, because I’ll be able to focus on looking at and building on the services we provide for patients rather than dealing with the mundane stuff that eats into so much of our time.

That makes us a viable business and ultimately, we want people to be coming through the doors.

We also need to be working with other practices as well, to improve our referrals and our hospital admissions for example, because we want to provide a community-based service in Enfield.

We’re a poor area and we need to make sure patients here can access the same services as patients in other areas.

Where do you sit with commissioning?

We’re one of the bigger practices in the Enfield GP Consortium, and we’ve been granted pathfinder status. We’re still in the stages of organising ourselves. We have GPs who have great ideas and when we’re unified and have an action plan of where Enfield should go, in consultation with the council, then we can start working on rebuilding and improving services.

In general, are you positive about the changes under clinically-led commissioning?

I’ve only been here for two years and I’m still trying to work out what the drive is in this area and therefore where we’ll be going. In principle, I think it’s a good idea, because who better to determine july 2011 | practicebusiness.co.uk

what the patients’ needs are than local GPs? I think the aim is to go back to the days of the family GP, who knew your family well. In terms of Enfield as a whole, I can’t make a judgment on how it’s going to work yet. It requires a lot of PCT support, and there are some great people in the PCT who can provide that, but I don’t think it will be enough.

What about PMs who have a vision to have an active role in commissioning? Do you think they’re well-placed to do so, or are they better off staying focused on their own practice?

I think there are some PMs out there who have great skills that can be utilised throughout the whole area, and work with other practices to help them perform better. There’s a good network out there too, if we can access it. For example, in City and Hackney [PCT], there’s a PMs’ forum and managers can go in, ask questions and get the help they need. Here, it’s a bit hit and miss – you have to bandy around an email and hope you get an answer. But we have some fantastic PMs with some great ideas they can input into the consortium.

Are you going to be one of those?

I’d like to, but right now I want to make sure I’m happy for the practice to be left to its own devices.

Once we’ve got all these [automated] elements in, I’ll be a frontrunner and I’ll go for it.

Your experience in consultancy should give you a good platform to do that.

I dare anyone not to want to get themselves involved in it, and I’m certainly that way inclined.

I want to ensure services are top notch. One of my key projects at City and Hackney was dermatology, and now that’s flourishing and I’m so proud of it. That’s the kind of thing that, when I came to Enfield, I wanted to get involved with. But work piles up and I’ve not had a real chance to get my teeth into anything yet. But with time freed up by automation, I’ll look forward to focusing on improving services at the practice and maybe getting into the consortium as well.

The DR-II - Fixed Professional Dictation Olympus has launched the next generation of Directrec USB microphones for professional dictation; The durable, stylish yet ergonomic design Slide switch and track ball for easy operability Highest voice recognition rating for improved efficiency Barcode module compatible with the DR-2300 for cost savings Fixed USB cable to prevent theft or loss in multi-user environments Integration with your existing systems Full support offering via our dedicated team

For your information pack please email: security@olympus.co.uk

www.olympus.co.uk

business intelligence and management sense for practice managers

management

32

The great dictator As pressures on costs and resources increase, ALLIE ANDERSON looks at how digital dictation technology can help Cost cutting and improved efficiencies in healthcare will no doubt continue to grab the headlines as the NHS evolves into its proposed new format. Practices are, of course, having to share this load as well as coping with the burden of CQC registration and organising themselves into consortia ready to hit the ground running with clinically-led commissioning.

With increasing demands on their time, practice managers will be examining every possible option for streamlining processes while safeguarding patient care.

An effective method of driving practice efficiencies is through embracing technology, as one Derbyshire surgery can attest. The Appletree Medical Practice in Belper has discovered the benefits of upgrading its traditional, tape-based dictation system to a digital software platform after it underwent a month-long audit that compared the performance of the two methods.

