Practice busines November 2011

practicebusiness + Inspiring Business Solutions for Practice Managers november 2011

Negative exposed

Negative equity in surgery premises and the issues it raises for retiring partners

Commissioning at the Gates The three practice manager leads at Gateshead CCG tell their story

Did you catch the flu?

We take a look at the 2011 flu campaign and share some last minute techniques

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

Adults and children from 36 months should receive one 0.5 millilitre dose. In children aged 6 months to 35 months clinical data are limited and dosages of 0.25 or 0.5 millilitre have been used. Children who have not been previously vaccinated should receive a second dose of vaccine after an interval of at least 4 weeks. Doses should be administered intramuscularly or deep subcutaneously.

Contraindications: Hypersensitivity to the active substances, to any of the excipients, to eggs, chicken protein, neomycin, formaldehyde, and octoxinol 9. Immunisation should be postponed in patients with febrile illness or acute infection. Warnings and precautions: Do not administer intravascularly. Medical treatment should be available in the event of rare anaphylactic reactions following administration

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

include, allergic reactions (in rare cases leading to shock, angioedema), convulsions, transient thrombocytopenia, vasculitis with transient renal involvement and neurological disorders such as encephalomyelitis, neuritis and GuillainBarré syndrome. For a complete list of undesirable effects please refer to the Summary of Product Characteristics.

Package quantities and basic NHS cost: Single dose prefilled syringes in single packs, basic NHS cost £6.59; packs of 10 single dose prefilled syringes, basic NHS cost £65.90. Marketing authorisation holder: Sanofi Pasteur MSD Limited, Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP. Marketing authorisation number: PL 6745/0095. Legal category: POM. Date of last review: July 2007.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291. uk15224 III

08/11

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

Mastering the art of spinning plates

Practice managers have never been shy of multitasking – in fact, you could say, it’s one of the things they do best. Whether it’s sorting out maternity leave, juggling the practice’s accounts, or making a monthly practice manager network meeting, there’s always something they should have done yesterday.

If I were to give this issue a theme, it would be about making the most of your time. We have a feature on the busy lives of three practice managers in Gateshead who sit on the commissioning board and manage to keep their practices running (p18). We also have an interview with another practice manager who works as the lead nurse at her popular walk-in clinic (she even had to run out of our interview to tend to a patient who had fainted).

What’s interesting about her story (p24) is not only is she fighting for practice managers to have a presence on her local commissioning board, but nurses too – the latter, she feels, are even less represented in commissioning than the former.

And while practice managers may be adept at spinning lots of plates, their GP counterparts may not be. With this in mind, we have an article (p3) on things you can do to lighten your GPs’ administrative load – without taking on extra work yourself – so they can see patients and you can get on with the endless list of tasks running through your head.

Here’s hoping you don’t lose your head in these coming months. It’s busy times, but without your input, your CCG would be very much worse off.

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

editor

hepatitis B how high are their chances?

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

Hepatitis B Vaccine (rDNA) ABRIDGED PRESCRIBING INFORMATION HBvaxPRO® suspension for injection.

Hepatitis B vaccine (rDNA) Refer to Summary of Product Characteristics for full product information.

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

– why let them take a chance?

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

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

Undesirable effects: Common side effects include: transient soreness, erythema and induration

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

Date of last review: June 2011

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291.

References: 1. WHO/CDS/CSR/LYO/2002.2: Hepatitis B 2. Immunisation against Infectious Disease. Chapter 18: Hepatitis B chapter, updated November 2009. Department of Health. www.dh.gov.uk/en/Publichealth/ Healthprotection/Immunisation Greenbook/ DH_4097254 Accessed October 2011 3. HBvaxPro® Summary of Product Characteristics 4. NHS Business Services Authority at: www.nhsbsa.nhs.uk/ Prescription Services/933.aspx Accessed October 2011 UK15324g 10/11

see inside for our guide to managing commissioning

P.10

Contents SECTOR 6

News

The latest news this month to help practice managers excel in their jobs

8

Executive editor comment

The latest on the Health Bill from controversial columnist Roy Lilley

COMMISSIONING 10 Commissioning news

A practice manager’s update on clinically-led commissioning

12 Comment

A further look into the future Part two in Roger Hymas’s predictions

18 Case study

Commissioning at the Gates Gateshead’s three practice manager leads

PEOPLE IN PRACTICE 24 INTERVIEW

Talking the walk-in Jo Broom takes us around her seven-day-a-week centre

MANAGEMENT 28 Clinical

Did you catch the flu? We take a look at success so far of the 2011 flu seasons

30 Clinical

QOF This month: Dementia

32 Legal

Negative exposed Negative equity in surgery premises and the issues it raises

33 Advice

Lessening the load A lesson in reducing GPs’ paperwork

WORK/LIFE 36 Top tips

Document security How to keep your data in good hands

38 Diary

Annette Given, practice manager at The Spa Surgery in Harrogate

sector

06

Practices strike difficult patients off their lists

Your monthly lowdown on the world of general practice

Practices have been taking a zero-tolerance approach to difficult and awkward patients by striking them off patents lists, leading to a six per cent rise in complaints to the Health Service Ombudsman (HSO) last year.

The Ombudsman’s review of complaint handling by the NHS in England for 2010-11 highlighted an increased number of complaints about the removal of patients from GPs’ lists, sometimes without warning.

Last year, 21% of all complaints about GPs investigated by the watchdog were about patient removals.

In one case, a terminally ill woman was removed from her GP’s list following a dispute between the practice and her daughter.

In another case, a woman was removed from her GP’s list after a Key Facts n Twenty-one per cent of ‘simple disagreement’ about unanswered telephone calls. all complaints about As GPs prepare to take on greater responsibility for GPs investigated by the commissioning patient services, the report warns that some are Ombudsman were about failing to handle even the most basic complaints appropriately patient removals, a rise of and patients and their families need to be encouraged to speak up six per cent compared to the and complain. previous year Ombudsman Ann Abraham explained: “There is a growing n The NHS has paid out recognition that patient feedback is a valuable resource for the £500,000 in compensation as NHS at a time of uncertainty and change. It is a resource that is result of poor patient handling directly and swiftly available, covering all aspects of service, care and this year treatment. But when feedback is ignored and becomes a complaint, it n The Ombudsman reived 2,581 complaints about risks changing from being an asset to a cost.”

GPs last year As a consequence of poor patient handling, the NHS has paid out £500,000 in compensation this year.

news

Practice partner defends selling patients private treatments A doctor at the heart of a privatisation controversy has defended his actions, which included offering NHS patients private treatments and sharing out their details.

John McEvoy, managing partner of York’s Haxby and Wigginton Health Centre, wrote to 30 patients offering them a range of minor procedures that he claimed were no longer funded by the NHS. The revelation has raised questions from medical professionals concerning practices’ allegiance to the NHS and their patients.

McEvoy said the letter had listed other private providers as well as his own clinic.

He told Yorkshire’s Press: “We didn’t really want to do this, but as the NHS has

november 2011 | practicebusiness.co.uk

stopped funding for some minor procedures, we decided to fill the service gap.”

The story has provoked criticism from health experts among fears of a privatised NHS. Science columnist Ben Goldacre condemned McEvoy’s actions: “If people in the NHS are selling private medical information about NHS patients’ medical histories from their private confidential health records, then some people have got the wrong end of some very important ethical sticks, and something has gone very wrong indeed.” Health chiefs have denied that the treatments were no longer available on the NHS and are seeking urgent talks on the matter.

07

SECTOR | news

clinical news Free CQC guide for practice managers The Medical Protection Society has produced a free guide to help primary care organisations register with the Care Quality Commission.

The guide was produced in response to primary care organisations and their practice managers, who admitted to being anxious about how they will comply with the associated regulations.

Dr Stephanie Bown, director of policy and communications at the MPS, explained: “The feedback we’re hearing, particularly from practice managers, is that they are apprehensive about how to comply with all the regulations, and are uncertain about what is required of them.

“Dental practices encountered a number of challenges with the registration process [last September],” she added.

She said many practices will already have processes in place they can use to demonstrate compliance and the guide suggests ideas to ensure these comply with registration requirements without unnecessary effort and anxiety.

“It is not enough to have policies and procedures in place – steps need to be taken to provide evidence to show that patients’ and service users’ needs have been met.” The guide splits the 16 key regulations into five categories (see box out for some examples).

Five CQC categories 1. Involvement and information – Respecting and involving people who use the service, e.g. draw up a chaperone policy for the practice, have an up-to-date website and train all staff in equality and diversity 2. Personalised care, treatment and support – Cooperating with other providers, e.g. have a system to ensure hospital referrals are not missed and all contacts from the out-of-hours service are reviewed by a clinician 3. Safeguarding and safety – Undertake infection control audits and provide details of how frequently these will occur; provide spillage kits and ensure all staff have been offered relevant immunisations 4. Suitability of staffing – Support workers by having an induction programme and appraisal system, incorporating training needs 5. Quality of management – ensure that there are systems in place for access control and a disaster recovery/management plan.

They said…

“”

“I know exactly how much David Cameron values general practice. People should be seeing this as a very positive thing about the role of a GP that people want more and more access” Professor Steve Field on how extending practice boundaries is the key to ensuring patient choice, but says they should not be extended beyond the borders of the CCG

Chronic conditions Chronic conditions, such as diabetes, cancer and obesity, cost UK plc over £20bn a year in lost productivity.

