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october 2011 YOUR GUIDE tO managing commissioning!

strength in numbers Are small CCGs even possible?

A guide to the patient participation DES

We find out practice managersâ&#x20AC;&#x2122; opinions on the enhanced service

Commissioning and clotted cream A West Country view of the Health Bill

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France Marketing authorisation number: EU/1/08/505/004 EU/1/08/505/005 Legal category: POM ® Registered trademark Date of last review: March 2011 References: 1. Aw D et al. Immunosenescence: emerging challenges for an ageing population. Immunology 2007; 120(4): 435–446. 2. Goodwin K et al. Antibody response to influenza vaccination in the elderly: a quantitative review. Vaccine 2006; 24(8): 1159–1169. 3. Laurent PE et al. Evaluation of the clinical performance of a new intradermal vaccine administration technique and associated delivery system. Vaccine 2007; 25(52): 8833–8842. 4. Nicolas JF, Guy B. Intradermal, epidermal and transcutaneous vaccination: from immunology to clinical practice. Expert Rev Vaccines 2008; 7(8): 1201–1214. 5. Intanza® 15 µg SmPC – February 2011. 6. Arnou R et al. Intradermal influenza vaccine for older adults: A randomized controlled multicenter phase III study. Vaccine 2009; 27: 7304–7312. 7. Immunisation against Infectious Disease. Chapter 19: Influenza, updated May 2011. Department of Health. http:// www.dh.gov.uk/en/Publicationsandstatistics/Publications PublicationsPolicyAndGuidance/ DH_079917 Accessed June 2011

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Editor’s letter EXECUTIVE EDITOR roy lilley www.roylilley.co.uk EDITOR julia dennison julia.dennison@intelligentmedia.co.uk CLINICAL EDITOR dr paul lamden REPORTER jonathan hills jonathan.hills@intelligentmedia.co.uk ACCOUNT MANAGER george petrou george.petrou@intelligentmedia.co.uk PUBLISHER david collingbourne david.collingbourne@intelligentmedia.co.uk DIGITAL MANAGER dan price dan.price@intelligentmedia.co.uk DESIGNER nicki wilkins nicki@b-creativedesign.co.uk PRODUCTION ASSISTANT natalia johnston natalia.johnston@intelligentmedia.co.uk CIRCULATION MANAGER natalia johnston natalia.johnston@intelligentmedia.co.uk

Do you stay or do you go now?

Practice managers of England have a decision to make: do they stay or do they go? And when I say go, I mean go to the CCG. It has become increasingly clear that the practice management profession has met a fork in the road – some practice managers will have to stay put to hold down the fort (read GP practice), while others will move up to join their local commissioning group’s board as the practice manager lead. Whatever choice you make, now is a time of stocktaking at practice level to make sure your strategies and policies are in place for the rocky road ahead. This edition of Practice Business is here to help you do that. Roger Hymas takes a look at whether commissioning is even possible with some of the CCGs (like the Red House Group) as small as they are (p12). It seems the Department for Health agrees with him, as leaders from the government have come out and said recently that there may well be such thing as too small when it comes to being a statutory CCG. After all, there will be certain set costs that all groups will have to swallow. Dame Barbara Hakin has promised to work with these smaller groups to find a way forward – but this may well mean merging them with others if need be. We would like to make an appeal to those practice manager leads in CCGs to get in touch at editor@practicebusiness.co.uk, and tell us your story. While you’re meeting with other practice managers in your area, we would love to hear what it is you talk about and what most concerns you. For example, we have a very interesting piece on the impact of commissioning on rural areas from a woman working in Cornwall (p19). Also, if your fellow practice managers aren’t already subscribed to Practice Business they can try it for free by emailing subscriptions@intelligentmedia.co.uk. We also take a look at the success of the patient participation DES on p30, to find out just how you lot are coping. If you’re feeling overwhelmed and need help getting your team on-board with commissioning and everything else coming the way of general practice these days, you’ll want to take a look at our article on change management on p38. Lastly, this month’s issue comes with a ‘Spotlight’ supplement on managing long-term conditions, which is intended as something to read yourself, then pass on to your practice nurse. Here’s hoping you have a lovely October.