Over the audit period, it took more than 31.5 hours to process urgent patient information using the old system, compared with just over one hour with the new software. Analysis of the time taken to process routine patient information also showed huge variance, with the digital system saving 71.5 hours – almost three days – a month. The practice’s IT and data manager, Lianne Burke, has identified improvements in staff morale as well as significant time efficiencies associated with the digital software.

“The staff are so much happier because they know they have better control over what’s going on and they are safe in the knowledge that they can turn the

july 2011 | practicebusiness.co.uk

urgent information around much faster because they don’t have to spend time searching for dictations,” Burke comments.

The market for analogue dictation equipment is fast declining, and most product replacements are with digital technology of some sort. Though many practices still use tape-based machines and may find the move to digital daunting, an upgrade is advisable, suggests Georgina Pavelin from Olympus. “With so many devices and support options now available there is no reason why users shouldn’t be benefiting from digital,” she says, pointing out that many of the parts for old-fashioned equipment are obsolete, causing prices to soar. While digital hardware and software may seem like an unjustifiable cost, sticking with the analogue status quo is arguably untenable.

Digital dictation has numerous advantages including increased clarity, instant delivery, the ability to prioritise tasks, security of data and integration with clinical systems to name a few.

Return on investment can be significant and quick, with efficiency gains reported of between 40 and 50% on the secretarial side alone. There is an abundance of technology available that is specifically targeted at the healthcare setting and therefore suited to meet the requirements of the busy practice.

Pavelin points out that some devices incorporate pin lock and encryption functions – and even a biometric fingerprint scanner – increasing the security of files stored on the device and safeguarding patient confidentiality. In clinical environments,

33

management | technology

footswitches enable hands-free transcription and free up desk space.

As practices become more involved in commissioning and staff attend numerous meetings, mobile working will inevitably become more common. Advances in everyday technology together with developments in the digital dictation market mean doctors and managers can now deliver dictation files to a secure NHS email using their own handheld device, such as an iPhone, BlackBerry or Windows Smartphone. Other emerging technologies, such as speech recognition, are also gathering pace and can be integrated easily into existing digital dictation systems.

Importantly, digital dictation can also facilitate the auditing and reporting process, essential in the context of both CQC legislation and commissioning.

With surgeries facing requirements to meet critical timeframes for certain types of referrals, like two week wait and choose and book, the ability to prioritise and identify documents and records is important. At the high end, digital dictation systems can include tools for the management of

There is an abundance of technology available that is specifically targeted at the healthcare setting and therefore suited to meet the requirements of the busy practice such referrals, while also enabling safe storage and easy reporting. This means that practice managers can view GPs’ referral patterns as well as those of other clinicians. As the biggest cost burden practices have to bear, managing refferals is essential in the changing landscape of primary care.

With compelling arguments for digitalising dictation in the practice setting and more technology coming onto the market, it seems that resistance to this technology may well be futile. As Pavelin says: “The move to digital is inevitable – therefore the sooner the better when it comes to cost and improved workflow.”

script file

Making repeat medication easier “We were keen to offer a helpful solution for patients who find it difficult to visit their local pharmacy – particularly commuters and the elderly”

Pauline Cook Practice manager Emmer Green Surgery

A forward-thinking practice in Reading is using an NHS mail order prescription service to offer patients a more flexible way to manage their repeat medication.

Emmer Green Surgery introduced the innovative solution from leading NHS mail order pharmacy Pharmacy2U three years ago to broaden the range of options for patients on repeat medication.

The 21st century service allows patients to order their script by telephone or online, with their medications delivered to their home or workplace.

Helping commuters

delivering health

Serving 9,400 patients, the practice recognised that certain groups of patients, particularly those who are elderly or have a long commute to work, often find it difficult to visit the surgery and collect their medications from the local pharmacy.

Practice manager Pauline Cook says: “The Pharmacy2U service has received great feedback from

patients. Many have a daily commute to London, which makes finding time to arrange and collect medications difficult. It’s also proved to be a useful service for many of our elderly patients.”

