Practice Business May 2012

PRACTICEBUSINESS + inspiring business solutions for practice managers

may 2012

FAT FIGHTERS

A look at the UK’s first practice-based physical activity referral scheme

STOP GAP

With GPs moving to commissioning, can practices handle the locum cost?

A VERY WILLING PROVIDER

Get your practice ready for CCG scrutiny

Practice Business is an approved partner with...

Editor’s letter EXECUTIVE EDITOR www.roylilley.co.uk EDITOR julia.dennison@intelligentmedia.co.uk ASSISTANT EDITOR carrie.service@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER george.petrou@intelligentmedia.co.uk ACCOUNT EXECUTIVE gabriele.zaccaria@intelligentmedia.co.uk PUBLISHER vicki.baloch@intelligentmedia.co.uk DESIGNER sarah.chivers@intelligentmedia.co.uk PRODUCTION/DESIGN peter.hope-parry@intelligentmedia.co.uk CIRCULATION MANAGER natalia.johnston@intelligentmedia.co.uk

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

Planning for the contingency of now

Thank goodness for practice managers. With all this running around happening with commissioning, it’s a good thing someone is left holding down the fort – assuming the practice manager isn’t on the CCG board, a member of a supporting PM group, or interested in commissioning. Oh wait.

Many of you are. Now what?

It’s clear practices have a lot to do to ensure everything runs smoothly at home base while the Health Act takes effect. Whether that means ordering locums in to fill in for absent GP partners (see p13) or training up staff to fill in for you (p34), with the reality of commissioning setting in, there’s little time for running around like a chicken with their head cut off. It’s now time to take a breath, get organised and take responsibility.

Whether you like it or not, the commissioning landscape is one of competition, so practices will have to look good for the CCG. This is not, therefore, the time to be understaffed, yet, perhaps ironically, many practices are just that. How are you all coping? In this issue, we address the topic of what to do to form a commissioning contingency plan, but we’re also keen to hear from practices to find out your point of view. Has commissioning helped or hindered you? Are you still as enthusiastic as always, or has the daunting feeling set in? Please get in touch with your stories on editor@practicebusiness.co.uk.

In other news, we bring you a case study about a practice in Tower Hamlets that is getting physical with its patients – and bringing fitness to them (p22). This is a great example of how a practice might be working proactively to fight the strain on primary care and it’s this kind of thing that will be looked on fondly by the CCGs. For more inspiration, see Roger Hymas’s last column on page 16. If you like what you read with him, you’ll want to subscribe to our new magazine just for commissioners. For more information on that, visit commissioningsuccess.com. In other news, here’s wishing you a very lovely month of May.

editor

Contents SECTOR 06 news Small practices fear closure and LMCs boycott boundary pilot 08 executive editor comment Roy Lilley counts down to the day of reckoning

PRIMARY PROVIDER 10 commissioning news

The Health Act’s impact on practices and patients take issue with out-of-hours

13 staffing

Stop gap With GPs moving over to commissioning, can practices handle the need for locums?

16 comment

Becoming a very willing provider Now that commissioning is under way, Roger Hymas gets you ready for CCG scrutiny

PEOPLE IN PRACTICE 22 case study

Fat fighters A look at the UK’s first practice-based physical activity referral scheme

MANAGEMENT 27 dictation

The great dictator Innovations and trends in practice digital dictation methods

30 legal

Success in selling out Cost versus market value when partners get ready to sell their shares

32 clinical

QOF Five QOF points available for maintaining an atrial fibrillation list

WORK/LIFE 34 advice

Get ready, get set How to get your practice team on board for commissioning

36 top tips

Managing LTCs The best equipment for managing long-term conditions in practice

38 diary

Practice blogger Ann Boyle on updating patient information

your monthly lowdown on practice management

sector

06

news

may 2012 | practicebusiness.co.uk

Small practices fear closure

Practice confidence has fallen, according to the latest Lloyds TSB Healthcare Confidence Index. In the post-Lansley landscape, GPs envisage consolidation and possible closure of smaller practices.

The findings were drawn from a survey of primary healthcare providers’ opinions on overall business confidence and outlook for the future.

The outlook of GPs was the least positive of the three primary healthcare providers researched, followed by Report findings pharmacists and dentists. Last year, GPs gave a more positive n 52% of GPs are confident in the confidence score and therefore showed the biggest fall in future of healthcare provision confidence in 2012. to patients in the UK, yet 60% Where any figure greater than zero represents a positive expect NHS services to reduce outlook and figures below indicate a negative one (the to some degree over the next maximum value achievable is plus 100 and minimum value five years achievable is minus 100), GPs registered minus 62. n 91% of GPs are expecting their GPs’ collective long-term confidence (looking ahead over financial pressures to increase the next five years) remains static since the last survey at over the next five years and 73% minus 81. expect a reduction in profits Ian Crompton, head of healthcare banking services for n 37% of GPs believe a move to Lloyds TSB Commercial, said: “GPs were feeling so negative commissioning groups is a good in our first survey published in October 2011, that we hoped thing, while 51% do not and a degree of regulatory clarity might lead to a more positive 12% are unsure outlook for 2012. It hasn’t arrived and every indication is that n 77% of GPs expect to still be the confidence of GPs is unlikely to improve until they can see a working to an NHS contract in final outcome. ten years’ time, an increase “GP responses to the second confidence index are quite from 59% in 2011 definitive in expecting significant change. For instance, 89% are n 50% of GPs would like to be expecting more practice mergers and 73% expect the demise of involved in premises ownership, yet only 19% are expecting to the ‘single-handed’ GP practice by 2017. have to move premises within “Even though practices this small have been in decline in the next five years. recent years, that still represents around 14.5% or 1,203 of UK practices, which GPs do not think will be here in five years.”

‘TripAdvisor-style’ feedback should be taken seriously Health professionals should take unsolicited online patient feedback about healthcare services seriously, a report finds.

Rather than dismissing comments, care providers, like practices, should use it to improve the quality of care they deliver, say researchers from Imperial College London and the University of California at San Francisco who looked at around 10,000 unsolicited online posts from patients on NHS Choices, rating the care they had received at 146 acute general hospital trusts in England throughout 2009 and 2010.

Among other things, NHS Choices provides a facility for patients to rate and score the NHS services they receive, including whether they would recommend them to a friend, alongside quality domains concerning

the cleanliness; whether they were treated with dignity and respect as an inpatient; how involved they were in decisions about their care; and whether staff worked well together.

The comparative analysis, which was presented last month at the 17th International Forum on Quality & Safety in Healthcare in Paris and published in BMJ Quality and Safety, showed that the proportion of patients willing to recommend a hospital to a friend was two thirds (67.4%).

07

SECTOR | news

clinical news LMCs boycott boundary pilot London LMCs have written to practices who volunteered to take part in a practice boundary pilot asking them to boycott the trial.

The Government has been seeking volunteers from Manchester, Nottingham and London to take part in pilots beginning last month, for which Tower Hamlets and City and Hackney volunteered.

The hope is that patients will have better access to their GP by not being restricted by practice boundaries. Under the scheme, patients would be able to register near their place of work if they wish.

The letter from London LMCs, addressed to all Tower Hamlets and City and Hackney practices, states that although Tower Hamlets PCT and City and Hackney PCT will be expected to pay for any additional costs incurred by commuters registering via the scheme, they will not be receiving any additional funding.

Extra costs will be incurred by prescriptions, community care costs and secondary care costs.

The letter states: “We have grave concerns that this pilot will result in reduced services to your existing patients.

“We believe that it is unacceptable for patients in two of the most deprived PCTs in the country to have funding for their services cut in order to fund this pilot.

“We urge you therefore to hold off agreeing to take part in the pilot unless and until the Government agrees to fully fund all secondary care, community care and prescribing costs.”