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P.10

Contents SECTOR 06

news Top news for practice managers this month

executive editor comment The latest from columnist Roy Lilley

COMMISSIONING 10

commissioning news A practice managerâ&#x20AC;&#x2122;s update on clinically-led commissioning

comment A look into the future Roger Hymas asks: are CCGs even possible?

analysis Commissioning, consortia, and clotted cream A West Country approach

PEOPLE 24

interview Organisational skills Practice manager Debbie Gladwell puts things right

MANAGEMENT 28

DES A guide to the PPG DES We find out the general consensus among PMs

clinical MFM This month: HIV

legal Paying for the bill The impact of the health bill on day-to-day practice

WORK/LIFE 38

change management Change is good How to get your team on-board

top tips Practice PR Get your practice better known

diary Geraldine Taggart-Jeewa pilots e-patient participation

SECTOR

PRIVATE FIRMS TO RUN 10% OF PRACTICES BY 2014 Around 10% of GP practices could be run by private enterprises by Key points 2014 if current trends continue, GP leaders believe.  Ten per cent of GP practices could The revelation comes after an investigation by GP Online under be run by private companies by 2014 the Freedom of Information Act found that four per cent of GP  There are around 315 privately run practices in England are currently run by a private provider. practices out of the 8,300 in England’s NHS Alliance GMS/PMS lead Dr David Jenner predicted that 152 PCTs 10% of practices will be run by a private company three years from  Some PCTs showed an increase in now, which would see numbers double from the level at which they the number of practices run by private currently stand. companies, with 11 moving to private He suggested that the main instigation for the drive would come control in 2011/12. from private companies capturing PCT-run practices as the PCTs’ roles start to reduce. Around 80 practices are currently run in-house on PCTMS contracts. Jenner added: “I think the pension changes and the NHS reforms will force GPs to run to the exit, particularly many older, singlehanded GPs – unless another practice merges with them before they retire, the practice vacancy would be tendered. Clearly there is an opportunity for private providers who are looking to gain market share.” The information gathered also revealed that some PCTs showed an increase in the number of practices run by private companies, with 11 moving to private control in 2011/12. RCGP chair Dr Clare Gerada said it was “inevitable” that the number of privately run GP practices would increase, asking: “What’s going to stop them?” She added that it was a “reasonable speculation” that 10% of practices would be run by private companies by 2014.

PATIENTS IGNORE GP EMAIL PILOT

your monthly lowdown on general practice

The Department of Health’s pilot to provide 24-hour online access for NHS patients has taken a signiﬁcant hit as only 89 patients from a potential total of over 30,000 have agreed to take part in pilots of its communicator scheme. As revealed by Pulse, Healthspace Communicator, which provides patients with email access to GPs via a secure online platform, is being piloted at six undisclosed sites across England. Only 36 doctors have agreed to take part as one pilot has already been forced to close, and another practice has pulled out amid claims that all correspondence had to be updated manually into patients’ notes.

october 2011 | practicebusiness.co.uk

Over a quarter of patients wait more than a week to see GP Over 25% of UK patients wait more than seven days to see their GP, according to a recent survey by Aviva. Less than a third of patients said they had been granted an appointment with a GP within two days, and 27% had been unable to get an appointment

within a week during the past year. Sixty-five per cent of patients said they had lived with a medical problem for longer than they would have expected, or didn’t even book an appointment because they weren’t able to get one at an appropriate time.

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

SECTOR

| news

clinical news Primary care receives most complaints Just over 148,000 written complaints about the health service were reported to the NHS Information Centre in 2010-11 for its annual collection; a 2.4 per cent (3,700) decrease in reported complaints compared with the previous year. The report presents data reported through two collections – one for family health services and one for hospital and community health services, which is voluntary for FTs. Between 2009-10 and 2010-11, the total number of written complaints reported on by the NHS Information Centre about family health services (including GPs and dentists) saw a slight decrease of 50 complaints – from 50,760 to 50,710. However in 2010-11, family health services received the most written complaints of any service area (30,780), accounting for three in five complaints recorded. This type of complaint increased by 0.5 per cent on the previous year, when there were 30,620 complaints of this type, accounting for 60% of all complaints. Key points The subject most complained about in family health  148,000-plus written complaints services was clinical service, which accounted for one about the health service were in three complaints. This type of complaint increased by registered in 2010-11 – a 2.4 per cent seven per cent on the previous year. decrease in reported complaints compared with the previous year NHS Information Centre chief executive Tim  Between 2009–10 and 2010Straughan said: “Data about 148,200 complaints was 11, the total number of written submitted to this report, but I would encourage all complaints reported about family foundation trusts to report their complaints to us, so health services (including GPs and that future reports can tell the complex story based on dentists) saw a slight decrease of 50 information from every trust. complaints – from 50,760 to 50,710 “It appears that medical and clinical aspects of care  Family health services received remain the biggest area of complaint within the NHS.” the most written complaints of any service area (30,780), accounting for three in five complaints recorded  This type of complaint increased by 0.5 per cent on the previous year when there were 30,620 complaints of this type, accounting for 60% of all complaints.