Taking the pressure off The service can take pressure off the surgery too.

Pauline continues: “Pharmacy2U receives prescription requests direct from the patient and these are then sent to us electronically for approval – it’s a straightforward and often time-saving process.”

Three hundred GP practices are currently using the Pharmacy2U service, which patients rate highly. A survey in 2010 revealed that 98.5% of patients found ordering their repeat prescription with Pharmacy2U more convenient than ordering it at the practice. www.pharmacy2u.co.uk/practice

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management | advertorial

Have service, will travel Most travel clinic staff are confident in their practice, but that doesn’t mean they’re doing the best job. We find out why confidence should not be confused with competence New research by MASTA has shown that while travel clinic staff consider themselves to be confident in their practice, there is often variability and inconsistency in the advice being given in travel clinics.

If the advice your clinic is giving is inconsistent and variable, and does not properly prepare travellers, you are at risk of complaints and even legal action if you fail in your duty of care. The nurses are able to administer vaccinations in a travel clinic through a patient group directive (PGD) or patient-specific directive (PSD), which give specific guidelines on what vaccines can be given and under what circumstances.

They will also be using various health information sources to enable them to perform a risk assessment.

Your PGD/PSD and health information should be working together and should be very specific about what action should be taken and when. Travel clinic staff need to work within their level of competence and according to local guidelines. Confidence should never be mistaken for competence.

Problems arise when a traveller needs specialist advice for a complicated trip that falls outside of existing PGD/PSD guidelines and also outside of the competency levels of the staff involved. Providing a consistent level of service should not be limited to what you alone can offer a traveller. Consider a young traveller who comes to your surgery with printed health information they have obtained from a reliable source. The information says that a specialised vaccine, tick-borne encephalitis, is recommended for the area they are going to and for the length of time he will be spending there. However that vaccine is not in your regular stock. In this circumstance, it is possible that the vaccine would not even be discussed further july 2011 | practicebusiness.co.uk

and the traveller sent away unprepared, with your clinic failing in its duty of care towards that traveller.

It is therefore important to know what provision for specialist travel clinics are available in your area and how you can compliment your provision by referring the traveller to a specialist clinic when necessary. Not stocking a vaccine does not mean it should not be offered to the traveller – if we ignore what we don’t have we are being inconsistent in travel health advice and variability in will occur.

Part of a good service is being able to signpost travellers in the right direction to ensure we are not leaving vulnerable people at risk and putting our practice at risk of litigation for failing to equip travellers adequately.

In order to monitor the consistency of your advice evidence based clinical protocols, good audit trails, and regular audits are essential to ensure you are offering travellers the right advice and vaccine options for their travel. Regular discussions regarding your provision of vaccinations, related to destinations, length of time away and personal circumstances should be discussed and measured against reliable, recognised sources.

In order to provide consistent, up to date advice, be aware of what you provide and if you need to refer on – do so as part of the consistent service you offer.

If the advice your clinic is giving is inconsistent and variable, and does not properly prepare travellers, you are at risk of complaints and even legal action if you fail in your duty of care

With you every step of the way...

...before they’ve even started their journey Now practice nurses can ask travellers to bring a MASTA Travel Health Brief to their consultation and it won’t cost a penny. It’s a clear summary of the vaccinations, antimalarials and protective advice patients need to consider.

This is just the first step. Over coming months MASTA will be launching an exciting range of innovations to support your travel clinic.

Get started at www.mastatravelhealth.com/professionals

C/11/07

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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 advisor to the Parliamentary Health Select Committee

july 2011 | practicebusiness.co.uk

QOF changes 2011/12

With more changes to the Quality and Outcomes Framework this year than ever before, Dr Paul Lambden takes a look at what quality indicators will stay and what will go This year there will be more changes to the Quality and Outcomes Framework (QOF) than in any previous year since the scheme was introduced and it promises to add significantly to the workload of the practice team. Some indicators have been retired, amended and replaced with new ones. Some criteria have been tightened and there are now some QOF values that will be locally determined.