The scheme runs for one year and is likely to benefit people moving home who wish to remain with their preferred practice; professionals wanting a practice near work or families needing a practice near their child’s school.

They said…

“” fact

“Britain’s 1.8 million gay and bisexual men are being let down by health services which often see homosexuality and bisexuality purely as sexual health issues. As a result hundreds of thousands of gay and bisexual men are in dire need of better support from health professionals” Stonewall chief executive Ben Summerskill in response to the world’s largest gay and bisexual men’s health survey

QOF has no impact on patient outcomes Financial incentives like QOF have no impact on patient outcomes, according to a study led by Dr Nicholas Steel on the QOF advisor team at NICE. The GPC defends the pointsbased system, however, arguing that the GP contract is in fact workload-based.

The pill for 13-year-olds?

Girls as young as 13 should have access to the contraceptive pill from pharmacies without the need for a GP prescription, an evaluation of a pilot in over-16s seen by Pulse has concluded.

A report from the pioneering scheme across five pharmacies in Southwark and Lambeth found it had successfully reached young women who had never previously taken the pill – with 46% of women using the scheme first timers.

It recommended the scheme – providing access under a patient group direction – be rolled out across the country, and that commissioners consider widening it to girls aged 13 to 16.

Get the latest news in your inbox Want to be bang-up-to-date on your health sector news?

Sign up to the PB Weekly e-newsletter and receive the latest practice manager news and views straight to your inbox. To sign up, email subscriptions@intelligentmedia.co.uk with the subject line “PB Weekly” or visit www. practicebusiness.co.uk.

diary DIABETES WEEK 2012 10-16 June www.diabetes.org.uk The impact of diabetes on the NHS was highlighted recently by statistics showing that 80% of the NHS’s £9.8bn diabetes budget is used treating preventable complications. John Sanderson, director of Hicom, commented: “The key to proactive management of diabetes is ensuring patients get treated quickly and early on in their condition and by empowering patients to take an active role in the management of their condition within primary care.”

practicebusiness.co.uk | may 2012

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.

Day of reckoning

When Robert Francis publishes his second report on Mid Staffordshire FT, ROY LILLEY believes all will have to answer

My bet is Francis will recommend that Monitor and the CQC will merge. Why not?

They are essentially the same thing may 2012 | practicebusiness.co.uk

What are you doing on 15 October? If you are still in the paper and ring binder era, put a red circle in your Filofax; if you are electronic, red-flag the day – when Robert Francis QC publishes his second report into the goings on at Mid-Staffs hospital.

He will pass it to the secretary of state who then has the discretion as to when it is published. My guess is it will not stay on his desk for long. If it does he runs the risk of it burning a hole through his in-tray and desktop. If he is considering a delay, I doubt the combined pressures of the press and the relatives will give him much peace.

The Department of Health seems worried. They have taken a very senior civil servant away from his daily duties and already have him preparing their response.

Bearing in mind he starts his new job in June and the report is not published until October, he must be preparing a very big response!

We can only guess what recommendations the report will make.

Listening to gossip and reading between the lines we can have an educated guess.

Who failed the patients at the hospital? Answer, everyone. So, expect changes to everything.

Monitor failed because in driving the trust board towards FT status they required unsustainable financial cuts that could only have impacted on the quality of frontline care. The problem? Monitor was not concerned with frontline care.

The Care Quality Commission? They didn’t liaise with Monitor and got stuck in an argument about data. The regional health authority, run at the time by the nowknighted David Nicholson, got stuck in an argument about data between Dr Foster (who was right) and a university (who appear to have been less right).

The trust board were hapless and hopeless. The unions powerless and the staff ignored.

My bet is Francis will recommend that Monitor and the CQC will merge. Why not? They are essentially about the same thing.

The regulators will not escape Francis’s wrath. They are busy regulating the very staff who have the responsibility for care but no power to change anything to make sure it is delivered safely and carefully.

It is the boards who have the responsibility and the power to make change happen. A license to hold public office for each and every board member must surely be on Mr Francis’ list?

The impact on the recent Health and Social Care Act; changes to monitor and the CQC; definition of roles for boards and their responsibilities and a different engagement for fewer regulators are only some of the challenges that await the DH. Hopefully 15 October will be a red letter day for healthcare in England and hopefully a fitting memorial day for the patients who so needlessly lost their lives.

PRIMARY PROVIDER

10

HEALTH ACT COULD HAVE ‘SEVERE IMPLICATIONS’ ON DATA The Health and Social Care Act 2012 will have “severe implications” for collecting and monitoring data about England’s health needs, experts warn.

In a paper published on bmj.com, experts argue the new legislation will make it “extremely difficult” to monitor health inequalities and access to care locally or nationally.

The administrative structure of the NHS is based on resident populations of defined geographical areas. Under the new legislation, health services can transfer to non-geographically based clinical commissioning groups.

Delivering commissioning in practice

CLINICAL SENATES KEEP COMMISSIONING LOCAL

This, warn the authors, is likely to lead to erosion of data quality, accuracy, and completeness.

For example, responsibility for services such as childhood immunisation, HIV and sexual health, and mental health will be located in local authorities. Since LA residents may be registered with any one of a number of different CCGs, the LA will have to subcontract these services to a CCG, which could outsource them again.

Although it will be possible to compare differences between CCGs, “the instability of the denominator population will hinder accurate interpretation of the data,” say the authors.

Finally, they argue that the transfer of resources and NHS staff to the private sector means they will no longer be counted in NHS bed availability and workforce statistics, creating problems for longterm planning.

In a speech at the Westminster Health Forum – ‘Developing clinical senates and networks: commissioning, integration and efficiency’ – last month, Dr Donal Hynes, co-vice chair of the NHS Alliance, will reiterate the need for clinical senates and networks to support CCGs’ localism.

According to Dr Hynes, clinical senates should act as a support mechanism for CCGs, rather than undermine their autonomy, by bringing together the clinical community over a relatively wide area to discuss and implement service reconfiguration.

He said: “If clinical senates and networks feel that they need to ‘control’ CCGs, we will be then recreating a top down bureaucratic structure that will undermine CCG’s localism.

“Local decision-making should remain strongly in the hands of clinical commissioners and their population.

Clinical senates and networks should be able to respond to and work with CCGs, without imposing their views on the localities. This is a new approach that will require a different type of leadership, one that is not dominated by specialists trying to protect the current structure in secondary care.

“CCGs will play a key role in delivering integrated care for patients and responding to local needs, whilst ensuring that the NHS continues to be financially sustainable.”

may 2012 | practicebusiness.co.uk

PRACTICE BUSINESS HAS LAUNCHED A NEW COMMISSIONING MAGAZINE

While we will still cover commissioningrelated topics from a primary care provider point of view, practice managers heavily involved in clinical commissioning will want to refer to our new bi-monthly commissioning magazine that launched last month, called Commissioning Success.

It will be targeted at decision-makers and participants in commissioning, from board members to commissioning support units and supporting groups. Because of our background in practice management, the magazine will focus on the management and strategy behind effective commissioning, as well as keep readers up to date with all they need to know in terms of news and updates.

If you’re interested in receiving a free copy, please email your details to subscriptions@ intelligentmedia.co.uk with the subject line “Commissioning Success”.

GPs better than private out-of-hours firms, say patients Private out-of-hours services are more expensive and rated worse by patients than those delivered by not-for-profit alternatives, such as GP cooperatives, a Pulse analysis reveals.

For-profit companies often matched the performance of not-for-profit and NHS providers on the national quality requirements under which contracts are monitored, but lagged significantly behind on separate patient satisfaction scores.

Just 59.5% of private services were rated good or very good by patients, compared with 65% for not-for-profit services and 64.7% for the NHS. Patients’ different views of services were only partly reflected in performance on key national quality requirements.