The study of 8,866 UK residents by Gallup and Healthways demonstrated that workers with normal weight and no “disease burden” reported fewer than four unhealthy days per year and missed less than one and a half days of work per year. However, obese or overweight workers with three or more diseases reported 60 unhealthy days per year and over 18 missed work days per year due to poor health.

MMR vaccine The percentage of children immunised for measles, mumps and rubella (MMR) has continued to rise and is approaching the highest percentage since before the autism controversy in the 90s.

According to an NHS Information Centre report, 89.1% of children in England had received the vaccine by their second birthday in 2010-11, compared to just 88.2% in 2009-10.

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

diary NHS REFORM: MANAGING THE TRANSITION

fact

People with complex health needs will have the right to ask for a personal health budget by April 2014. Health Secretary Andrew Lansley said these personal health budgets “clearly fit” with the future direction of an NHS to which patient choice is central. “They allow people to work with the NHS so that they can receive more personal, more tailored care which fit with an individual’s life and uses resources most effectively,” he said.

The Barbican, London 10 November

BREAK THROUGH! NHS ALLIANCE 2011 CONFERENCE Manchester Central Convention Complex 30 November – 1 December

practicebusiness.co.uk | november 2011

08

SECTOR | news

Roy Lilley Roy Lilley is executive editor of Practice Business.

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

november 2011 | practicebusiness.co.uk

Waving the red flag

Is Lansley trying to score a goal in extra time? ROY LILLEY gives a play-by-play of the recent RCGP conference This year Liverpool was the home for the Royal College of General Practitioners’ annual thrash. It is one of the few national conferences that runs into the Saturday and it is not unusual for the last day sessions to be thinly attended. Not this year: GPs have a lot to talk about. The last session on the last day was Andrew Lansley – perhaps the last secretary of state for the NHS. All week the talk of the conference had been: Would the audience walk out?

In this footballing-of-all-cities, some delegates were planning to hold up a forest of red cards when he got up to talk; slow hand claps were also suggested. In the event, Lansley was given a polite, but chilled hearing.

He came bearing gifts (of sorts). Lansley told his audience that auditing would be extended to 11 new areas, including HIV and breast cancer.

He said publishing better data would allow patients to make more informed choices and specialists to “compare themselves with the best”.

The GPs were not interested. They wanted to give Lansley a grilling. And they did. For over half-an-hour, the secretary of state endured a barrage of questions about his real intentions for the future of the NHS. He was good, stood his ground but was clearly cross. He rounded on his audience: “For years GPs have been telling me: ‘If only they would listen to us, we could do it so much better.’” He went on: “Well, I am now ‘they’. I am listening to you. And I do want you to do it better.”

Lansley insists the secretary of state will remain in charge of the NHS; this was in contrast to a legal briefing published that morning in the lead-up to his conference appearance by the left-wing lobbying group, 38 Degrees, which said he wouldn’t. Time and time again Lansley rebutted accusations that he wanted to “privatise the NHS”.

When all was said and done, there was more said than done; and no one was any the wiser. We are still faced with the prospect of a patient visiting their MP asking for their help to hurry up a much needed hip operation. All your MP may be able to say is that they can no more haste treatment than they can shorten the queue at Tesco’s deli.

And, patients are faced with the prospect of their GP telling them they do not need a hip operation – painkillers and physio will do the trick; then hobbling home wondering if that is right or if the GP is simply trying to save money to make their year-end quality premium, commissioning bonus bigger.

The Department of Health made a partial climb-down over the quality premium last June, saying the Health Bill would only offer incentives for improvements in patient care and reductions in inequalities. But it insisted a premium would only be paid if clinical commissioning groups kept within budget. The DH said the ‘size and nature’ of quality premiums was under discussion, as were its original plans for commissioners to divide up premiums among member practices.

Liverpool was Lansley’s opportunity to set the record straight for all time. He didn’t. It was an open goal and he missed. A straw poll conducted by his audience showed an overwhelming majority remained against the bill and its impact. This was an own goal for the DH and the audience didn’t need to reach for their red cards: Lansley knows he is trying to slip in a winner in extra time.

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commissioning

10

Empowering practice managers in consortia

Health Bill completes second reading in house of Lords The second reading of the Health and Social Care Bill was completed last month by the House of Lords, dismissing calls from medical professionals to halt or amend the legislation.

The bill will now go to a committee of the whole house for line-by-line examination; it will then return to the upper chamber and back to the Commons before being given royal assent. Two amendments were tabled in the House of Lords.

Lord Rea tabled a motion that, if passed, would have meant the bill would go no further in the Lords and could not pass into law in this session of parliament. The House of Lords defeated the amendment by 354 votes to 220 – a majority for the government of 134 votes.

The second proposed by peers Lords Owen and Hennessy, would delay the bill by sending

the legislation for consideration by a threemonth special committee. Government ministers have said that the second option would most likely end all possibility of the ºbill being passed.

A Department of Health spokesperson commented on the news: “The vote today moves us one step closer to delivering a world-class health service that puts patients at its heart and hands more power to health professionals.

“We now look forward to working with the Lords to scrutinise the bill during committee stage to improve our plans further.”

This comes after nearly 75% of GPs agreed with calls from leading medical professionals for the Health and Social Care Bill to be withdrawn, according to a survey by the RCGP.

Your monthly guide to managing commissioning

Programme launched to help CCGs with their planning processes A new programme of workshops has been launched by MSD to help clinical commissioning group leaders develop their plans and reach the specifications required for authorisation. Dubbed ‘VIA’, it has been validated by the NAPC and the NHS Alliance and is free to use.

With the idea that most of England is covered by pathfinder CCGs, VIA offers a self-assessment tool so that potential CCGs can keep track of their progress towards authorisation.

Rebecca Wild, commissioning manager at MSD, said: “We developed this sponsored programme as a result of dialogue with our NHS customers, and we believe it responds to key issues for CCGs

“”

november 2011 | practicebusiness.co.uk

such as building scale, developing leadership and engaging stakeholders. We invite CCG leads to get in touch with us to discuss how VIA workshops could help them in planning their future success.”

Potential CCG groups can select single or several modules, which cover six domains, as part of the VIA programme to determine what stage they have reached in becoming an authorised CCG group through self-assessment.

VIA compliments the NHS Commissioning Board’s guidance and the work of the National Pathfinder Learning Network to help pathfinders become statutory by April 2013, when the NHS Commissioning Board will take over if they can’t.

They said…

“Though many of us have opposed this bill, it has a high chance of becoming law. If that happens, the NHS needs the best people possible to lead it away from the disasters we are anxious will come to pass. Malcolm Grant is one of those people.”

Dr Richard Horton, editor of medical journal, The Lancet, on Professor Malcolm Grant, provost and president of University College London’s appointment as chair of the NHS Commissioning Board

Practice insight

CCGs should not be ‘bullied’ on size Clinical commissioning groups should be determining their own size, not primary care trust clusters or strategic health authorities, the NAPC/NHS Alliance Clinical Commissioning Coalition has insisted.

While smaller CCGs could be less viable when corporate governance costs and the management of financial risk is considered, Dr Charles Alessi, chair-elect of the National Association of Primary Care, says these must be balanced with the “all-important need to keep engagement and close relationships with local GP practices, clinicians and patients”.

Dr Michael Dixon, chair of the NHS Alliance, added: “Each CCG will need to provide a good case for its composition and size. No one really knows what the ideal size of a CCG is and we need to remember that this is bound to vary according to circumstances and geography.

“The worst case scenario is that the future size of any CCG depends upon the presumed management allowance and costs of running a statutory organisation, rather than the size that is necessary for them to carry out their functions most effectively.”

The Clinical Commissioning Coalition has found that many CCGs are in fact being “bullied” into being a certain size, and insist that this is contrary to the principles of locally-led clinical commissioning in the first place.

The coalition is working with the Department of Health to look at how small a CCG might reasonably be, and how small CCGs can meet the requirements for future National Commissioning Board authorisation.

“Until this work is completed, it is entirely inappropriate for either PCT clusters or strategic health authorities to dictate to their constituent CCGs how large or small they should be,” concluded Dr Dixon.

The Clinical Commissioning Coalition is urging CCGs to use the configuration gateway and resist pressure from PCT clusters and SHAs. They ask them to get in touch if they encounter any difficulties.

A user friendly time-saver “The switch to EMIS Web went like a dream. If any practice is wondering whether to move, I would say bite the bullet and do it!”

A practice in Birmingham has seen the benefits of EMIS Web – just two weeks after switching from another system.

Angela Hegan This month we talk Angela Hegan, business manager at to Angela Hegan of Halcyon Medical in Birmingham, which Halcyon Medical in serves 8,500 patients – the majority of Birmingham about how whom are students – said switching to the EMIS Web is saving new system could not have been smoother her time and making and the practice was seeing improvements consultations easier in working practices within just two weeks of going live.

“We have had an excellent experience,” Hegan commented. “We moved to EMIS Web from a standing start in just five weeks, thanks to our fantastic IT department at the PCT and the EMIS support team, who were so helpful and patient. We all worked together, made sure everyone was on board, and stuck to our plan. It went like a dream.”

EMIS Web lets the practice see all the info they need about a patient on one screen, including test reminders, and consultations are easier as a result. “The GPs no longer have to dip in and out of different bits of software, which is saving an enormous amount of time.”

Hegan said the EMIS Web templates were particularly useful. “If for example we have an asthmatic patient, the GPs can fill in a tailored template there and then.