Below is a run through of the key changes.

Retirements. Indicators totalling 91.5 points have been scrapped, releasing points for amended and new indicators

2010/11 QOF ID

2010/11 indicator wording

Points Threshold

CHD5

Percentage of patients with CHD with a record of BP in the previous 15 months

7

40-90%

CHD7

Percentage of patients with CHD with record of total cholesterol in previous 15 months

7

40-90%

DM5

Percentage of diabetic patients with HbA1C in previous 15 months

3

40-90%

DM11

Percentage of diabetic patients with BP in previous 15 months

3

40-90%

DM16

Percentage of diabetic patients with record of cholesterol in previous 15 months

3

40-90%

STR5

Percentage of patients with stroke or TIA with record of BP in previous 15 months

2

40-90%

MH7

Percentage of patients with 3 schizophrenia, BAD, etc. who do not attend for annual review, followed up by practice team within 14 days

40-90%

EP7

Percentage of over 18 epileptics on drug 4 treatment with record of medication review with patient/carer in previous 15 months

40-90%

Info4

If patient removed from practice list, practices provides explanation in writing and info on finding a new practice

1

–

1

–

Record21 Ethnic origin for 100% of new registrations PE7

Percentage of patients in appropriate 23.5 national survey, able to obtain consultation with GP (in England) within two working days (regional variations apply)

70-90%

PE8

Percentage of patients in appropriate national survey able to book an appointment with a GP more than two days ahead

60-90%

35

For many this has raised the gravest fears that the QOF will be progressively tightened until GPs cannot meet the challenges set for them in ever-increasing requirements.

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management | QOF

Replacement indicators – indicator wording amendments.

Fourteen existing QOF indicators have been amended to form 19 new indicators:

2010/11 QOF ID

2010/11 QOF ID

2011/12 QOF ID

2011/12 indicator wording

Points

Threshold

CHD11

CHD14

Percentage of patients with MI (from 4/11) treated with ACE (or ARB if intolerant), aspirin or alternative, beta blocker and statin (unless C/I)

10

40-80%

Patients newly diagnosed with angina (from 4/11) referred for specialist assessment

7

CHD2

PP1

CHD13

PP1

2011/12 QOF ID

2011/12 indicator wording

Points

Threshold

MH14

aged over 40 who have record of total cholesterol:hdl ratio in preceding 15 months

4

40-90%

MH15

aged over 40 with record of blood glucose in preceding 15 months

5

40-80%

MH16

aged 25-64 in England and 5 Northern Ireland (20-64 in Wales and 20-60 in Scotland) who have had cervical screening in preceding 5 years

40-80%

MH4

MH17

Percentage of patients on lithium with record of creatinine and TSH in previous nine months

1

40-90%

MH5

MH18

Percentage of patients on 2 lithium with record of lithium level in therapeutic range in previous 4 months

40-90%

DEP2

DEP4

Patients with new diagnosis of depression during last 12 months with assessment of severity at diagnosis using validated assessment tool

40-90%

DEP3

DEP5

Patients with new 8 diagnosis of depression and assessment of severity during previous 12 months who have further assessment 4-12 weeks after initial recording using validated assessment tool

40-90%

Newly diagnosed 8 hypertensives recorded in previous year, aged 30-74, who have had face-to-face CV risk assessment within 3/12 of diagnosis using risk assessment tool

40-70%

DM23

DM26

Percentage of diabetic 17 patients with last HbA1C of 59 mmol/mol (7.5%) or less in preceding 15 months

40-50%

DM24

DM27

Percentage of diabetic patients with last HbA1C of 64 mmol/mol (8%) or less in preceding 15 months

8

40-70%

DM25

DM28

Percentage of diabetic patients with last HbA1C of 75 mmol/mol (9%) or less in preceding 15 months

10

40-90%

DM9

DM29

Percentage of diabetic patients with record of foot examination and risk classification. 1 low risk (normal sensation, pulses present), 2 increased risk (neuropathy, absent pulses), 3 high risk (neuropathy, absent pulses, deformity or skin changes or previous ulcer), 4 ulcerated foot within preceding 15 months

4

40-90%

17

40-80%

It should be noted that the QOF points for the old DEP2 have been reduced by eight and for DEP3 have been reduced by 12.