Private providers saw 91.2% of urgent cases within two hours – compared with 95.3% for not-for-profit and 91.6% for the NHS. But private providers gave 84.1% of urgent cases definitive assessment in 20 minutes, compared with 82.4% for not-for-profit providers and 82.7% for NHS trusts.

The Primary Care Foundation said there was too much focus on fulfilling national quality requirements, and urged commissioners to also consider patient satisfaction, audits of clinicians and integration of services.

Henry Clay, director at the Primary Care Foundation, said: “Sometimes there are good reasons why the service is where it is, but in other cases I hope they will think how they can improve.”

Dr Peter Holden, GPC negotiator and a GP in Matlock, Derbyshire, said: “Not-for-profit, John Lewistype co-ops are the way to do out-of-hours. If you are insisting on a dividend, there’s only so much money to run the service.”

Fast facts n 59.5% of private services were rated good or very good by patients, compared with 65% for not-for-profit services and 64.7% for the NHS n Private providers saw 91.2% of urgent cases within two hours, compared with 95.3% for not-for-profit and 91.6% for NHS trusts.

13

provision | personnel

Locums: Counting the costs A move towards commissioning has seen a rise in the use of locums in practice, which can mean escalating costs for practices if they’re not careful.

Polly Ellison looks at the trend so far and sees if it risks getting out of control

The recently passed NHS Health Bill means that in April 2013 commissioning power will be transferred to GP-Led clinical commissioning groups (CCGs).

Already GPs are feeling the effects of this extra commitment. Recent findings suggest that GP locum costs, for many practices, are escalating but this is just the tip of the iceberg. Underneath there are many more issues at stake.

Some GP practices around the country have increased their use of locum GPs to replace their GP principals who are working on CCGs. While there are only a small group of GPs directly involved with CCGs, all surgeries, from time to time, have to attend CCG-led information meetings so that they can learn of all that their CCG is proposing to do over the coming few years. As a result GP locum costs have risen and the workload in the practices has increased.

Âť

practicebusiness.co.uk | may 2012

14

provision | personnel

Dr Sanjay Shyamapant, Gloucestershire LMC committee member and Tewkesbury GP principal, highlights the issues surrounding locums: “Before GPs may have been expected to attend meetings once or twice a month. Now those on the CCG are committed to two or three days a week. Although there is backfill monies for locum cover it is not the same as having a partner in the practice. Locum cover is now required for greater lengths of time which raises issues of locum availability and quality.

It is difficult for practices to find good locums who can commit to a long period of time in one practice.

Practices are fortunate if locums can be found and are reasonably priced. This can leave smaller practices struggling.” It is not only the cost and the quality at stake, as Dr Shyamapant explains: “Long-term locum cover is damaging for the whole practice in view of continuity of care, QOF work etc. A long-term locum who gets to know a practice can be helpful but it cannot replace the work done by a partner.”

Practices are having to bear some of the cost of this extra work, and evidence would suggest that many have ended the 2011/2012 financial year out of pocket as a result of their new commitments. It is questionable as to whether or not the locum backfill paid to practices really covers either the locum time or the extra work that is generated as a result of a GP principal being out of the practice. Usually backfill only covers the cost of the surgery not all the paperwork and home visits. The practices are not getting back all the money that they need to cover for the loss of one of their GP principals so are, in effect, subsidising the CCG work.

Dr Shyamapant is one of many GPs now worried about the long-term future of GP practices as he explains: “With insufficient money in GMS and a pay freeze for the last few years, GPs have to look very critically at the work they are doing and the amount of money it brings in. Smaller practices in particular will struggle and practices will have to federate in order to survive.”

For some years now, work has been piling up on the GPs’ doorstep. The new NHS health bill provides more pressure for GP practices as locality executive board member and GP appraiser, Dr Chris Kinchin, a GP in Cheltenham, Gloucestershire, explains: “There are many extra pressures on practices besides GPs taking time out to do work in the CCGs. Some GPs are working more than ten sessions a week simply to cover the basics without giving themselves time off. This is setting a very dangerous precedent. The pressure on GPs is evident to their GP appraisers.” may 2012 | practicebusiness.co.uk

There is an additional twist to the current situation as Dr Kinchin explains: “There are a small group of GPs working very hard to try and implement all that the government has requested of them, for the good of all GPs. However, as the pressure on the CCG GPs grows there is little time to feedback to those GPs working hard in their practices. The volume of emails alone can add an extra hour to a CCG GPs working day. I would not be able to be involved in the executive work if I was working fulltime. I would simply not have the time to do it.”

CCG GPs are very much on a learning curve and there is an enormous amount of work to be done.

Little surprise, then, that GP locum costs are rising.

There is more to the situation than increased costs however, as Dr Kinchin explains: “As a GP appraiser I see enormous pressure on GP principals at this time. It is worrying as there is only a finite amount of work that people can do before we start seeing people go off sick with stress and depression. If the workload continues this will be a real danger.”

Perhaps one of the first duties of the CCG is to see that primary care has sufficient resources within which to operate. Without a fully operational primary care service, no CCG could begin to make the savings required of them over the coming years.

There is only a finite amount of work that people can do before we start seeing people go off sick with stress and depression. If the workload continues this will be a real danger

15

provision | advertorial

PathFinderRF – supporting more effective referrals, cost savings and outcomes for ccgs Clinical commissioning groups (CCGs), such as Corby, Peterborough, Borderline, South East Staffordshire, Welland and South West Lincolnshire are implementing PathFinderRF across their practices to achieve substantial cost savings and improvement in the quality of referrals.

PathFinderRF provides a fully supported referral pathway system that integrates national guidance, local procedures and patient information with an appropriately worded referral template. It also provides a portal to other useful information, such as local formularies and therapeutic policies, that can be updated by the CCG on a real-time basis. Furthermore, PathFinderRF can be audited at CCG or practice level to determine how templates are being used, so improving the consistency and reliability of care.

The success of local healthcare systems depends on the quality of care pathways and the compliance of clinicians with these pathways. CCGs face the need to manage costs and quality, and so ensure that care pathways deliver the best affordable practice.

Closing the quality gap often requires a change in clinical practice.

With the need for redesign simultaneously across many care pathways, this presents a major challenge for commissioners going forward – but one that can be addressed with an effective referral management scheme.

Successful referral management schemes should be enabling, rather than restrictive, and support commissioners’ need to communicate the desired changes to all clinicians, and so improve the patient referral pathway and experience within available resources. This should contribute to the QIPP saving plan for CCGs, and for GPs it should meet the requirements of QOF and also support efficiencies such as reducing administrative costs – so encouraging take-up and adherence.

PathFinderRF is a web-based system that is now available nationally and is helping CCGs meets these objectives. It is based on a referral management system that has been widely used across Northamptonshire for some years. As Dr Darin Seiger, GP chair, Nene Commissioning, says: ‘PathFinder ensures my colleagues and I have easy access to the latest referral guidance and forms that have been agreed with each trust and helps maintain consistent

adherence to evidenced and up-to-date clinical pathways.

The benefits to patients, GPs and our consultant colleagues in Northamptonshire have been incalculable’.

This view is borne out by local GPs, such as Dr Catherine Massey, who says: ‘PathFinder is great – easy to use, very useful to have everything in one place and speeds up time taken to process referrals’. In terms of saving time, the Redwell Medical Centre describes that ‘PathFinder saves each GP between 30 and 45 minutes of administration time each working day’.

Hospital specialists are also keenly in favour. For example, Kheng Chew, a local obstetrics and gynaecology consultant, says: ‘I have found that referrals received from GPs supported

by PathFinder are much easier to use as they provide consistent information in a set format’.

A unique strength of PathFinderRF is that its referral templates can be amended as required by a local CCG to reflect local requirements. The templates are interactive, and can be integrated with all the main GP systems as well as with Choose and Book.

They support referral decision-making through prompts and guidance on the history, examination and investigations that should be completed prior to referral.