It’s making life a whole lot easier for them.

Sixty per cent of our patients are students, and we have a new intake every year. It is much quicker to input the patient history with EMIS Web.” She also finds it easy to run searches and reports. “I was able to run three successive medication searches for a PCT prescribing audit within minutes with no training, simply by reading the user guide. I always used to hand over this job to somebody else when we had our old system. But EMIS Web is so easy and www.emis-online.com intuitive to use.”

12

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

november 2011 | practicebusiness.co.uk

GP-led commissioning

commissioning | news analysis

Part 2

How GP commissioning will change primary care In the second of this two-part series, Roger Hymas explains why nothing will be the same again

I had a brief spell as a PCT commissioning director. It was probably made even briefer by the humdinger of a row that I had with a very senior NHS official when I was told by him that ‘commissioning was not about the money’. His career has prospered and he now has an even more senior position as the DH enforcer for commissioners’ budgets. Often I think he might now be feeling differently as NHS finances tighten and an increasing number of PCTs and trusts are reporting larger deficits.

Nobody in government will own up to it, but money is probably the principal reasons why CCGs, GPs and practices are being given the responsibility for commissioning budgets. Everyone now realises that GP practices are the only part of the system that has any chance of controlling NHS costs, essentially by capping demand and securing better local care pathway design.

In another period of my life, I ran a large health insurance company. The principal business driver of this organisation was to make sure that the cost of claims (drugs, tests, procedures, community care) did not exceed income. In Bupa’s case, this came from policyholders’ premiums and for CCGs it will be the allocation they get as PCT budgets are redrawn to reflect CCG boundaries; claims will have to be settled from these budgets.

This will make information management the big new priority. Commissioners will be resolute, dogmatic even, about collecting what is essentially claims information – requiring a ‘book entry’ for every single thing that happens to every patient. Claims will be sorted by patient, disease group, population

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11:40

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The session will start with all nonclinical rooms. During the lunch period the clinical areas will be inspected. The remainder of the afternoon will be spent going through paperwork requirements to meet the outcomes in the essential standards.

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commissioning | news analysis

segment, provider or care pathway. Back office data warehouses will collate this knowledge and bring extraordinary new insights into healthcare delivery.

Powerful algorithms will provide the data analysis and produce the reports. The databases will know all about every patient’s engagement with health care providers. Individual practice managers will work with the CCGs to collate and interpret the reports for their own GPs. Price information will be backed up by continuous surveys of patient quality. This data will then be sorted, processed and manipulated to drive most GP commissioning decisions and eventually begin to reshape patterns in referral management. Ultimately, it will lead to a fundamental re-engineering of care provision.

This is when we get to real commissioning: these innovations will raise it to an art or even a science.

CCGs will want to know where the financial risk sits and how to manage it. Detailed – very detailed – targets and budgets will be set and incentives and penalties created for good and poor behaviour. The entire commissioning scene will be dominated by the spectre of financial risk. It will become a gigantic game of pass the parcel (and, of course, inside the parcel is the ticking bomb of increasingly pressured NHS finances). Much as I know it will become unwelcome, I see it as inevitable that consortia will start to behave like health insurance companies, maybe like health maintenance organisations (HMOs) or maybe even independent practice associations (IPAs), both of which prevail in the US. Go to Google for the definitions.

But there is a second, maybe just as important, aspect of CCG finances that I want to cover. This is the budget for commissioning support – the money required to provide the admin to ensure that commissioning is delivered effectively. And, as I prepared this piece, I realised that what was about to be opened was a huge Pandora ’s Box and the potential of a complete system redesign for primary care practices. The starting point is that it’s absolutely critical for CCGs and practices to put in place the back office systems they’ll need to record all of the payments to providers for the care they deliver and check their validity and justification. Systems of this sort are complex and they don’t come cheap, but I think they will be the single dependency that enables a CCG to manage its budget and thus continue to be authorised.

The commissioning support budget should be between three and five per cent of the cost of the NHS budget. If we round annual NHS expenditure november 2011 | practicebusiness.co.uk

to £100bn, then about £4bn or £80 per member of the population a year will be spent every year, forever. This is about what some PCTs are spending at present. This is still at the low end of international experience, and about half of what’s spent in countries dominated by health insurancebacked funding systems. Commissioning support for England won’t be anywhere near this, but even so, it will become a pretty large industry in its own right and one that GPs will soon work out would be best if they owned themselves.

A lot of practices will quickly decide there’s no chance they are going to cede control of the engine room of their businesses to a PCT or the NCB. So, one move I can see happening pretty quickly is for the commissioning support element of CCGs moving into separate parallel business organisations, outside the scope of CCGs, which can only exist as statutory bodies. These businesses will be owned first by the GPs who make up the local CCG. Over the years, these operations are likely to merge to secure the benefits of scale and who knows they might eventually become larger public companies.

The entities that deliver the support role already exist in the private health insurance industry, where they are called ‘third party administrators’ or TPAs (see Wikipedia for a definition). It’s possible that in the long-term, only a handful of TPAs will provide support services to CCGs, particularly as the number of CCGs reduces over the years as they merge as well.

Come with me and make one final, albeit big, leap. This involves the TPAs merging with the CCGs’ practices to become integrated primary care organisations. In this scenario, we would see a cross-over whereby the practice ‘back office’ starts to control the ‘front-of-house’. GPs (and maybe senior practice managers) will then start to put together chains of local, regional, even national practices as they evolve into super consortia. There are already signs of this happening in this country – The

Nobody in government will own up to it, but money is probably the principal reasons why CCGs, GPs and practices are being given the responsibility for commissioning budgets

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commissioning | news analysis

Practice’s merger with Chilvers McCrea, for example.

This would lead to a break-up of the current geographical arrangement of NHS commissioning organisation administration as these chains of GPs start to compete with each other locally – just like opticians. GPs, as they sell up, would become equity shareholders in what would be significant businesses. By 2025, it’s possible that there will be only a few giant commissioning organisations with fully integrated business support functions. GPs and practice managers who invested in the first round would then find themselves with a significant additional pension pot.

So if all this change is going on in back offices, what about the ‘front-of-house’ for GP practices? Healthcare trends always evolve slowly. The current partnership set-up will continue to decline, albeit slowly, but the principals will always be looking for their exit. This means practices will merge into networks, which will get larger and larger. When they do, the financial engineers will arrive. There’ll be sale and lease-back of premises, securitisation of cash flows and even reinsurance of some of the financial risk. GP practices will start to compete locally for patients.

In our future scenario, as is currently the case, sometimes GPs will be commissioners, sometimes providers. Some of the group practices will become even bigger to become community treatment centres, others will become part of integrated care organisations. Many will decide to deliver a lot more hands-on care, treating many patients who today go to the local DGH. A few practices will specialise in particular patient types, those with particular conditions like COPD or diabetes.

Some will begin to create special relationships with local or regional health providers, who could deliver general medicine or be specialist organisations. Others will decide to become part of foundation trusts’ supply chains, even to the point where the GP practices are controlled by the FT. In this situation, the financial risk (along with the budget) can be easily transferred up the line from the GP surgery to the hospital. By then, most practices will have moved the risk of high-cost patients, for example those with long-term conditions, to a hospital or even another specialist provider.

The real issue about risk management is that at the end of the day it’s managing the 15% of patients who are sickest and who consume 80% of the NHS budget. Commissioners will scrutinise care arrangements for these people in fine detail: most will be ‘case managed’ continuously for the november 2011 | practicebusiness.co.uk

The real issue about risk management is that at the end of the day it’s managing the 15% of patients who are sickest and who consume 80% of the NHS budget rest of their lives. Specialist organisations will emerge – disease management companies, already a phenomenon in the US – to look after patients with conditions like diabetes.

The flip side of risk is, of course, opportunity.

High-cost patients are essentially the most valuable for care providers and represent the largest ‘profit’ opportunity. On top of their NHS financial entitlement, these patients will, in the future, bring their personal health budgets and sometimes their own top-up payments or insurance to pay for the kind of care they choose. Nobody will want to discuss it, but this population segment will become a huge business, maybe worth as much as £20bn a year. Providers will compete aggressively for these patients. And because they’re at the beginning of the ‘supply chain’, seeing new patients every day, the position of the GP becomes a critical business success factor.

So, there you are. That’s my attempt at extrapolating the present into the future, really no more than a bunch of informed guesses. What, of course, is certain is that each of these trends will be driven by the self-interests of the players involved.

You can also be certain that whatever takes place, it won’t happen in a linear way. There will be huge disruptions. But we can be certain of one thing. Despite a very bumpy start, GP-led commissioning is going to happen and the impact on the NHS will be profound and forever.

Yes, we can expect plenty of fireworks, starting soon. GP-led commissioning might have seemed like a damp squib for a long time, but believe me, the blue touch-paper is about to be lit and when that happens, it will take off like a rocket.

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CASE STUDY | williams medical supplies

A system of support With CQC registration now a requirement, and with a clear timeline, practices may be wondering where to turn. Luckily for them, help is at hand with the Williams Health and Safety Management System A successful registration with the Care Quality Commission will act as a license to trade for GP practices, which means those that don’t comply could risk closure, and many practices are unsure where to begin making sure they meet all the requirements.

A helping hand While this may feel daunting for many, the Williams Health and Safety Management System has been developed in collaboration with practice managers to suit the environment in which they work, and has been designed specifically for ease of use in the primary care environment.