Some indicators have been modified as follows:

DM12

DM30

Percentage of diabetic 8 patients with BP 150/90 or less in preceding 15 months

40-71%

DM12

DM31

Percentage of diabetic 10 patients with BP 140/80 or less in preceding 15 months

40-60%

MH9

Percentage of patients with schizophrenia, bipolar disorder or psychosis: MH11

who have a record of alcohol consumption in preceding 15 months

4

40-90%

MH12

who have a record of BMI in 4 preceding 15 months

40-90%

MH13

who have a record of BP in preceding 15 months

40-90%

4

Indicator wording

Change

Points

Threshold

Practice can produce register of COPD patients

COPD1 >COPD14

3

–

Percentage of patients with COPD diagnosed after 1/4/11 with diagnosis confirmed by post bronchodilator spirometry

COPD12 >COPD15

5

40-80%

Percentage of patients on MH register with comprehensive care plan documented in record between individuals, carers or family

MH6 >MH10

6

25-50%

There is a significant number of new indicators with a total of 108.5 new points achieved either by the indicator retirements detailed above, or by reductions in point values. The key change is the shift of emphasis from clinical improvement to financial and performance improvement. This will require co-operation of all clinicians in the practice and may be unachievable if the practice is using locums.

Âť

practicebusiness.co.uk | july 2011

38

management | qof

2011/12 QOF ID

indicator wording

Points

Threshold

EP9

Percentage of women under 55 on anti-epileptic drugs counselled about contraception, conception and pregnancy in the previous 15 months

3

40-90%

LD2

Percentage of patients on learning disability register with Down’s syndrome 18+ with record of TSH in previous 15 months

3

40-70%

DEM3

Percentage of patients with new diagnosis 6 of dementia from April 2011 with record of FBC, Ca, glucose, E&U, LFTs, TFTs, Vit B12 and folate within six months of entering register

40-80%

QP1

Practice conducts review of prescribing to 6 assess whether clinically appropriate and cost effective, agrees with the PCO three areas for improvement and produces draft plan for each by 30th June 2011

–

QP2

Practice participates in external peer review of prescribing with group of practices and agrees plans for three prescribing areas for improvement with group and then with PCO by 30 September 11

–

QP3

Percentage of prescriptions complying 5 with agreed plan for the first improvement area as a percentage of all prescriptions in that improvement area during period 1/1/2012 – 31/3/2012

Locally determined

QP4

Percentage of prescriptions complying with agreed plan for the second improvement area as a percentage of all prescriptions in that improvement area during period 1/1/2012 – 31/3/2012

5

Locally determined

QP5

Percentage of prescriptions complying with agreed plan for the third improvement area as a percentage of all prescriptions in that improvement area during period 1/1/2012 – 31/3/2012

5

Locally determined

The practice meets internally to review data on secondary care outpatient referrals provided by the PCO

5

QP7

Practice joins external peer review with groupof practices to compare secondary care outpatient referral data either with practices in the group or in the PCO area and proposes areas for commissioning or service design improvements to the PCO.