Suggestions for alternative management plans are also available with each template. Embedded in the pathway prompts are local and national guidance which can be assessed by selecting the appropriate link, together with relevant patient leaflets and/ or other useful information. Updates to national guidance (for example, NICE guidance) are provided on a regular basis, and the local CCG has the option of accepting or declining each update, based on local guidance and needs.

16

provision | 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. You can reach him to clarify any issue at rogerhymas@btinternet.com

The chosen ones

As practices compete for business from the CCG, Roger Hymas looks at how to become a very willing provider and asks: Commissioner or provider – what kind of practice are you?

I’ve enjoyed my 18 months writing for Practice Business, but as I’m a commissioner through and through, the editor (the one who should be obeyed) has asked me to move across to the new sister magazine, Commissioning Success.

Before you go, she said, it might be a good idea to tell the readers, and especially those who have a bias to move their practices in that direction, about what commissioners look for in a good provider, particularly as we move into the completely uncharted waters of the new post-act NHS. I’ve spoken to a lot of GPs and PMs over the past few months. What I’ve noticed as a growing trend is that all the discussions about GP-led commissioning seem perversely to have stimulated a real interest in GP-led providing, which is good, because I’m convinced that we need a lot more diversity and new options in local health care provision in the years ahead. And it’s entirely right that GP practices respond to this opportunity.

More choice will be good for patients. It’s also where government health strategy has been wanting to take us for the last ten years. The mantra has consistently been about moving a greater proportion of care out of hospital. Perversely, at the same time, billions have been poured into their construction and development. Patients always fill the capacity that’s created for them and this will be the year when the number of scheduled hospital outpatient appointments in England tops 100 million. That’s two for every member of the population.

Yet we all know that the hospital is usually an inappropriate location for all minor care, consultations and simple diagnostics. The best place for a lot of it to be done is in homes, practices and community clinics, not in megalithic general hospitals. So we need more local care pathways: GPs will need to commission them and GPs will need to provide them.

Choice, an element of DH policy which has almost been suppressed, is something which we’re going to hear much more about in the years ahead.

First, though, we must break the dogma of NHS conservatism, the inclination of which is to protect hospitals.

»

may 2012 | practicebusiness.co.uk

18

provision | analysis

Diversity and localism in care provision will be central to a more successful and sustainable health care system and GP commissioners will want to encourage these moves.

The patient as an active healthcare consumer will be a growing trend. Baby boomers, the coming generation of healthcare users, know all about consumerism. Arguably, this ‘golden generation’ invented it and have been practising it for years across a huge range of purchasing activity. They are definitely not going to be compliant patients as their parents were. They will be assertive, demanding users of the NHS and they will insist on care delivery that is convenient and right for them. Of course, the best placed providers that can take advantage and react quickly to this situation will be GPs, both of the commissioning and providing varieties. They sit right at the front of the healthcare supply chain.

If you add it up, about £50bn of cost is associated with 100 million hospital outpatient appointments. If I’ve got my noughts right, that’s about £500 each (you have to add on top of the consultations, the costs of diagnostics, procedures, even major ops, all the PbR drivers, plus the huge overhead of running a big hospital). One more statistic I’ve quoted before in these columns – a staggering 30% of patients get referred back to their GP with no further action required from a hospital consultant. According to my maths, 15 million first attendances happen that don’t really need to happen, at say £200 each. That’s about £3bn a year.

A great deal of them start with the GP referral, implying a very good reason for everyone to think twice in the practice.

Certainly, if I were a healthcare payer (another commissioning role), I would like to see a lot fewer referrals, without compromising patient safety of course, which is paramount. And then I’d like to see a lot more referrals to appropriate, low cost (and inevitably much more local) pathways. I’m hoping that CCGs are going to get started commissioning these as soon as they assume control. PCTs never had much success.

The consequence of all of this is that the NHS will have to encourage a new and so far undiscovered new management capability – the hospital downsizer. Every lecture I’ve been to by eminent health service experts over the last couple of years has been about downsizing hospitals. But as may 2012 | practicebusiness.co.uk

you see from the stats, somehow it just doesn’t get to happen. There is no medical need for everything to be done in hospitals. Hospitals should be for the big, complicated events in healthcare. They should only be there to provide specialised and expert treatment for patients with complex needs for surgery or diagnostics. ‘Every day’ technology – telehealth, remote monitoring, Skype, more accessible records, for example – can be used for everything else, particularly if it involves patients who are happy to use it. Indeed, you’ll probably already find many consumers are ahead of the healthcare systems who still have to adopt it.

What I’m suggesting is, of course, completely contra-indicative to current hospital policy, ambition and strategy. You’ll find the evidence in the long-term plans of every acute hospital in the country. Each of their business plans will show a growth gradient headed to the top-right hand corner of the page.

One of the causes of this is that generally PCTs have not been proactive in helping GPs change their referral behaviours or encouraging alternative provision outside hospital. Also, very few GPs have accepted pathways created by PCTs. There will be different sets of motivations and behaviours when GPs take over.

Coincidentally, at the very moment I’m writing this, a blog drops into my mailbox. What it is saying is that as many as one third of hospitals in America will close by 2020. The reasons cited hinge around changing medical practice and consumer preferences.

But the biggest impact on care location will be the impact of GPs to change it themselves. GPs will provide and commission new pathways and patients.

And at the same time they will finally convince

»

We all know that the hospital is an inappropriate location for minor care. The best place is in homes, practices and community clinics. So we need more local care pathways: GPs will need to commission them and GPs will need to provide them

20

provision | analysis

patients and communities that the widely held public belief that hospitals are good for local safety is wrong. They will determine that carefully constructed and well-executed care pathways are best practice medicine and are safe, even safer, for patients.

People trust doctors on these matters. And when this message gets through to patients, the public and politicians, it will finally end the general hospital paradigm after 150 years.

One last story (a true one) that I will leave with you is a working seminar I attended last month with a very progressive metropolitan CCG. It decided – bravely I thought – to get patient support groups to come to an all-day working session on what they wanted from commissioning. This was a real exercise in patient and public engagement that I would recommend to all aspiring CCGs. For a start, it ticks lots of CCG authorisation boxes.

Anyway, where we got to in the course of the day was a discussion on how well care pathways were working. Or not. Eventually, we got to do some simple mapping of care pathways and where they most often failed the patient. This phenomenon from another customer service industry is called ‘The Moment of Truth’ (Google it and “Jan Carlzon”). As you might have guessed, where the bulk of problems occurred was in the ‘hand-offs’ between different may 2012 | practicebusiness.co.uk

care organisations. Significantly, most were about access, transport and appointments, rather than actual medical care. This was usually rated as excellent, but often the barriers to actually obtain it were a huge disincentive to the continuity of care. Many patients gave up or the system gave up on them. I suspect this is a huge part of the DNAs we see in NHS statistics.

The purpose of this anecdote is to get GP commissioners to think about how, as they assume responsibility, they organise, choose and contract the best care. Patients, consumers, customers, users, call them whatever you want, will have to be listened to and researched; indeed, their feedback should be actively sought.

New providers that can deliver this complex bundle of real needs should be encouraged.

Hospitals should see care pathways and, therefore, their supply chains, reaching outwards from their fortresses into the community, not reaching inwards.

There is a subtle difference. Creating these win/ wins is critical to the success of this next phase of NHS development. GP practices, whether they are commissioners or providers, will be essential partners for its attainment.

I wish you every success because if you get these parts of the providing agenda right it will help me enormously with Commissioning Success.

Like what you read?

Don’t miss your monthly dose of Roger Hymas.

You can now read his columns on commissioning in our new sister magazine Commissioning Success. To sign up for a free subscription, email subscriptions@ intelligentmedia.co.uk with the subject line “Commissioning Success”.