It’s a full audit system to help meet the 16 outcomes of the essential standards outlined by the CQC. An audit day starts off with an inspection of all the rooms in the GP practice, focusing on non-clinical rooms and their related paperwork in the morning; moving on to the clinical areas next; and spending the afternoon going through general paperwork requirements to meet the outcomes in the CQC’s essential standards.

It is set up by a fully trained health and safety adviser, with all policies complying with the health and safety standards to meet the CQC outcome regarding safety and suitability of premises. All of the policies and templates are designed specifically for the primary care environment and are supplied in a software package and optional paper manual. There is also a full audit system available for practices to take home so they can carry on the good work after everything has been set up.

As we understand the way that general practice works, all policies and risk assessments are bespoke to the practice, with maintenance plans and ongoing assessments – so there is year round peace of mind that your statutory duties are met.

Fact box The management system includes the following areas: 30 policies to meet CQC standards on premises safety and suitability with a further set of arrangements and templates 26 risk assessment templates covering all parts of the practice Full induction system including all handouts for training COSHH database with all of Williams’s products in hazard sheets form Full training database Infection control audit system Health and safety audit system Fire safety audit system Fire risk assessment and a further template for the following years Other Services to meet Outcome 10: Legionella surveys Health & safety training in all 4 areas in one quick session, fire, manual handling, COSSH and general health & safety i.e slips & trips, display screen equipment and law.

CQC in practice Scott Hollis, CQC manager for Williams Medical says : “We’ve carried out extensive research and we know how to guide practices through the CQC process based on our experience with private surgeries.” For practices who are concerned about the looming deadline, Scott offers some reassurance: “CQC registration is coming and you may be worried about the timescales, as well as not knowing enough about the process. We are here to help, having experienced it already.”

Contact details 01685 845555 medicalservices@wms.co.uk www.wms.co.uk

practicebusiness.co.uk | november 2011

18

COMMISSIONING | case studies

The Gates-keepers Val Hempsey, Sue Sohi and Sheinaz Stansfield are all practice managers in Gateshead working with very different patient populations, despite their close proximity. They were brought together as practice manager leads for GatNet Clinical Commissioning Group. Julia Dennison interviews all three of them to get their perspective about commissioning and find out what their individual roles entail Practices across Gateshead, south of the river Tyne from Newcastle, have always had a great reputation for collaboration – their practice managers form part of a robust network known throughout the country for its close ties. It’s no surprise that commissioning has been a fairly smooth transition in the area and the local Gateshead Clinical Commissioning Group, which comprises all 35 GP practices in Gateshead, is already an exemplary pathfinder with a successful history of practice-based commissioning. When it became a pathfinder, the CCG known as GatNet held an election for its board members, comprising five GPs, three practice managers and one nurse. The three practice managers elected were Val Hempsey, managing partner of Bridges Medical Practice; Sue Sohi of Glenpark Medical Practice and Sheinaz Stansfield of Oxford Terrace Medical Group, who look after the practice development; communications; and patient and public involvement (PPI)/quality respectively. Here are their commissioning stories. november 2011 | practicebusiness.co.uk

How can you complain about decisions that are being made if you’re not part of the process?

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COMMISSIONING | case studies

Case study 1 Val Hempsey Bridges Medical Practice Practice manager lead – practice development Despite being in the midst of refurbishing and moving her practice, as well as sitting on the steering group of the Practice Management Network (not to mention the high number of speaking engagements she’s asked to do across the country), Val Hempsey still finds time to sit on the Gateshead Clinical Commissioning Group board as the practice manager lead for practice development.

As the single partner at her GP practice, Hempsey is used to being treated on a par with GPs, something she feels is important for commissioning.

In Gateshead, it’s a given that practice managers play a lead role in commissioning, and frankly, this practice manager couldn’t imagine it any other way.

“I struggle to understand when I hear that it’s not quite like that in other areas,” she says. “I think: ‘How do they get the work done?’ Are GPs doing the management or admin work? I don’t understand it.” For commissioning to succeed, Hempsey believes the practice manager’s input has to be valued, but that certainly hasn’t always been the case in general practice. “Years ago, you worked for the GPs and if the GPs allowed you to be out of the practice to work on something else that was good,” she says. “When I first started, I worked for who I considered a brilliant GP who [treated me as an equal], but I was lucky and some practice managers don’t even have that now.”

The practice manager’s role is evolving, and will do so more, Hempsey predicts. Where previously, practice managers would task themselves with running the practice down to the very detail of “ordering the paperclips”, now, they’ve got more important things to do. “It should be about strategy, business opportunities, planning, commissioning, providing and contracting,” she says of the profession. “You’re purchasing services – you’re not purchasing the photocopier. Although that still happens, it’s not the practice manager’s priority.” Bridges Medical Practice is only a small practice of 4,000 patients, but Hempsey still has an office manager who deals with those kinds of things – “I just step in if there’s a problem,” she adds.

Hempsey was a shoo-in for a role on the GatNet CCG board, as she was its practice manager lead under PBC. The main difference now is that as a would-be CCG, board members are given very

specific roles to carry out. “We thought more about the function than the form,” she explains of when the board was set up. “A lot of [other pathfinders] get caught up on how many GPs, practice managers and nurses they have. We thought about what we had to do and who would best fit into those roles.”

Hempsey’s role on the board is around practice development, which means making sure all the practices are moving quickly enough to enable them to deliver the commissioning agenda. This is facilitated

by Hempsey ensuring they have the right information, data and understanding of what needs to be done.

And of course, not all practices are involved at the same level. “Some take a back seat, but they’re not excluded,” she explains. She also makes sure to keep tabs on what’s going on nationally to bring it back to Gateshead.

In conclusion, Hempsey sees commissioning as a “career move” for practice managers. “It they don’t get involved with the concept, they’re not going to be practice managers, they’ll be administrators,” she explains. “I think a lot of people have the title [practice manager], but not everybody has the responsibility.”

Fact box Practice Bridges Medical Practice Contract PMS Staff 18 GPs Five Patients 4,000

practicebusiness.co.uk | november 2011

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COMMISSIONING | case studies

Case study 2 Sue Sohi Glenpark Medical Practice Practice manager lead – communications Sue Sohi has been working for Glenpark Medical Practice for 14 years. She started as the assistant manager back when it only had 7,500 patients (it now has 9,300) and as the job got bigger and there was more work coming into primary care, the practice manager at the time became the business manager and Sohi became practice manager.

“It used to be a one-man-job, a bit of a cottage industry, and a practice manager could deal with whatever came in and just needed an assistant to help with the overflow,” she says. “It then got to be a business from that cottage industry so it needed a business manager to look after things like the enhanced services etc, and a practice manager to run the practice.”

The practice manager’s role is a busy one at this practice, which has a branch surgery in the form of nearby Dunston Health Centre and three registrars to train. “That became a big job in itself and a very responsible one at that,” she remembers of her evolving role. When the business manager retired three years ago, Sohi was offered that job, but with further changes to general practice, she felt it was more productive to oversee both the practice and business manager roles with the help of two assistants. She believes this management team of three rather than two will also help with commissioning.

Sohi was happy to get involved with the CCG board, but she insists it can’t be to the detriment of her role as manager of Glenpark, which she says is her “bread and butter”. “This is my day job and this has to come first,” she explains. “The reason I got onto the CCG board is because I’m a practice manager, so if I didn’t have this job, I couldn’t be on it.” What’s happened as a result is if she doesn’t have the time to do everything she needs to do at practice level, she takes the work home or works on her days off. This is exacerbated by the fact that one of her assistants is currently on maternity leave.

Sohi calls herself the “newbie” on the GatNet CCG board because she’s the only practice manager lead not to have been involved in PBC. However, she’s taken to the role very quickly; it’s in her nature: “When my children were small I was on the board of governors at their school because I’ve always november 2011 | practicebusiness.co.uk

The reason I got onto the CCG board is because I’m a practice manager, so if I didn’t have this job, I couldn’t be on it thought: ‘How can you complain about decisions that are being made if you’re not part of the process?’”

As communications lead, Sohi liaises with the other practice managers in the group, while working with the communications lead at the PCT to try to learn what it is she’s supposed to do. She’s been busy working out who the stakeholders are for the CCG, for example the media, and developing communication ties with them. Whatever comes her way, Sohi is ready to get stuck in. “I feel quite excited about it actually,” she says.

“I am daunted; it is a challenge, but I keep thinking: ‘Well, if we don’t do it, who’s going to do it?’”

Fact box Practice Glenpark Medical Practice Partners Six Clinical staff 20 Admin staff 17 Patients 9,300

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COMMISSIONING | case studies

Case study 3 Sheinaz Stansfield Oxford Terrace Medical Group Practice manager lead – PPI and quality Sheinaz Stansfield has been practice manager of the Oxford Terrace Medical Group for three years.

Having first trained as a nurse, she became a PCT commissioning manager in 1992 at the inception of the purchaser/provider split and since then, she’s been through all the different incarnations of commissioning – from fund-holding to locality commissioning. She originally came to Gateshead to set up practice-based commissioning for the PCT and helped set up GatNet, so it’s safe to say she’s an authority on commissioning.

She first came to the Oxford Terrace Medical Group to work on its PBC information system and the next thing she knew she was headhunted for the practice manager’s position when it became available.

“Because I’ve got commissioning and clinical skills, I couldn’t have come into general practice at a better time,” she says. “There aren’t many people with commissioning as well as nursing skills and being able to combine those, I can really look at what we can do for clinical commissioning to improve the quality of services for the patients across Gateshead.”