5

–

QP8

Practice engages with development 11 of and follows three agreed care pathways for improving management of patients in primary care setting to avoid inappropriate outpatient referrals and produce a report of action taken to PCO no later than 31/3/2012

–

QP9

Practice meets internally to review data on emergency admissions provided by PCO

–

QP10

Practice participates in external peer 27.5 review with group of practices to compare data on emergency admissions either with practices in the group or in the PCO area and proposes areas for commissioning or service design improvements to the PCO

QP6

july 2011 | practicebusiness.co.uk

7

Two indicators remain unchanged but with reduced points values: 2010/11 QOF ID

2010/11 indicator wording

2010/11 Points

2010/11 Points

Threshold

DEP1

Percentage of patients on diabetic or CHD register for depression case finding undertaken during previous 15 months using standard screening questions

8

6

40-90%

BP4

Percentage of patients with hypertension with record of BP in preceding 9 months

18

16

40-90%

For many this has raised the gravest fears that the QOF will be progressively tightened until GPs cannot meet the challenges set for them in ever increasing requirements In three indicators the thresholds have been increased:

– 2010/11 QOF ID

2010/11 QOF ID

2010/11 indicator wording

2010/11 Points

Threshold

CHD6

CHD6

Percentage of patients with CHD in whom last BP in previous 15 months was 150/90 or less

17

40-71%

Percentage of patients with history of stroke or TIA in whom last BP in previous 15 months was 150/90 or less

5

40-71%

Percentage of patients with diabetes in whom last BP was 150/90 or less

8

40-71%

STROKE6

5

DM12

–

DM 30

These changes within the QOF are challenging, frightening and threaten to intrude upon the clinical care of patients. But failure to comply with them will cost practices dear. Practices will have to co-operate and work efficiently to provide the required information cost-effectively to ensure that excessive time is not lost to the more bureaucratic requirements.

39

management | legal

A partnership for prosperity GP partnership agreements and catering for joiners and leavers can be complicated. Lawyer Oliver Pool sets out some of the legal issues to think about when partners are joining and leaving the practice, like when to seek legal help and when it can be avoided Oliver Pool is an associate at Veale Wasbrough Vizards specialising in GP partnership agreements.

He can be contacted on 0117 314 5429 or at opool@vwv.co.uk.

When a partner leaves, if everything is amicable then you don’t necessarily need to incur the cost of instructing a solicitor. As long as the partnership agreement is up-to-date, the partner can serve his or her notice on the other partners and the provisions of the partnership deed will regulate the rest of the process.

Having said this, if the partnership agreement has not been updated since 2008, then you may need to update it before the partner retires, otherwise there is a risk of the outgoing partner not getting entrepreneurs’ relief and having to pay capital gains tax at 28% rather than 10%. To avoid this, the partnership agreement should be amended to impose an ‘unconditional obligation’ on the retiring partner to sell his share on retirement. Agreements prepared before 2008 will feature an ‘option’ for the retiring partner to sell his share – but this is no longer sufficient on its own.

Being a partnership at will is very dangerous in the event of a fallingout, because the partnership can be dissolved at any time by any partner – a nightmare scenario, as the PMS or GMS contract comes to an end and has to be retendered, and any bank loan becomes repayable immediately Legal update sponsored by Veale Wasbrough Vizards Oliver Pool is an associate at Veale Wasbrough Vizards specialising in GP partnership agreements.

He can be contacted on 0117 314 5429 or at opool@vwv.co.uk.

It’s a different story when new partners join, though. Many practices wait until the new partner has got through their mutual assessment period before signing a new deed – but in doing so, they are placing themselves at risk. The law is clear that when a partner joins a partnership, the existing partnership deed falls away, and what is known as a ‘partnership at will’ arises until a new partnership agreement is signed. Being a partnership at will is very dangerous in the event of a falling-out, because the partnership can be dissolved at any time by any partner – a nightmare scenario, as the PMS or GMS contract comes to an end and has to be retendered, and any bank loan becomes repayable immediately.