PRACTICEBUSINESS

How do you like your news and analysis? practicebusiness.co.uk is championing the role of practice managers everywhere you are

+ TWITTER Follow us @practice_biz on twitter twitter.com/@practice_biz

+ FACEBOOK Like us on Facebook for exclusive discussions about the topics affecting your role Search for ‘Practice Business’ on facebook.com

PRACTICEBUSINESS

+ Not forgetting

practicebusiness.co.uk

We’re helping bursars and business managers lead the online conversation, come and join us today and get a free subscription*

TERMS & CONDITIONS * Practice Business magazine is free for the first six months to first-time subscribers who qualify: finance, practice and business managers at surgeries and practices. For those who do not qualify: annual fee is £68.

one-to-ones with the people making a difference

people

22

Let’s get physical The UK’s first practice-based physical activity referral scheme is paying dividends for obese patients. Julie Penfold speaks to Myra Ward, practice manager at the Gadhvi Practice, one of eight practices offering the Healthwise scheme to patients across City and Hackney

may 2012 | practicebusiness.co.uk

23

people | case study

According to latest government statistics, one in four adults is now obese. One deprived London borough has been discovering the health benefits of a physical activity referral scheme (PARS) which, uniquely, operates in a general practice surgery setting. Healthwise is run by Greenwich Leisure Limited (GLL) and is commissioned by NHS City and Hackney. The scheme, which also runs across three leisure centres owned by Hackney Council, is aimed at breaking down barriers to physical activity and tackling health inequalities in the borough.

The general practice-based element of the Healthwise scheme was launched two years ago.

It is run by two GLL exercise facilitators who carry out motivational interviewing, exercise classes and assessments. The scheme is available across eight general practice surgeries across City and Hackney, where the six-week programme is offered free to patients.

A recent report by NHS City and Hackney on the success of the PARS scheme identified that most patients are referred to Healthwise by their GPs or practice nurses for obesity and its related conditions.

The results showed that patients joining the UK’s first practice-based scheme more than doubled the number of 30-minute bouts of moderate level activity they took over a six-week period. The report also indicates that upon completion of the practice programme, many patients take advantage of a heavily-subsidised gym membership, based within a leisure centre setting, to continue their progress.

Practice manager Myra Ward tells us more.

Could you describe what the Healthwise practice-based scheme involves for patients?

We started to offer the Healthwise PARS scheme to patients two years ago. Our Healthwise exercise facilitator Ellen Akoto comes into the practice every Friday to meet up with patients who have been referred onto the programme. Ellen weighs the patients, advises them on diet and arranges exercise classes or fitness sessions for the following week, such as keep fit on Thursday afternoons, which takes place at the practice. All of Ellen’s fitness equipment is stored at the practice, ready to use with the group.

As well as conducting exercise sessions here for the patients, Ellen also refers them onto other places including the King’s Hall leisure centre or to venues for swimming. Patients are also involved in walking and numerous activities that Ellen encourages them to try.

How are patients referred onto the scheme?

Patients are first referred onto the scheme by a GP or practice nurse. The patient would be told they need to become more active. The GP would typically ask if they would like to have some free exercise or weight loss advice and usually this appeals to the patient. Following the patient’s appointment, they would be directed to reception to complete their own form. It is not a case of the doctor ticking boxes and asking the patient a million and one questions; patients complete their own information. The form would remain at reception until it is reviewed by Ellen when she arrives on a Friday morning. Ellen will firstly go through all the forms from patients who want to join the scheme. From there, Ellen would contact the patient to book their first assessment, where she would introduce the scheme to the patient and create a tailored plan after discussing their individual requirements. There is never an instance where Ellen cannot help someone. If it is a condition where physical exercise would not be useful, she will refer them onto hydrotherapy or another alternative therapy. She reviews every situation individually and refers where necessary.

How do patients respond to the Healthwise sessions?

The numbers attending the sessions have really grown and we feel Ellen has a lot to do with this growth in interest as she is really friendly and is excellent at what she does. The patients that have enrolled onto and attended the six-week practicebased scheme have all benefited greatly. Their health has improved vastly and, most importantly, they have all become more aware of exercise and enjoy being active. Our patients find the Healthwise sessions a lot of fun, they love attending. In fact, the two additional practices under the Fountayne Road Health Centre roof have also asked if they too can refer some of their patients into the group based at our practice. We do firmly believe much of the patient interest is down to Ellen’s expertise as she is fantastic with our patients. A typical group will consist of ten patients, though we have seen groups of up to 25 patients lately. Our patient groups include people from all walks of life and all ages. We sometimes have family members in the same group, including mums and their sons or daughters. The Healthwise word is spreading around the patients and there is a real interest in how the scheme can help them.

»

Fact Box Practice: Gadhvi Practice Patients: 5,300 Clinical staff: Four doctors, six nurses plus two parttime specialist nurses – cardiovascular and diabetic.

Also numerous health visitors and district nurses attached to the practice.

Non-clinical staff: Eight PCT: City and Hackney CCG: Rainbow/Sunshine Practice manager: Myra Ward Time in role: Nine years Background: Myra Ward believes her extensive background in banking, regularly meeting and reaching targets, comes in very handy for her current role. Prior to her banking career, she was actually a receptionist at the Gadhvi Practice, later returning to take up the post of practice manager, which she thoroughly enjoys.

practicebusiness.co.uk | may 2012

24

people | case study

What impact does offering the scheme have on the practice?

The staff feel the Healthwise scheme is very useful for improving the wellbeing of our patients. Offering Healthwise in our practice also cuts down on the number of appointments requested by the patients who are referred onto the scheme. For our patients who are diabetic as a result of obesity, or for those who are out of work and find themselves eating as a comfort, leading to weight gain, offering a scheme of this kind at the surgery is really wonderful. The patients are able to exercise in familiar surroundings and are able to meet with other patients who are also in similar situations and need to lose weight. It is really enjoyable for the patients. When I am working in my office, I can often hear the screeches of laughter coming from the patients in the Healthwise group. Everyone just enjoys the sessions so much.

Our patients tell us the equipment Ellen uses in the sessions is so good; it does not feel as if they are exercising. When one of the doctors recommends a referral to the Healthwise scheme, but the patient is unable to attend the surgery-based exercise sessions because of work, a solution is always found. They would still come to see Ellen, who would slot the patient in somewhere else to enable that patient to continue with their exercise when they are not at work. It feels great for the patients to have a dedicated exercise facilitator on hand to advise them.

Following the six weeks, do patients continue to keep up levels of activity?

Yes, patients do very much remain active. As the end of the six weeks approaches, Ellen will review where patients are going onto to continue their physical activity and will provide advice on access to swimming or walking groups, all within their budget.

In some instances, suggested exercise sessions may be available for free. They are also advised they can return at anytime to have a chat with Ellen if they have any questions.

Do you find the subsidised gym membership, offered upon completion of the six-week practice-based scheme, is popular with patients?

The subsidised monthly gym membership fee is very popular with our patients; many are very excited to take up the offer. I feel it is a brilliant idea, the ÂŁ12.25 monthly fee, is a great saving and is a big incentive for patients to continue with their weight loss goals. may 2012 | practicebusiness.co.uk

What are the typical results for patients at the end of the six weeks?

After six weeks, patients do commonly experience weight loss. They all become more active and see less of their GP as a result of the Healthwise scheme.

We also find patients are more confident and feel very proud that they have lost weight. Patients will usually go onto to continue their progress at a gym or may join a swimming or walking group instead.

27

management | technology

Speak easy How up to date is your dictation recording system? Carrie Service looks at the benefits of ditching the tape recorder and upgrading to digital

Speaking from experience, I know I couldn’t live without my digital dictaphone. Well, perhaps that’s a bit extreme – I couldn’t work without it. The thought of scribbling down every word of an interview (having no knowledge of shorthand), frankly, terrifies me. Using a dictaphone has meant that I never have to worry about this. In addition, if I (allegedly) misquoted somebody, I would have it all down on record as back up. For GP practices that produce countless important medical documents every day, digital dictation is even more essential. So why are so many reluctant to switch?