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“NHS Choices has proved to be a popular and effective decision support tool permitting more efficient self-management and selftriage by the public. [Removing] potentially avoidable consultations can result in considerable capacity savings in primary care” Professor Azeem Majeed, author of a study in the Journal of Royal Medical Society Short Reports on NHS Choices saving £90m in GP appointments

Gastro infections Infectious intestinal disease (IID) now affects up to 17 million people in the community in the UK annually, and rates in England have increased by nearly 50% since the early 1990s, delegates to Health Protection 2011, the Health Protection Agency’s annual conference at Warwick University, were told last month. Norovirus infection accounts for around three million of these cases, while Campylobacter is responsible for around 500,000 cases. Around 18.8 million working and school days are lost as a result of IID in its totality, as 11.4 million people of working age are affected and one million cases present to general practice.

High blood pressure NICE’s hypertension guidelines are to be changed after research revealed ‘white coat syndrome’ is a bigger problem than initially thought. The syndrome in which patients’ blood pressure rises when visiting a doctor’s surgery has drastically affected diagnoses and is reported to occur in up to 30% of diagnosed patients who actually had blood pressure within the normal range when measured over 24-hours. The new guidelines recommend the measurement of blood pressure at home with the aim of decreasing incorrect diagnoses and mis-prescribing of expensive blood pressure drugs.

diary NAPC ANNUAL CONFERENCE 2011 AND VISION AWARDS ICC Birmingham 1–2 November

MDDUS EMPLOYMENT LAW WORKSHOP The administrative workload for GPs is rising. A survey of 1,600 registrars, partners and sessional primary care doctors by GP Online has found that the majority (85%) complain about an increase in paperwork over the last year, mostly due to the creation of pathfinder clinical commissioning groups.

MDDUS’s London office 2 November

NHS REFORM: MANAGING THE TRANSITION The Barbican, London 10 November

practicebusiness.co.uk | october 2011

SECTOR

| comment

Roy Lilley Roy Lilley is executive editor of Practice Business. He is an independent health and policy analyst, writer and broadcaster and commentator on health and social issues

Who wants it?

Where GPs have always been gatekeepers, now they’ll be running the turnstiles. ROY LILLEY asks: are you ready? I’ve been out and about a bit lately and talking to some real people for a change. I was with a group of GPs and it’s got me worried. I’ve come to the conclusion they don’t have the first clue what they are letting themselves in for! Most seem to think that GP commissioning is a throwback to the halcyon days of fundholding, the rose-tinted era of boutique commissioning; some nice easy elective bits and pieces. When you actually explain what it is they are going to be responsible for, you can feel the mood change in the audience. Worse, I don’t think they are in the least bit prepared for the legal conundrum that lies at the heart of commissioning groups. Current GMS/PMS regulations say: ‘A prescriber shall prescribe the medicines and appliances which are needed’ by their patients. Note the word ‘shall’. In law it means the same as a duty to. This is the clause that preserves the trust between a GP and a patient. It is the few words that translate into the GP being our ‘friend in the business’ or ‘health broker’, the person we trust to do their best to make us better. Once GPs are running clinical commissioning groups, they will have another duty. They will be duty bound not to exceed their budgets. The Department of Health’s publication ‘Liberating the NHS’ is very clear about this point. It says: ‘CCGs will have a duty to ensure that expenditure does not exceed their allocated resources… Good financial management sits alongside and complements GPs’ clinical responsibilities to patients…” GPs have always been the gatekeeper of our care. Now they are set to run the turnstiles. If a patient needed a drug or treatment the PCT didn’t want to pay for, the GP could special-plead on our behalf. If he won, we knew why we loved the GP. If he lost, we still loved the GP for trying. Under the new arrangements, GPs will have to sit behind their desk, look the patient in the eyes and say: “You can’t have what I know you need and I am part of the system that says so.” Suppose for a moment a CCG needs to save money and instructs GPs to follow a less-than-optimal care protocol. Should the GP say: “I’m giving this to you, doing that for you and I know it is not the best you could have.”? This ‘denial of care’ moves the GPs into a very uncomfortable place. It will make the lawyers fatter. So far I’ve yet to meet a GP who wants to do it.