If the new partner doesn’t sign anything on joining then they can’t be obliged to leave at the end of their probation, and they can’t necessarily be obliged to fulfil any deal you did with them when they joined – such as obliging them to buy a share of the premises after a certain time – if you don’t write anything down, they could go back on their word. Aside from anything else, it is cheaper to get the partnership agreement agreed before a new partner joins, because a new joiner is much less likely to seek to negotiate the agreement than a partner who has been at the practice for a year and feels entitled to a say!

The key to a successful succession is first, communication – partners should not hide their intentions from each other – and secondly, planning.

If a succession is on the horizon, talk to your accountant and if you are taking on a new partner, speak to your solicitor ahead of time as well.

practicebusiness.co.uk | july 2011

work/life

40

Accredit to the practice

advice for busy lives

For practice managers eager to skill-up for the added task of commissioning, Julia Dennison provides an update on the latest qualifications available As the practice management profession becomes more widely recognised, particularly with the onset of commissioning and registration for the Care Quality Commission, the list of professional qualifications available gets longer. As more responsibility falls on the shoulders of practice managers and many prepare to go above and beyond their daily duties to sit on the board of clinical commissioning groups, the forward-thinking practice manager will be looking to be as qualified as possible in preparation for the dawning of a new, general practice-led NHS.

Qualifications The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists (AMSPAR) works with City & Guilds to provide qualifications recognised by Ofqual for the sector. Particularly relevant is the level five Certificate/Diploma in Primary

july 2011 | practicebusiness.co.uk

Care and Health Management (DPCHM) (formerly known as DPCM); these are the only qualifications designed specifically for managers in general practice and the increasing demands of the primary care sector.

The programme is open to existing managers and potential managers in a health or social care environment and core units cover topics relating to primary care including managing medical ethics and legal requirements, financial management, managing information and leading teams. Optional units, which will be particularly useful when preparing for the big-picture thinking needed for commissioning, include ‘Developing the manager as a critical thinker’, ‘Becoming an effective leader’, ‘Managing for efficiency and effectiveness’, and ‘Managing recruitment’.

These units are provided by training company Syder and Young over two years – the first year as a certificate and the second year as an optional

41

work/life | qualifications

quality management within the ever-changing context of health and social care (see box out).

Assessment is conducted via a work-based reflective portfolio and, for the senior and executive candidate, a focused professional interview. The IHM has identified the need for four levels of Accredited Manager accreditations, to give managers at all stages of their careers an opportunity to access the programme. The levels are:

Pictured | Newly qualified IHM Accredited Managers

diploma. Syder and Young offers a range of qualification programmes in primary care and one of the newest and most popular for practice managers is the four-day Institute of Leadership Management (ILM) Level 7 Award, which comprises two days on ‘Leadership in Practice’ and two days on ‘Developing a Reflective Leader’.

As an independent professional body for managers working in the health and social care sectors, the Institute of Healthcare Management (IHM) also has a range of management courses including the Managing in Health and Social Care post graduate certificate and diploma, a vocational training scheme for practice managers, Milestones (bite size, flexible modules of learning), and Elements (an e-learning suite of self-study generic modules), which form the basis of accredited programmes delivered by other organisations.

Accredited Manager Programme An important step in the augmentation of the practice management profession is the launch of the IHM Accredited Manager Programme, following a successful pilot and early adopter programmes involving 17 practice managers, many of whom have been featured in Practice Business, including Val Hempsey of Bridges Medical Practice, Alison Sample of Whickham Cottage Medical Centre, Sam Clark of East Barnwell Health Centre and Russell Vine of Hassengate Medical Centre.

The programme is accredited by Middlesex University and has been developed by the IHM to provide a way of demonstrating a manager’s individual competence across 11 behaviours of

Front line managers – managers whose roles focus on a specific team or processes, within narrower parameters than the role of the middle manager Middle managers – managers whose roles are mainly operational in focus Senior – experienced managers who may be within three years of a board position, their role containing a mix of strategic and operational responsibilities Executive – board-level experience or aspiring board level, their role being predominantly strategic.