»

practicebusiness.co.uk | may 2012

28

Digital switchover Elsewhere, moving over to digital has been the natural progression: VHS to DVD, tape to CD, CD to MP3 – even TV is now digital. But for some reason with dictation, people still hold on to analogue.

Georgina Pavelin, marketing product specialist for audio at Olympus, says this is due to a fear of the unknown: “It’s what they’ve always been using.

We find that moving over to digital can be quite daunting for them.” This could be because of the way digital dictation products are presented by suppliers, continues Pavelin: “[Many] digital dictation manufacturers are getting a bit too technical, so we need to take it right back to basics so that people can understand.” Terminology such as ‘bit’ and ‘gigabyte’ might be meaningful to someone used to data storage, but for a secretary using the same tape machine for the past decade, it can be like another language.

Some practices are holding on to their tape recorders in a bid to save money but, using outdated equipment can actually have the opposite effect, explains Pavelin: “[Tape recorders] don’t really exist anymore. We don’t make them anymore, I don’t think any of the other manufacturers are still making them and you can’t even really get the parts to repair them anymore.” This is where the costs start to spiral. Many practices are afraid to order something that they won’t know how to use, so they automatically reorder the same machine when their old one breaks. Tape recorders are now actually more expensive than they were originally and much more difficult to get hold of. Mick Smith, IT manager at Fordingbridge Surgery in Hampshire, was unsure whether the costs of investing in newer technology would be worth it at first. “The initial outlay did seem expensive at the time,” he explains, “but once we bought the equipment the actual annual costs are relatively low.” Money saved by efficiency savings and not having to buy new tapes or parts for repairs made the transition worthwhile.

Fast forward Upgrading your tape-with-note-attached system will allow clerical staff to save huge amounts of time. Not having to skip through long recordings to find the right part for transcription won’t do staff morale any harm either. It might be that some initial training will be needed, but most manufacturers will provide this if you ask, so stick with it and you’ll soon notice the difference to the day to day running of the practice.

“Since switching to digital dictation, we now have a streamlined process where recordings are instantly may 2012 | practicebusiness.co.uk

We now have a streamlined process where recordings are instantly available for typing available for typing,” says Smith. “All dictations are saved on the server for recovery – this is something we couldn’t even think about with tapes.” It also means recordings can be emailed rather than posted so you can have an instant response, and it might save you a few pounds in recorded deliveries too.

Pause and reflect As a GP himself, Dr Andrew Whiteley, MD at Lexacom, was concerned that tapes were not confidential and often contained a mix of routine and urgent referrals, meaning they were not prioritised properly. He took matters into his own hands and decided to develop his own dictation software. Whitely advises GP practices to move on and embrace digital dictation for their own benefit: “Being able to dictate a referral letter or a diagnosis while, or immediately after, seeing a patient, minimises the risk of recording incorrect or incomplete information. The sound quality is far superior to tapes, ensuring more accurate transcription and users can keep an eye on workload and monitor how quickly work is being progressed.”

Sue Lawson, practice manager from Dunblane Medical Practice, had similar frustrations before her practice switched over to a digital system. “Using tapes encouraged bad habits,” she explains. “Doctors would wait and record all their letters and actions in one hit to fill up a tape. Our secretaries would end up with an unexpected deluge of work, with no way of knowing whether the tape contained urgent referrals or how long the dictations were.”

Taking the words out of your mouth Why not throw voice recognition software into the mix? This allows dictated documents to be instantly transcribed, without having to type it up by hand.

Anne Durand-Badel, international marketing manager for Nuance Healthcare, explains: “Beyond simply digitally recording their reports, clinicians can have them recognised instantly. It is up to them to then choose their preferred workflow.” Some clerical staff might see this as a threat to their job, but it could actually allow extra time to complete other more pressing tasks. Once it’s up and running, your staff won’t know how they worked without it.

30

MANAGEMENT | legal

Success in selling out The valuation of surgery premises can be tricky territory.

Veale Wasbrough Vizards’ OLIVER POOL looks at cost versus market value when partners sell their shares How do you calculate what you get paid when you sell your share of your surgery? It depends what your partnership deed says, of course. Most practices simply pay out a retiring partner at whatever the market value of the premises is at the time. If the partners can’t agree what the surgery is worth, a valuer should be instructed to tell them. (A specialist surveyor with experience in primary care premises should always be used to minimise the chance of disputes arising.)

Many practices provide for partners to be bought out at the greater of: a) the market value at the time, and b) the cost at which that partner bought in (more often than not this figure is their share of the cost of building).

This arrangement is almost unique to primary care.

Often GPs make these arrangements to guard against the perceived unfairness of a retiring partner having to pay money into the practice on retirement to cover his or her share of negative equity. It can be seen as unfair for the continuing partners to require such a cash payment given that a) they would be in receipt of notional rent, but also b) they should (in theory) benefit when property prices rise and eradicate the negative equity.

There is less certainty these days of property prices moving upwards so as to eradicate negative equity

The question of whether to allow partners to sell out at the greater of cost or market value is particularly acute when partners are developing or buying new premises. Older partners who are closer to retirement are often reluctant to participate in the development risk of a new build, only to find that it is immediately in negative equity. It is for this reason that many practices have – particularly over the last 15 years – provided for a retiring partner to sell out at the greater of cost or market value, leaving the remaining partners to bear the negative equity with the hope that property prices will increase.

In the current environment it is harder to justify this sort of arrangement. There is less certainty of property prices moving upwards so as to eradicate negative equity and many older partners find participating in a new build, even for a short time, worthwhile for the tax advantages (especially capital allowances). With this in mind, many practices are not happy to allow older partners a risk-free exit. There is no right answer and it is an issue for all partners to agree. Your solicitor and accountant will be able to help guide such discussions, but whatever is agreed, it should be clearly recorded in the partnership deed.

If you would like more information on the above please contact Oliver Pool on 0117 314 5429 or opool@vwv.co.uk

Legal update sponsored by Veale Wasbrough Vizards VWV can review your partnership deed without obligation and provide a fixed-fee quote for an month | practicebusiness.co.uk update2010 or renewal if needed. Visit vwv.co.uk/site/sectors/primaryhealthcare for more information, or contact Oliver Pool on 0117 314 5429 or opool@vwv.co.uk

32

management | qof

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

Atrial fibrillation

Once dismissed as a given for the aged, atrial fibrillation is now considered a serious cause of death and five QOF points are available for practices maintaining a list of affected patients. Dr Paul Lambden discusses the condition

A heart in atrial fibrillation looks like a bag of worms may 2012 | practicebusiness.co.uk

Not so many years ago, atrial fibrillation was treated fairly casually by the medical profession, often looked on as a complication of old age and treated with digoxin if considered necessary. Nowadays it is recognised as an important cause of mortality and morbidity that should be diagnosed and treated effectively to prevent complications. The condition is believed to affect half a million people in the UK, more commonly in men and increasing with age. The incidence doubles with each decade over 50 and nine per cent of patients over 75 will have atrial fibrillation. Its importance is recognised in the QOF where five points are available to a practice maintaining a list of patients with atrial fibrillation.

In a normal healthy heart beating at between 60 and 80 beats a minute, each contraction involves the muscular walls of the heart squeezing blood out of the heart, into the arteries and around the body. It then relaxes and more blood is drawn into the heart from the veins to fill the heart again. The cycle is repeated with each beat. If the heart develops atrial fibrillation (AF) it beats in a random and uncoordinated manner, often so fast that it cannot relax to draw in blood between contractions. Efficiency is therefore reduced. A heart in AF often looks like a bag of worms.