For the past three years, Stansfield has been the organisational development lead for the GatNet board, which continued from her work at the PCT. “They wanted me to continue the work that I’d started; they didn’t want me to lose that continuity,” she adds. In this role she helped see the transition of GatNet PBC group into Gateshead CCG. “It does feel very different,” Stansfield says of pathfinder status.

“Before we were influencing the PCT to do the best we could for the patients of Gateshead, but now that we’ve become a clinical commissioning group, we’re actually driving forward the agenda and we’re making the decisions; so whereas we used to engage with the PCT, now the PCT engages with us.”

Her role on the board is overseeing patient and public involvement (PPI) and quality. Currently, her key PPI task is making sure the group achieves the assurance for patient and public involvement to become a statutory body. “My day-to-day role is about developing the infrastructure to support that,” she explains. “We’ve tried not to reinvent the wheel; we’ve tried to look at what the PCT has set up that works for Gateshead.” The hardest thing about working with communities, she says, is when people “parachute in november 2011 | practicebusiness.co.uk

and out” and there’s no continuity. “For patient and public involvement, that continuity is so important,” she insists. To help identify which PPI structures work best, she has employed the help of a local engagement board and a patient and public involvement group. Ideally, the PPI representative on the CCG board would be a layperson, explains Stansfield, but since she doesn’t represent any particular community, she feels she’s up for the job, as long as she stays in touch with the patient groups at all times, including developing the one at her own practice. “Being the champion for patient and public involvement on the board, I need to be the championing the cause of how we’re going to do it to improve general practice,” she says. Meanwhile, the work she’s doing with quality has been focused on clinical variation by using the combined predictive model to improve services for patients with conditions, such as respiratory diseases, for example. She’s also looking into how they can use community matrons more effectively.

Stansfield sees the commissioning side of her role as being very separate from the provider side. “What’s really important for me as a practice manager is to maintain my focus in the practice and to make sure that my practice, as a provider of services, is actually delivering in this competitive market where the focus is moving away from tickboxing to outcomes, and that is going to demand my full attention.”

Fact box Practice Oxford Terrace Medical Group Partners Six (including one nurse practitioner) Clinical staff 12 Admin staff 17 Patients 10,600

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people

24

one to ones with the people who matter

Tourist attraction Open 12-hours a day, seven days a week, Salisbury Walk-in Health Centre is a saving grace for the tourists who happen to fall ill on their visit to the picturesque corner of England nearby to Stonehenge. JULIA DENNISON speaks to practice manager and nurse JO BROOM Sunny Salisbury is one of England’s more popular tourist destinations. World-renowned for its cathedral, with its original copy of the Magna Carta, and nearby Stonehenge, the market town receives an influx of visitors every day and while some opt to stay a while, others traipse through in cars and coaches. For the unfortunate few who fall ill during their visit, there is a walk-in health centre adjacent to the main car park, providing a convenient solution to those in need of it.

november 2011 | practicebusiness.co.uk

Opened in April 2009, Salisbury Walk-in Health Centre, which also sits on the banks of the picturesque Avon River, is operated by a consortium of local GPs called WilcoDoc and co-owned and managed by Ashley House Clinical Services. It is open from 8am to 8pm, seven days a week, including bank holidays, and offers primary care services to everyone, whether they are registered with their own GP or not. On average, the centre sees around 500 walk-in patients a week.

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people | interview

manager. “I like to think the staff have more respect for me because they know that I know what it’s like [to do their job], because I do all the rubbish shifts as well,” she says. “If I ask them to do something, I feel they know I know what I’m talking about, rather than just being the practice manager.” She does anticipate, however, that if the practice gets busier, it could prove a challenge maintaining a dual role and has already dropped one of her clinical sessions due to being too busy.

Broom hasn’t been very involved with commissioning yet, which is not for want of trying.

“They’re developing the commissioning groups at the moment [locally], but they seem very reluctant to include nurses in them and it’s all very much GP-led,” she says. “I’ve been very vocal in saying I don’t agree with that.” As nurses take on more responsibility within primary care, she feels commissioning groups should recognise that by putting them on the commissioning board. But she’s been through this before. “This is what’s happened with all of the chronic disease management within primary care, because who does all of that? Well, it’s [the nurses]. The GPs do very little of it, in reality, because they haven’t got time, and that’s fine. I think it’s just about recognising those different skills that we all bring to things like commissioning.”

A juggling act Practice manager Jo Broom has her hands full – for not only does she oversee the business of running the busy health centre, she’s the lead nurse as well and holds two clinical sessions per week. When the practice opened, she was asked to manage the practice alongside her nursing role, despite having no experience in management. However, she was able to learn the ropes quickly thanks to a very competent team. “I was totally terrified for the first six months,” she admits. “You don’t realise all the things that go on behind the scenes when you’re just coming in and doing your job,” she says of what has surprised her about the management side of running a practice.

While the most challenging aspect of her job as manager, she says, has been people management, she enjoys a huge amount of job satisfaction, referring to the practice as her “baby”, having overseen it from its beginning.

As Broom speaks to me, she’s called out to tend to a patient who has fainted – a telling reminder of just how busy straddling clinical and management roleS can be. “It’s quite the juggling act,” Broom confirms, though she doesn’t mind – in fact she thinks being a clinician enhances her role as a

Walk-in services As a walk-in centre, Salisbury sees a wide range of patients types – from those who can’t get an appointment with their usual GP practice to those with no fixed abode – and under its contract, the practice is paid for every person who books in.

Because of the centre’s elevated number of homeless patients, Broom has been working on extending its outreach to other related services in the community and is trying to secure funding to extend the walk-in centre’s offering in this area. “We do our best to direct them to other services within the city that deal with the homeless and try to get them in touch, if it’s appropriate, with the council or the emergency housing department,” she says. “We’re very much trying to develop that side of our service because we do feel we have quite a good role to play in that and actually quite well placed to do it.”

Being a tourist city and situated next to the coach park means the health centre’s other typical demographic are people who are passing through.

“All of the drivers know that we’re here so if they’ve got somebody who’s en route who’s not feeling well, they can stop here and bring them in.”

»

Fact box Practice Salisbury Walk-in Health Centre Registered Patients 250 Salaried staff Seven PCT Wiltshire Practice manager Jo Broom Time in role Three years Background After training as a nurse, Broom became a midwife for 12 years. For health reasons, she went to work for what is now the Care Quality Commission for two and a half years. In 2004, she was approached by a GP to help develop the nurse practitioner’s role in the UK while completing her nurse practitioner’s degree.

She worked as a nurse practitioner in Andover and was soon approached by the medical director of the Salisbury Walk-in Health Centre to apply for what she thought was just a nurse practitioner’s job, but was offered the role of practice manager as well, which she took and has been working as both ever since.

practicebusiness.co.uk | november 2011

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people | interview

Registered patients Thanks to a consistent grown in popularity, the health centre has grown its registered patient list. “Our major business was just with walk-in patients initially, but in the last six months our number of registered patients has been going up by the day,” comments Broom on the now 250-strong list. “People have realised that we’re here and appreciate the accessibility and that’s made a huge difference. I think most of the [registered] patients first came in as walk-in patients and decided to register with us because they’ve realised how easy it is to access appointments.” Currently, the centre only has around six or seven registered patient appointments a day – but this is on the increase. Practice staff inform patients of the option for registration if they are new to the area or looking for a GP and Broom has been working to improve the health centre’s website to advance its search engine ranking. “We just feel that in the future [having registered patients] may make our position more viable with all of the restructuring because you constantly have to think ahead.”

Balancing the registered patients with the walk-in patients can sometimes prove a challenge. “We’re learning by the day as it’s becoming slightly more complicated [the more registered patients we have],” Broom says. “We’re really having to evaluate our service at the moment and look at the clinics that we’re running in order to be able to give the registered patients the appointments they want and still maintain the accessibility for everyone else.”

With the convergence of PCTs in line for the new health agenda, it’s unclear what the future holds for Salisbury Walk-in Health Centre, particularly as it is commissioned by Wiltshire PCT. “There was an issue over what would happen to this building and the services within it and at the minute, that’s all still very much under negotiation,” Broom says. “It’s a moving feast. At the moment we are here for the foreseeable future and we will carry on doing what we’re doing until someone comes along and says we’ve got to go.”

In a bid make its claim more secure, Broom is looking into a range of private services to add on november 2011 | practicebusiness.co.uk

to what the centre already offers, such as a holiday vaccination clinic, which she says is “building up slowly but surely” and a yellow fever centre after one of their nurses went on the course, a service that is “few and far between” in the area. She is also considering having Well Woman/Well Man clinics, in regards to which she is currently in conversation with the local private hospital.

With a growing number of registered patients and a building reputation, Salisbury Walk-In Health Centre is starting to outgrow its premises. The health centre rents the rooms it uses from Great Western Hospitals in Swindon, which has recently taken over the community services in the area from the primary care trust and so have taken over as official landlords of the building as of the end of August. As we speak, Broom is in the process of bargaining for more space so they can run an extra clinic. “We’re getting to the point now where we feel that we’re outgrowing where we are – but it’s been a bit of chicken and egg because we’re not sure what’s happening with the PCTs and commissioning and where we might be going,” Broom explains.