Accredited Manager status is current for three years from the date of the award. Managers who wish to continue their status beyond that time must submit their statement of intention to renew submit to the IHM six months before the expiry date.

On 12 April, the IHM held its first awards ceremony at Reynolds Porter Chamberlain’s offices in London and the awards were presented by Rob Smith, head of gateway at the Department of Health. Sample spoke of her personal development, and how she has explored a range of different and more effective ways of working since participating in the programme, and how this has been valued by her colleagues.

With the onset of commissioning, acting as registered manager under the CQC, enhanced services and new QOF standards, the role of the practice manager will be in flux in the next few years. Now is your chance to stand out from the crowd, and often the best way of doing this is to ensure you’re as qualified for your profession as possible.

Continuing professional development has never been more important for practice managers, agrees consultant Pauline Webdale, who is a fellow of AMSPAR. “The oft-quoted ‘bottom up’ change will only work with adept and highly skilled managers supporting and guiding partners to the right decisions for their patients and their practice – something most have always done, and now all will need to do,” she comments. “As Macbeth discovered a landscape on the move is not to be trusted, so managers must make sure they can see the wood for the trees.”

Eleven behaviours of quality management To become an IHM Accredited Manager, you must be able to demonstrate the following 11 behaviours: 1. Contextual leadership 2. Managing the political and stakeholder environment; working collaboratively 3. Delivering outputs 4. Putting safety first: managing risk 5. Managing resources effectively and efficiently (sustainability) 6. Building winning teams 7. Communication and relationship management 8. Improvement and innovation 9. Integrating equalities and diversity 10. Reflection 11. Governance. practicebusiness.co.uk | july 2011

42

Work/life | diary

Practice diary Tim Maslin Tim Maslin is practice manager at The Woottons Surgery in King’s Lynn, Norfolk and has been in the role for a year and a half

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

THIS MONTH: Tim Maslin discusses patient satisfaction in determining practice performance

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

july 2011 | practicebusiness.co.uk

Patient choice, satisfaction and outcomes – this is how the performance of primary care is set to be determined in the future. Clearly, the new patient participation enhanced service is seen as a vehicle to encourage patients to share their views and experiences, which in turn will no doubt be surveyed to gauge our success or failure. But how do we ensure these views are fairly and accurately translated into a representative measure?

Now I am passionate about customer/patient service, and I firmly believe that we should always provide a service that at least matches patient expectations, and ideally exceeds them. However, I am relatively new to the NHS, having previously worked in the pharmaceutical sector, where we had various measures in place to monitor performance. Sales, delivery performance, quality, profit and loss, complaints etc. – a fairly short list of simple key performance indicators that could demonstrate how we were performing in comparison with forecast and previous years. In addition, we would share these measures with our customers and hold regular reviews with them. It all worked pretty well, and most importantly, it was transparent. My difficulty is in understanding how we can achieve an objective system in primary care that accurately reflects patient satisfaction and

outcomes – judgements that, by nature, tend to be subjective and emotive.

Sure, we can demonstrate choice through our choose and book figures, although they need a fair amount of investigation beforehand. But do we really understand how patients would determine success or failure? I suspect not, as many of the patients I speak to have completely different expectations. Many (me included) consider success as the ability to avoid illness (and therefore treatment) for as long as possible, but also that we are diagnosed, treated and if necessary referred promptly when we need to be. Others enjoy the regular reassurance from their GP and would feel isolated without it. With the absence of any common ‘right first time’ approach, creating an objective system of monitoring both satisfaction and outcomes becomes difficult, and likely to be subjective. Let’s hope that we don’t see another PE7 or PE8, with laughably insignificant numbers of patients contacted and their views extrapolated to represent the entire practice population.

There is no quick or easy answer, but I am convinced that what we must do is engage with all our patients, including the silent majority, if we are to find a truly representative voice – now wouldn’t that be real patient participation?

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