AF develops because of electrical disturbances in the heart. Simply an electrical ‘node’ in the upper part of the heart normally maintains the normal rhythm and rate. If abnormal electrical impulses develop and override the normal ‘pacemaker’, AF is the consequence, leading to the rapid irregular pulse rate. The reason for the development of AF is not fully understood but ischaemia (lack of blood flow) to the pacemaker node may be a cause and the condition may be triggered by excess alcohol or smoking. Other causes include some drugs and medicines, diabetes, an over-active thyroid gland and following surgery of any kind. Sometimes no cause can be found to account for the fibrillation.

AF may be paroxysmal (coming and going and any one episode lasting less than 48 hours) or persistent (lasting more than seven days). It may last indefinitely and becomes permanent if it resists attempts to control it by medical means.

Anyone suffering from AF may become aware that their pulse is rapid and irregular and they may experience palpitations. They may also suffer from dizziness, chest pain, breathlessness, palpitations and tiredness. However, some patients with AF continue to feel completely well and experience no palpitations or irregular pulse. The loss of efficacy of heart activity can lead to the development of low blood pressure and may result in heart failure. Although AF is not directly fatal, the slowing and eddying of the blood in the heart chambers may lead to clotting and, if small pieces of the clot break off and circulate in the blood they can lodge in the brain causing a stroke. Someone with AF is six times more likely to have a stroke and twice as likely to die as someone with normal heart rhythm. Up to 10 QOF points (AF5) are available for establishing the stroke risk using a risk stratification scoring system (CHADS2) for 40-90% of AF patients in the preceding 15 months (see box out).

AF is confirmed by electrocardiogram and other investigations are undertaken to exclude causes such as hyperthyroidism. The risks of failure and stroke, even in those patients who are well, are significant and treatment is

aimed at restoring normal rhythm where possible (cardioversion), controlling rate and rhythm in patients where cardioversion is not possible and reducing the risk of stroke by using drugs that reduce blood coagulability.

Cardioversion, shocking the heart back into normal rhythm, is more successful in those patients who have had AF for less than three months. In those patients who resist cardioversion, another technique can be employed to destroy the abnormal electrical pathways. It is effective but relapses are common. A further technique is to insert an electric pacemaker into the heart to control the rhythm. Where the AF is established and cannot be controlled using electrical means, there are drug therapies which can cause the heart beat to revert to normal and others such as digoxin that moderate the rate and make the heart beat more powerfully. Any patient who has persisting AF is treated with a drug which reduces the likelihood CHADS2 i is a schoring system of clotting of the blood. Aspirin and for recognising high-risk AF warfarin are commonly used. patients which is simple to use. It scores up to six for the Up to six QOF points can following risk factors be achieved (AF6) in 50-90% of CHADS2 scored patients of one C - congestive heart failure 1 point recorded in the previous 15 months H - hypertension 1 point and treated with anti-coagulant or A - aged 75 or over 1 point anti-platelet therapy. A further six D - diabetes mellitus 1 point points (AF7) are available for 40-70% S2 - previous stroke or TIA 2 points of AF patients scored with CHADS2 greater than one and treated with 0 = low risk, 1 = moderate anti-coagulation therapy. risk, 2 or more = high risk

work/life

34

advice for busy lives

On your marks

may 2012 | practicebusiness.co.uk

With the influx of new services being delivered in primary rather than secondary care, Carrie Service looks at ways to make sure GP practices and their teams are ready to take on these new responsibilities

35

work/life | advice

The way practices operate is experiencing a complete overhaul. The line between primary and secondary care is becoming less fixed as some secondary services move from the hospital to the doctor’s surgery. What will this and the additional changes that come with it, such as the CQC and commissioning, mean for the practice, and are you prepared?

Choosing an approach Joanne Bartlett, director of healthcare consultants Primary Care Partnership, believes GP practices will have a difficult decision on their hands when choosing how to present their offer of new services to patients.

They will have to pick between increasing their own range of services and using those run by private companies: “With a rising number of healthcare services being provided in a primary care setting through Any Qualified Provider, GP practices will increasingly be presented with a dilemma: To find time and resources to deliver a wider range of GPwSI [GPs with a special interest] services themselves or simply to host outside organisations such as their local foundation trust or a private sector provider to deliver the service.”

There are complications involved with both options though, so weigh things up and choose carefully.

“Providing the services themselves may involve further training, investment and a significantly increased workload, but is likely to offer a greater level of control and ownership,” says Bartlett. On the other hand, “hosting services may encounter challenges with public perception, but is likely to enable practices to offer a far greater range of high quality services, with little extra workload”. Another factor to consider is that by taking the outside organisation option you have the possibility of raising some extra revenue. “Through charging rent and service charges to external organisations, we have calculated that a typical practice could generate income of circa £15 – £20k per year – space permitting – for each speciality hosted,” comments Bartlett.

Your role as practice manager is going to change and it’s important that all staff under your supervision know when you will and won’t be available to help them

CQC panic As the dark cloud of the CQC looms, some practices are over-thinking what they need to do to prepare, and are acting impulsively. A report in Pulse in January highlighted the pressure GP practices are feeling to be CQC

ready. It revealed that despite the CQC ensuring practices that buying third party software to prepare for registration wasn’t necessary, a firm claimed to have already sold their programme to 1,000 practices in the UK. The CQC have accused the companies of scaremongering and do not advise practices to invest in these types software. Victoria Howes, design team leader with the CQC, told Pulse: “They don’t seem to add anything to what you can do for free. I have yet to see one that reflects how we regulate because they don’t talk about outcomes.” Many practices have regretted making purchases too far in advance, so assess what resources you already have and see what processes you can implement in house before making investments. Ask yourself if these companies can really be so sure about CQC registration when the clinicians themselves are still largely in the dark.

Can you manage?

Whenever changes are made in a business or organisation, the manager tends to take the brunt of any issues that arise, and GP practices are no different.

Making all staff aware of changes, no matter how little they will be affected by them is vital. Although it’s been said many times, communication is one of the most effective but often neglected management tools.

Your role as practice manager is going to change and it’s important that all staff under your supervision know when you will and won’t be available to help them out, especially if you are playing a big part in commissioning for your area. Being closely involved with the CCG might mean that you will have to sacrifice a portion of the time you dedicate to the surgery itself, and staff should be made aware of your increasing workload. This will not only benefit you, but will help staff to organise their own workloads, as (no doubt) there may be certain tasks that require your presence. Figuring out how much the practice will be involved as a whole is also crucial to allow for sufficient planning. Dame Barbara Hakin, national director of commissioning development wrote in her most recent GP and Practice Team Bulletin: “Each practice needs to agree which team member is going to be their clinical lead for commissioning issues. This person will need to make sure that everyone working in their practice, including session GPs, nurses, practice managers and other staff, support the lead clinician in identifying the changes most needed to improve services.” Keeping staff in the loop by identifying how their roles will differ as more services are added to the practice will help to boost morale and make them feel valued as part of the practice team. practicebusiness.co.uk | may 2012

36

WORK/LIFE | top tips

10 WAYS TO

make your practice better equipped FOR LTCS

1

DON’T BURY YOUR HEAD IN THE SAND: Around 15 million people in the UK have at least one long-term condition.

LTCs are the single largest burden on the NHS and managing them accounts for more than three quarters of England’s total health and social care expenditure. Understanding and accepting the extent of the problem is the first step to better management.

2

IDENTIFY PATIENTS WHO ARE AT RISK: Effectively managing LTCs rests on pinpointing patients who most regularly use hospital services and therefore whose chronic conditions are least effectively managed in primary care. Make use of local risk profiling tools.

3

ASK THE EXPERT: GPs are the fountain of knowledge on their own patients and their needs, but it’s important to tap into the experience and expertise of specialists in your consortium and in local secondary care.