She also wonders where Salisbury Health Centre will sit when the new 111 service is rolled out nationally in 2013, coinciding with the disbandment of the PCTs. “It’s been a case of wanting to move forward but having to hold back a little bit just to see where we’re going to fit into that whole scene,” she says. “But I’m positive we’ll have a role still and we will fit in.” Indeed, a service like what this health centre offers, which helps defer patients away from the local hospitals and minor injury units, epitomises what commissioning holds to heart – putting primary care first. The staff at Salisbury Walk-in Health Centre want to take this further and are hoping to open an x-ray facility on site. Despite these changing times, Broom and her team have every reason to be positive about their future role, no matter what commissioning might throw at it.

I think the staff have more respect for me because I know what it’s like to do their job

business intelligence and management sense for practice managers

management

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On the flu campaign trail With the flu season on its way and the immunisation process in full swing, JONATHAN HILLS takes a look at how practice managers can reach as many patients as possible Most eligible patients are quite aware of the importance of flu immunisation. There are, however, always a few who manage to slip through the net. The numbers of patients immunised against flu has declined in recent years. Just 48% of over-65s received the jab last year,compared with 54% in 2009. Similarly, just 26% of under-65s in high-risk groups (including people with asthma, diabetes, heart disease and pregnant women) received it, compared with 31% the year before. The lull in the prevalence of “flu pandemic” stories in the media has undoutedly added to the falling vaccination numbers. Nevertheless, these statistics show a concerning trend.

Annette Given, practice manager at The Spa Surgery, Harrogate, shares advice on how she prepares for the flu season, stating that “elderly patients who are not regular attendees” are a particularly tricky demographic to reach. “We write to all at-risk patients who are reaching their 65th birthday as they may not be aware that they are now eligible for the flu vaccine.”

She believes sending letters in August inviting patients to Saturday vaccination clinics is a good technique.

november 2011 | practicebusiness.co.uk

Michelle Webster, practice manager at Woodseats Medical Centre in Sheffield, agrees that elderly patients are hard to engage. “They have not had vaccines before and do not understand the benefits of vaccination against flu,” she says. She recommends finding a means to alert as many patients in a specific group as possible for maximum impact. “We also contact local residential and nursing homes asking them to ensure consent of our patients for the vaccine – the homes are then visited by a combination of our practice nurses and local district nurse team.”

When practice mangers speak about the difficulties of trying to alert those hard-to-reach patients, most say that it is a matter of getting the message across again and again by as many means as possible with the most direct and practical approach.

It may seem natural to assume that most over-65s call up for the flu jab are more likely to have an existing relationship with their practice in the first place, but some patients may become eligible for the jab without having much previous contact with the practice. Young pregnant women are a good example. Midwives are

29

management | flu

very good at encouraging expectant mothers to have the jab, suggests Given.

Customising the content of letters sent to different patient groups, stating why they, specifically, are eligible for the jab, is likely to have an elevated success rate, as patients understand their own health risk.

In Webster’s practice, the whole team gets involved in promoting the annual flu campaign and receptionists are able to advise patients as to whether they fall into a target group.

After reaching as many patients you can, the only thing left is persistence. Some patients will take a while to engage, waiting for the media adverts or even the weather itself for a prompt. “We send reminder letters, postcards and text messages in October and run ‘mop-up’ clinics in November and December, holding onto stock right up to March so we can still vaccinate as required,” says Given.

Webster explains that there should not be a missed opportunity when it comes to getting as many

patients as possible immumised. A flu campaign, she says, will often involve phone calls, follow-up letters and notices in surgery, as well as giving opportunistic advice and counselling regarding the advantages of being vaccinated.

With the vaccination period nearing its end, there is nothing more to do than continue to deliver the message – prompt patients about jabs, double check your lists and registers for letters, emails and texts, brief your receptionist on alerting vulnerable patients if they are visiting the practice and hope they come in before they cath the flu.

It is a matter of getting the message across again and again by as many means as possible with the most direct and practical approach script file

A patient’s story “The mail order service is easy to use and saves us taking two taxis to collect repeat prescriptions. I would recommend it to anyone”

John Pinch Patient

delivering health

Eighty-year-old John Pinch and his disabled wife no longer have to depend on family members or expensive taxi trips to help them pick up repeat prescriptions, thanks to an innovative NHS mail-order pharmacy service.

Mr Pinch, a patient at the Moatfield Surgery in East Grinstead, takes seven different drugs for COPD, and his wife, who has arthritis and Lupus, is prescribed 13 medications. They signed up for the Pharmacy2U service two years ago and have never looked back. He said: “It was a bit of a struggle to get to the doctors, two miles away. My wife and I are at separate GP practices and sometimes we had to take two taxis to collect repeat prescriptions. When we found out about the mail order service, we realised it was just the job.”

The Moatfield Surgery is one of 300 GP practices currently offering patients the free NHS service from

Pharmacy2U. This enables patients to have their scripts dispensed without having to contact their GP directly or collect the paper prescription.

Medicines are delivered free of charge to their home or work, and patients can opt in to a free telephone or email reminder service.

Medication always on time For Mr Pinch, the reliability of the service is the key. “If we haven’t requested our medication, Pharmacy2U will phone up to remind us that a prescription is due. The advisers are very helpful and go through the medication with you. It’s delivered to our flat, and it’s always on time. I would recommend the service to anyone.” www.pharmacy2u.co.uk/practice

30

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

Dementia

Dementia affects around 20% of people in their 80s and incidence increases with age. GP practices can get up to 15 QOF points for regularly reviewing the condition among their patients. Dr Paul Lambden explains why it’s important

If dementia is suspected, it is helpful to see the patient with a relative to ‘fill in the gaps’ november 2011 | practicebusiness.co.uk

Dementia is a condition characterised by a progressive deterioration in intellectual function beyond what might be expected from normal aging and is a major cause of disability in the latter stages of life. The word is derived from the Latin ‘de-‘, ‘without’, and ‘ment-‘, from ‘mens’ – ‘mind’. There are nearly 600,000 dementia sufferers in England and it is expected to double in the next 30 years. It is estimated to affect about 20% of people in their 80s, which increases with age.

Dementia is not a single disease but a collection of signs and symptoms that vary from affected person to person depending on severity and cause. Symptoms may include memory loss, difficulties with reasoning, communication, judgement, language and problem solving. There are several different types. which are usually progressive, worsening over time.

Alzheimer’s disease is commonest and characterised by clumps of protein (plaques) that form around brain cells and disrupt function. Vascular dementia is the second most common and results from declining blood flow to the brain leading to brain cell death. It may be gradual or rapidly progressive. Lewy body dementia is similar to other types, can vary in degree on a daily basis, but is gradually progressive. Symptoms similar to Parkinson’s disease may occur with this form of dementia. Fronto-temporal dementia occurs with shrinkage of the frontal and temporal lobes of the brain and usually develops in people under 65.

It is relatively rare. Other types of dementia are Korsakoff’s syndrome, associated with chronic alcoholism and thiamine deficiency, and dementia pugilistica (boxer’s dementia) associated with receipt of multiple blows to the head.

The risk of vascular dementia can be influenced by lifestyle. The development of atherosclerosis (deposits causing hardening and narrowing of the arteries) is influenced by diabetes, obesity, smoking, excessive alcohol, lack of exercise and eating a high-fat diet, resulting in the death of brain cells from lack of oxygen. Blood supply to the brain may also be interrupted suddenly by thrombosis or embolism causing a stroke with acute loss of brain cells. A proportion of stroke sufferers go on to develop vascular dementia.

Diagnosing dementia, especially in its early stages, can be difficult because the presentation may be distorted by other factors. These include other medical problems such as illness, vitamin deficiency or drug side effects. If dementia is suspected, it is helpful to see the patient with a relative to facilitate the collection of information and ‘fill in the gaps’. Assessment includes detailed history, examination, review of medication and evaluation of mental abilities. There are questionnaires that can be used to assess mental impairment. The Mini-Mental State Examination (MMSE) is commonly used and assesses short- and longterm memory, attention, concentration, communication skills and understanding instructions. The series of questions scores a maximum of 30 points. Above 25 is considered normal, 18-24 indicates mild to moderate impairment and below 17 indicates serious impairment. Allowance should be made for those patients with poor education, who may score poorly without suffering from dementia.

Other investigations include blood tests to rule out a range of illnesses and biochemical disturbances such as vitamin deficiency. Up to six QOF points can be obtained for undertaking FBC, calcium, glucose, renal and liver function, TFTs and Vitamin B12 on up to 60% of newly diagnosed patients recorded six months

practicebusiness management | QOF

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

before or after entering the register. Computerised tomography (CT) or magnetic resonance imaging (MRI) scans are used to understand the physical state and structure of the brain. Medical and mental assessments are normally undertaken by GPs but the more detailed assessment and scanning are usually carried out by neurologists or neuropsychiatrists. Five QOF points are available for maintaining a register of patients diagnosed with dementia.

Management of dementia depends on diagnosis and interventions to improve quality of life. The diagnosis must be explained sensitively to the patient and the family, for whom support services must be quickly established. That support may be delivered at home, in hospital or in a care home by trained staff. Access to peer groups is also important. Quality standards for dementia are published by NICE. Patients with dementia should stay as independent as possible but will need progressively more care, often residential, over time. Medication, such as antidepressants, anxiolytics, anticonvulsants and anti-psychotic drugs may be necessary to control symptoms. Anti-dementia drugs such as donezepil (Aricept), rivastigmine and galantamine are used but their efficacy, particularly after symptoms have developed, is still a matter of debate. Regular review is important and up to 15 QOF points are available for reviewing up to 60% of the diagnosed patients in the preceding 15 months.