4

THE PATIENT IS A WHOLE PERSON: Whether you favour a shared services approach to managing long-term conditions or believe that will lead to more fragmented care, it is crucial to bear in mind that the patient is not just a set of different though often linked conditions. Consider them and their diseases holistically.

5

PATIENT KNOWS BEST: Wherever possible, encourage patients to manage as much of their own care as is practicable. This helps relieve some of the burden and can empower the patient.

6

THINK OUTSIDE THE BOX: Maximising the number of patients who self-manage is key, so think creatively about how you can do this. Engaging with non-traditional providers – such as social enterprises, community groups and private companies – might be an option. One example is promoting vouchers for community-run exercise or weight loss programmes.

7

IMPLEMENT JOINT CARE PLANS: Patient buy-in often increases if they are involved in the decisions made about the treatment and management of their conditions. Whether it’s explaining the benefits of monitoring their symptoms and disease at home or more general education about their medicines, it is important that they know what’s happening.

8

THINK ABOUT SUPPLIES: Finding the right equipment and products that help a patient become more compliant in managing their condition can help reduce costly complications.

Balance quality of the product with price and conduct trials for heavy usage items to ascertain if they work and are well received by patients. Contact manufacturers to see if you can save money by buying direct from the source on high volume items.

9

WORK WITH YOUR COMMISSIONING COMPATRIOTS: Any strategy for managing chronic disease needs to be implemented comprehensively, rather than different members of CCGs doing different things – one looking solely at promoting self-management, another embarking on risk profiling, and a third trying to do everything itself.

10

UTILISE THE RESOURCES AT YOUR FINGERTIPS: There are a multitude of online resources that are aimed at helping commissioning groups tackle the LTC minefield. The Department of Health (http://www.dh.gov.uk/en/Healthcare/ Longtermconditions/index.htm) and The King’s Fund (http:// www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_ of_care/the_management_of_1.html) are a good starting point.

may 2012 | practicebusiness.co.uk

SUBSCRIBE NOW AND GET 6 MONTHS FREE

As more care moves into the community, general practice faces a time of great opportunity and much challenge: increased competition, greater accountability and a need for strategic, top-quality business management. Practice Business supports practice managers with information-packed articles, the latest news analysis, best practice interviews and easyto-read guides to all aspects of your role. All this can be yours free for six months – how’s that for best value?

SUBSCRIBE TODAY AND RECEIVE...

+ SECTOR NEWS

tions for Practice

+ Inspiring Business Solu

Managers

+ Inspiring Bu

october 20

november 2011

siness So

lutions fo

r Practice

Manager

11

News analysis and sector comments every month

practicebupsrinaecsts icebusiness

+ BEST PRACTICE

Inspirational interviews and case studies

YOUR GU tO mana IDE cOmmIss GInG IOnInG!

+ CLINICAL INFO

Easy-to-read clinical updates and our exclusive guide to QOF

+ MANAGEMENT ARTICLES

Advice-filled articles on all aspects of practice management

osed Negative exp and in surgery premises Negative equity s for retiring partners the issues it raise

streng

g at the gates CommissioNiN manager leads at

Are small th in numbe rs CCGs even possible?

The three practice their story Gateshead CCG tell

A guide We find ou to the p Attiieen A ntt pArtic t practice pA managers’ pA Atiio on n opinions ipAt on the en des commis hanced se A West Co sioning And rvice untry vie cl ot te w of the Health Bil d creAm l

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

Practice Business

er with...

is an approved partn

Practice

Business

is an appro ved partn

er with...

CALL: 020 7288 6833 EMAIL: subscriptions@intelligentmedia.co.uk WEB: www.practicebusiness.co.uk/subscribe/ *TERMS & CONDITIONS In order to qualify for a free subscription, the recipient must be a first time subscriber and be a finance, practice and/or business manager with purchasing authority at surgeries and practices in the UK or Ireland. For those who do not qualify log on to our website to subscibe for half price. For details or to subscribe contact Natalia Johnston on subscriptions@intelligentmedia.co.uk, +44 (0)20 7288 6833 or visit www.practicebusiness.co.uk/subscribe/

s

38

Work/life | diary

Practice diary Ann Boyle Ann Boyle started working in the NHS just over 15 years ago as a receptionist and soon worked her way up to become manager for a large GP practice in the North. You can follow her blog at BeyondtheReceptionDesk.wordpress.com

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

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

THIS MONTH: In the final part in a series, blogger Ann Boyle discusses changing patient addresses quickly How does your surgery update patient information – especially change of address?

In a surgery that I worked for this was seen as one of the less important jobs – and the receptionist doing this job worked three days a week. So often a change of address could be in her tray for a few days – and longer if she was on holiday.

That was until a patient came into the surgery to see the doctor – she was 35 years of age, a wife and mother of two children. She was complaining of stomach pains. The doctor examined her and felt it would be best to refer her to the local hospital for more tests. The doctor dictated the letter while the patient was sitting in front of her.

The patient came out of the surgery and went to the front desk to book another appointment and then informed the receptionist that she had in fact moved – the receptionist asked her to complete the appropriate form and put the form into the receptionist’s tray that dealt with the changes of addresses.

Later that afternoon, the secretary typed out the letter to the hospital that the doctor had dictated. The letter went to the hospital with the patient’s old address on as it had not been changed.

The patient came back to the doctor about six weeks later saying that she was feeling worse and still had not heard from the hospital.

The doctor telephoned the hospital and after a while it was discovered that the hospital had written to her old address with an appointment and she failed to attend and they never followed up on failed appointments.

The doctor at this point was extremely worried and asked for the patient to been seen asap. She was and it was discovered that she had stomach cancer.

The patient underwent surgery and treatment but sadly died some months later.

The husband of the patient came into the surgery to discuss the delay in his wife being seen at the hospital. We discussed the situation and while he did not want to place any blame, he did want assurance that this would not happen to another patient.

So, from that day on our policy on ‘change of address’ changed. Every single receptionist, as soon as she was given a change of address, was to enter it onto the computer system and the patient’s notes immediately.

So for any doctors’ receptionist/manager reading this please adopt this policy and ensure that whenever you have a patient change of address it is done immediately.

PHS Wastemanagement is a national waste management company that specialise in offering customised collection, disposal and recycling solutions for all forms of healthcare wastes including clinical, pharmaceutical and dental.

Our comprehensive range of services are designed to ensure the cost effective, environmentally sound and compliant removal of all difficult to manage wastes.

With a network of PPC (Pollution Prevention Control) permitted and licensed sites, our experienced, fully qualified team is always on hand to provide you with the right advice and support to safely and legally deal with your wastes.

With increasing legislation and the demand to be more environmentally conscious, the pressure is on many organisations to balance the right disposal route, while getting the best value for money. We understand that you have a Duty of Care to make sure that your waste is handled, stored and disposed of correctly.

Contact us today, quoting S1462: Telephone - 02920 809090 Email: - productinfo@phs.co.uk Website - www.phswastemanagement.co.uk

JPen Medical is the market leader in on-site testing and calibration of healthcare equipment.

With nationwide coverage, testing more than 60,000 healthcare medical devices each year, we are the only service company that meets best practice guidelines.

Our engineers operate throughout the UK coming to your place of work to test and calibrate your equipment on-site. This is the fastest and most cost effective method of maintaining the annual testing and calibration of your diagnostic equipment.

JPen Medical is recognised as the UK’s most thoroughly trained and professional testing and calibration company. Not only certified by the manufacturers, we are also accredited by the National Physical Laboratory working in accordance with UKWF guidelines.

All of our graduate engineers are trained to the highest level and operate to ISO 9001 quality standards, ensuring consistent, reliable validation of your equipment.

Contact us today, quoting S1462 Telephone - 0845 602 8067 Email - info@jpenmedical.co.uk Website - www.jpenmedical.co.uk