Prevention of dementia is disappointing, although there are some measures that may help prevent vascular dementia. These include a healthy diet, regular exercise, avoidance of obesity, stopping smoking and ensuring blood pressure is normal or controlled and diabetes, if present, is well managed. Success in caring for patients with dementia depends on understanding and eliminating family fears. With the right support, care can be successful and rewarding.

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32

management | legal

A negative impact Is negative equity once again rearing its ugly head? Oliver Pool, an associate at Veale Wasbrough Vizards, asks the question, and discusses the implications for GPs owning surgery premises

Recent concerns over the future values of commercial property raises the spectre of negative equity in surgery premises. There is no doubt that values have fallen, even when valuers take account of the fact that notional rent is paid when coming up with valuations. Partners in the middle of careers should be in for long enough to ‘ride out the blip’, but for incoming partners, and those approaching retirement, it is important.

In the last recession, it often came as a nasty surprise to retiring partners who owned a share of the surgery premises that they would be expected to buy themselves out on retirement. But this is what happened in a number of cases, especially where partnership deeds were silent on the issue, and especially where partners had been involved in costly new-builds, where the price of the development had exceeded the market value. This situation may be rearing its head again.

It is not uncommon for a partnership to ‘shield’ retiring partners from negative equity by including provisions in the partnership deed that provide for retiring partners to be bought out for at least what they contributed, or at least the previous acquisition cost.

This raises the issue of the goodwill rules – paying above the market value for surgery premises can be deemed to be a transfer of goodwill, which is, of course, illegal.

However, in practice these arrangements have not been called into question, as long as there is a clear preexisting agreement, and to date there have not been any prosecutions under the goodwill rules.

Including such provisions in the partnership deed will be particularly important for practices that are contemplating new-builds – older partners in particular

may be unwilling to participate if they are risking being bought out for a loss in a few years’ time (the best idea for partners nearing retirement is not to participate at all, but to allow the others to ‘get on with it’ and indemnify them).

Incoming partners may be reluctant about buying into negative equity. We often hear incoming partners asking why they should have to take over the share of a liability not of their own making. The answer is that partnership ‘comes as whole’ – if you want to be a partner you have to accept the whole package and can’t reject the bits you don’t like – the alternative is to find a different partnership, or to be a salaried GP. At the same time, what cannot be achieved by the partnership deed is to bind incoming partners to buy in at a certain price unless they specifically agree to it, because of course incoming partners aren’t yet bound by the terms of the partnership deed. Further, it may be permissible for the partnership to buy a retiring partner out above market value, but to insist that an incoming partner pays more than market value is much more likely to be a breach of the goodwill rules.

The best way for this to be dealt with is to see the transaction as one in which partnership protects retiring partners from negative equity, rather than the incoming partner directly taking on the outgoing partner’s share of liability. In any case it may be worth checking the partnership deed to see if it deals adequately with these issues.

Legal update sponsored by Veale Wasbrough Vizards For further information on legal issues relevant to GPs, please contact Oliver Pool, an associate at Veale Wasbrough Vizards who offers specialist legal advice to the GP sector and those advising GPs, on 0117 314 5429 or opool@vwv.co.uk

33

management | workload

Lesson for the load GPs have been complaining of too much paperwork, impacting their time to see patients. If this is true, what can practice managers do to lighten their load? Julia Dennison takes a look It’s no hidden fact: GP stress levels are reaching epic proportions.

With responsibility, comes accountability (and with accountability often comes bureaucracy). At a time when their role is set to become increasingly in demand under the shouldered weight of commissioning, and when 84% say the complexity of their consultations has increased in the last years (according to the BMA), the amount of administrative work they need to do is also on the rise.

According to a survey of 1,600 registrars, partners and sessional primary care doctors by GP Online, 85% said the amount of paperwork they do has increased over the last year and as a result, GP partners were only able to spend around 60% of their time with Stats patients. Half of GPs say they are even considering leaving the profession because of it. Any practice manager knows that a good GP is hard to find, so will be holding on to the ones they’ve got and the patient consultations they represent with a tight grip.

and facts

85%

Technology ignored Even newer research has confirmed this collective drowning in paper suffered by GPs continues to be a problem – despite advances in electronic communication. Shockingly, GP surgeries are inundated with nearly 200 million clinical documents sent in the post each year – at an estimated cost of £1 per letter.

of registrars and doctors say the amount of admin they do has increased over the last year

»

practicebusiness.co.uk | november 2011

34

management | workload

Indeed, according to a survey of 673 practices by Healthcare Gateway, GPs still receive the vast majority of patient information, such as discharge letters or test results from other NHS organisations, through the post, despite nearly every single practice (96%) preferring to receive documents electronically.

Instead of a GP instantly accessing their patient’s information, these paper documents need to be scanned and input into the system first, something that takes practices an estimated 18 hours per week in admin time.

The first place to start when lessening the GP’s workload is by looking at making it easier to share patient information, something which, unfortunately, is not always the decision of an individual practice.

Fortunately, there are companies that can help facilitate data sharing between healthcare organisations (with patient consent, of course). “Paper documents are a major irritant for GPs and practice staff. We are operating 19th century communications in the 21st century,” agrees Dr William Lumb, clinical informatics lead for NHS Cumbria, who is currently working with just such a company to facilitate recordsharing between out-of-hours doctors and GPs on three different computer systems.

There are also tools out there that allow hospital correspondence to feed directly from hospital systems into the practice’s workflow system. There are three major benefits of this approach, says Ric Thompson, MD of PCTI, provider of Docman. The first is speed of delivery – “near real-time delivery can be achieved from the point a hospital letter is created,” he says.

“Also, the rich clinical audit trail provides assurances that letters have not only been delivered but have been processed by the practice. This includes managing letters delivered in error. Finally there are significant cost savings that can be achieved from removing the paper and associated resources required to manage it.”

Dave Mills, patient services and IT manager at Dr Anscombe and Partners in Oxfordshire uses just such a system and he says the biggest benefit is his GPs can action 80-90% of letters in just one click. “We have set up various ‘quick steps’ [macros] to save GPs a lot of time; irrespective of the IT skill level of a GP, the system is easy to use with confidence. This has saved our 12 GPs a lot of time,” he says, which has saved his practice around five hours a week in staff time.

One hopes that with the collective sharing of information that occurs under commissioning, CCGs will work towards facilitating a unified approach to electronic communication. To make this possible, electronic document management techniques should november 2011 | practicebusiness.co.uk

Paper documents are a major irritant for GPs and practice staff.

We are operating 19th century communications in the 21st century be employed at a practice level. “By using these types of tools, practices can remove the time consuming processes of passing paper around the practice and move towards becoming ‘paper light’,” comments Thompson. With the right tools, GPs can annotate patient letters on screen, add comments, or forward on with instructions on what actions are required next. “This removes the manual process of searching through a paper file to locate the information and also removes the administrator’s preparation time.”

Overwhelming tasks In the GP Online survey, 78% of family doctors cited prescribing and medicines management initiatives as increasing bureaucracy and a similar number said QOF, revalidation or CPD requirements added to their admin too.

To help with these tasks, Michelle Webster, practice manager of Woodseats Medical Centre, uses templates.

“We are very template-driven and are currently utilising more than 60 clinical templates that have been developed in-house,” she says. “This ensures that all clinicians adopt the same approach to symptoms and diseases and also ensures consistency in clinical coding.

This not only helps guide the clinician through the correct diagnostics, protocols and read codes but also makes it easier to achieve maximum QOF payments, as everything is read and coded appropriately.”

There’s further help from technology like digital dictation equipment, which allows GPs to use speech recognition software to produce letters before the patient leaves the room. “The average person speaks seven times faster than they can write,” comments Georgina Pavelin of Olympus. “Before digital dictation was an option, practices would give their rush jobs to their fastest typist or place on the top of the ‘to-do’ pile – to type 95 words per minute was impressive, and a 90-minute tape could be transcribed in a few hours.”

If practices don’t act now to reduce and streamline GPs’ administrative tasks, they will find consultation time squeezed – thus resulting in fewer appointments and patient disengagement as an outcome, and with the potential of lax practice boundaries in April, it might just cause them to leave.

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

36

WORK/LIFE | top ten tips TOP 10 TIPS FOR

KEEPING YOUR DATA SECURE A practice has a responsibility to look after its patient information. TIMI OLOTU gives you the top 10 tips for keeping your surgery’s data and documents secure

Data going missing is a common predicament for the health sector. Just last month, Surrey and Sussex Healthcare NHS Trust admitted to losing a memory stick with the confidential details of hundreds of patients on it. The month before, a medical student lost a data stick with 87 patients’ personal information at the University Hospital of South Manchester NHS Foundation Trust, resulting in a breach of data laws. Unfortunately, these events have proven to be unisolated. In an age where more people are capable of digital trickery, how can a practice protect itself? Here are 10 tips to turn your shaky defenses into fortified garrisons.

1

Move your info off-site. If you can afford it, one of the best ways to protect valuable medical information is through specialist off-site firms. Companies like this are highly experienced in the field and may offer an extra line of defense.

2

Install fingerprint technology. Another way of limiting access to medical information is through the use of biometric technology such as fingerprint scanners. If you limit the number of people in your practice who can access sensitive information, and you safeguard this decision using biometric barriers, this would aid your cause immeasurably.

3

Get patients involved. As a practice you might have an ethical and legal duty to protect your patients’ information, but it is also worth helping them become more aware. Simple advice such as telling them not to share medical information with anyone other than their assigned medical practitioner could go a long way.

6

Invest in encryption software. Good encryption software, when applied to your medical data, turns it into a mess of computer babble to anyone without the password/decoder.

Obviously hackers exist, but the higher the quality of your encryption software, the harder it is for them to be cracked.

7

Limit access. Role-based access control is the ability to restrict access to different data, based on individual job function.

Steps like this can limit information theft via insider leakages.

8

Divvy up the work. Segregation of duties involves making sure that critical tasks in an organisation are not performed by a single person. This is a key element to fraud prevention as it prevents absolute power from corrupting absolutely.

9

Install CCTV cameras. advice for busy lives

When it comes to the protection of the actual physical files in your practice, nothing beats having eyes on the ground. Surveillance cameras and a few people watching over your data couldn’t hurt.

4

5

Invest in a good safe. In keeping with traditional

methods, it may also be worth investing in heavy duty, high quality safes. The best ones now are often electronic, but just make sure you get one that is difficult to crack. november 2011 | practicebusiness.co.uk

Create an audit trail. Creating a granular audit trail in a database means that all accesses may be logged to the individual user level, so if something does disappear, you would have a clue as to where to look first.

10

Know thy enemy. Finally, it is important that you keep tabs on the enemy. You should keep in touch with the most common techniques used by attackers, otherwise how will you know what dangers to look out for and how to protect yourself against them?

37

WORK/LIFE | advertorial

TRAVEL IN THE MODERN AGE IT drives quality and productivity in travel health

D

espite quality gains in many general practice areas, travel health should still be regarded as a work in progress. In a climate of increased litigation risk, failing to ensure travelling patients are given advice of the highest standard can result in negligence – a failure in the duty of care.

Private travel clinic providers like MASTA already use bespoke IT systems to guide the consultation process and minimise advice variability within and across their network of clinics. Is now the right time to look at applying similar solutions more broadly across the NHS? REDEFINING HIGH QUALITY TRAVEL HEALTH The quality of travel health advice still varies dramatically between practices, even with available travel health information sources such as TRAVAX, NaTHNac and MASTA. Recent case study research showed only 13% of practice nurses considered the full range of diseases for a given itinerary, even when referring to their preferred information source(s) (MASTA, 2011).

Variability is likely to be due to a number of issues, including the competency of the clinical staff through training,

absence of clinical protocols, together with their level of experience in providing advice for different travel health risks and vaccinations. Beyond this, clinics use a variety of different paper-based and online tools to capture travel risk information and vaccinations administered.

Development of innovative IT systems should be travel health specific, acknowledging a clinical process that is unique. Any system should meet duty of care requirements and this means more than simply recording vaccines administered – it needs to demonstrate that all the risks of travelling (including destination, activity and individual risks) have been assessed and these have been managed as far as reasonable. It should ensure a clear audit trail is available providing a full record of assessment, recommendations given and action taken – all that could be referred to in the event of possible future legal proceedings.

MORE PRODUCTIVE CLINIC Systems can also deliver those soughtafter productivity improvements by asking travelling patients to complete an online form well before coming into the clinic.

Built-in functioning, including easy-to-use tick- and drop-down-boxes can aid the recording process during the consultation,

both potentially saving time. Finally, IT solutions can complement and create efficiencies elsewhere in the practice through online appointment making and follow-up scheduling.

But while IT can deliver measurable improvements in the quality and productivity of travel health services, it needs to be seen alongside competently trained clinical staff, utilising these systems. Together this will ensure a consistently high quality service is delivered, ultimately benefiting the travelling patient.

ABOUT MASTA With 25 years of experience, MASTA delivers a wide range of travel health services to clients, including the NHS. MASTA emphasises a consistent approach to providing travel health consultations across its clinic network through IT systems and training – including a bespoke etravelclinic consultation management system.

To find out more about how MASTA can help, please visit www.masta-travel-health. com/professionals or contact them at travelhealth@masta.org.

practicebusiness.co.uk | november 2011

38

Work/life | interview

Practice diary Annette Given Annette Given is practice manager at The Spa Surgery in Harrogate

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

november 2011 | practicebusiness.co.uk

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

THIS MONTH: ANNETTE GIVEN explains why it’s OK to delegate I had just returned from a much needed holiday to a call from my sister in Ireland to say that my elderly mother was hospitalised and we need to find her a place in a nursing home for convalescence – this ultimately might be a permanent home. I was devastated to think that my mum might not go back to her lovely home, and returned to Ireland straight away to help sort things out. This has meant that I’ve been out of the practice for three weeks out of the last six weeks with several additional weekends of going back and forth across the Irish Sea – all part of the rich tapestry of life that can happen to any of us.

This absence brought home to me the unrelenting surge of change and development that we, as PMs, deal with week in and week out, as my inbox showed me on my return! On top of this, more than ever before, GPs and their practices are coming under scrutiny by a whole host of organisations – and ultimately the buck stops at the PM’s desk. The danger of not being on top of my game could have given me more than one sleepless night but luckily my saviour has been that we have clear lines of governance and accountability in the practice as in any well-run business.

Wikipedia defines good governance as ‘consistent management, cohesive policies, guidance, processes and decision-rights for a given area of responsibility’. In other words, who does what, when and how?

This begins with an up-to-date partnership agreement and managers should not consider that this document is remote from their responsibility.

They should have a complete understanding of the content and the implications for the day-today working of the practice. I believe that this document, alongside the NHS contract, should inform how the practice is organised and run ultimately to ensure the protection and safety of the patients who choose to register with the practice.

Although the manager is often the linchpin, each and every one of us needs to ensure that every member of the practice team from the partners to the cleaners know what their responsibilities are and that they are well trained and capable of doing their jobs. Don’t try to do it all yourself! Building a team of confident, well-motivated individuals who have pride in their jobs, will make for a happy workforce and a well-run organisation.

Of course it can go wrong – without doubt, it will at some point! But we need to show that we have taken every course of action we can to learn from our mistakes and improve our systems and procedures so the same mistake does not continually happen.

We have CQC, re-validation and answering to our fellow commissioners on the horizon – getting the basics of governance in place now will go a long way to maintaining manageable stress levels over the next couple of years.

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Pharmaceutical form: Suspension for injection. Slightly opalescent liquid. Supplied in a pre-filled syringe. Therapeutic indication: Prophylaxis of influenza, especially in those who run an increased risk of associated complications. The use of Viroflu® should be based on official recommendations. Dosage & administration: Adults and children from 36 months: 0.5 ml. Children from 6 months to 35 months: Clinical data are limited. Dosages of 0.25 or 0.5 ml have been used. For children, who have not previously been vaccinated, a second dose should be given after an interval of at least 4 weeks.

Immunisation should be carried out by intramuscular or deep subcutaneous injection. Contraindications: Hypersensitivity to the active substances, to any of the excipients and to residues. The vaccine may contain residues of the following substances, e.g. eggs, chicken proteins, polymyxin B and neomycin. Immunisation shall be

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postponed in patients with febrile illness or acute infection. Warnings & precautions: Due to the risk of high fever, consideration should be given to the use of alternative seasonal influenza vaccines in children under the age of 5 years. In case it is used in children, parents should be advised to monitor for fever for 2–3 days following vaccination. As with all injectable vaccines, appropriate medical treatment and supervision should always be readily available in case of an anaphylactic event following the administration of the vaccine. Viroflu® should under no circumstances be administered intravascularly. Antibody response in patients with endogenous or iatrogenic immunosuppression may be insufficient. Interactions with other medicinal products and other forms of interaction: Viroflu® may be given at the same time as other vaccines. Immunisations should be carried out on separate limbs.

It should be noted that the adverse reactions may be intensified.

The immunological response may be diminished if the patient is undergoing immunosuppressant treatment. Following influenza vaccination, false-positive results in serology tests using the ELISA method to detect antibodies against HIV1, Hepatitis C and especially HTLV1 have been observed. The Western Blot technique disproves the false-positive ELISA test results. The transient false positive reactions could be due to the IgM response by the vaccine. Pregnancy & lactation: The limited data from vaccinations in pregnant women do not indicate that adverse fetal and maternal outcomes were VIR/076/180811/P. 10/11

attributable to the vaccine. The use of this vaccine may be considered from the second trimester of pregnancy. For pregnant women with medical conditions that increase their risk of complications from influenza, administration of the vaccine is recommended, irrespective of their stage of pregnancy. Viroflu® may be used during lactation.

Undesirable effects: The most common reactions locally are redness, swelling, pain, ecchymosis and induration, and systemically are fever, malaise, shivering, fatigue, headache, sweating, myalgia and arthralgia. These usually disappear within 1 to 2 days. In one clinical trial fever of 39–40°C was found in children. Special precautions for storage: Store in a refrigerator (2°C to 8°C). Do not freeze: the vaccine must not be used if it is inadvertently frozen. Protect from the light.

Package quantities and basic NHS cost: Single dose pre-filled syringes, basic NHS cost £6.59. Legal category: POM. Marketing authorisation number: PL 15747/0005. Marketing authorisation holder: Crucell Italy S.r.l., Via Zambeletti 25, 20021 Baranzate (MI), Italy. Date of last revision of prescribing information: October 2011.

www.crucell.co.uk