Most seem to think that GP commissioning is a throwback to the halcyon days of fundholding, the rose-tinted era of boutique commissioning; some nice easy elective bits and pieces october 2011 | practicebusiness.co.uk

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Commissioning

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Practice managers take the CCG lead Practice managers are eager to take a lead role in clinical commissioning groups, according to a recent NHS Primary Care Commissioning (PCC) survey. Helen Northall, chief executive of PCC, said: “This survey shows that practice management has completely got the idea that they have to become team players, whether that’s working together as providers or in commissioning groups. “Of course practice managers need to stay focused on keeping the business healthy, but the survey provides strong evidence that clinical standards and the health of patients are still top priorities,” she continued. “It also suggests that practice managers are

new Commissioning steering group The NHS Alliance and the National Association of Primary Care (NAPC) are forming a steering group to communicate the CCGs’ concerns to the government, following the launch of their independent coalition in support of commissioning. Michael Sobanja, chief executive for the NHS Alliance, said: “We want to ensure that the coalition fulfils its main remit of being a truly representative voice for all CCGs as well as

commissioning in context

Empowering practice managers in consortia

“”

october 2011 | practicebusiness.co.uk

ready to take a leading role in CCGs, but questions remain about whether practices are prepared to invest enough in training and development.” The budgets that are available to practices to use on training and development remain small however, as only three per cent of practices allocate more than £5,000 to training, with the average practice dedicating as little as £500 for such purposes. Furthermore, a fifth of practice managers said they did not know how much their practice spent on training and development, suggesting that resources are not available and that formal budgets may have not been identified.

giving them the support they need to be successful.” Mike Ramsden, chief executive for NAPC, added: “These developments are intended to strengthen the voice of primary care and make it a serious force to be reckoned with in dealing with the challenges ahead in terms of powerful providers and the NHS Commissioning Board. Currently the balance of power largely sits with providers, although it is the commissioning bodies that should be determining the agenda. Through this development with the NHS Alliance, we hope now to provide a counterbalance to the existing arrangements.”

They said… “[CCGs] seem to be at the periphery and bottom tier of the commissioning hierarchy, not at its centre, as they should be. This needs to be a two way process, from the development of the National Commissioning Board downwards and between future CCG leaders and the Department of Health. This dialogue needs to look at how the whole system will work” NHS Alliance chairman Michael Dixon on why CCG authorisation should be a dialogue between the NHS Commissioning Board and the GP-led groups

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Size really does matter, says DH Clinical commissioning groups that are too small could be financially unviable, leaders from the Department of Health have said. At a joint conference from the National Association of Primary Care (NAPC) and the NHS Alliance last month, Dame Barbara Hakin, MD of commissioning development at the Department of Health, admitted that smaller CCGs might not be able to survive on their own. She said the fundamental issue was how CCGs maintain a connection to their local population while being large enough to handle fixed costs, such as paying board members and audit fees on top of everything else they need to budget for. “Unfortunately, there is a point that these fixed costs could mean you don’t have enough money left to do what you need to,” she said, warning against CCGs finding out too late that they don’t have enough to cover it all. “We have to flush that out early… There is a way to work together without being a statutory organisation. It could be about risk-pooling for services or unforeseen management costs.” Dame Barbara said she would be happy to work with smaller CCGs, if they can prove they are viable. “In terms of some areas of commissioning support, you will get a more effective, cheaper service at scale,” she added. “Think laterally about the possibilities.” Speaking at another NAPC meeting later that evening, Hannah Farrar, NHS London’s director of strategy and system management, said CCGs were budgeting on £25 per patient in funding. Once fixed costs were subtracted from this, London CCGs were left with £20 per patient on average, varying between £3 and £23 depending on size. Asked about the lowest viable patient population, she said: “If it’s less than 100,000 population, I think you are going to really struggle to get the calibre of support needed.” Health Secretary Andrew Lansley unveiled a ‘ready reckoner’ tool at the NAPC/NHS Alliance coalition conference, designed to allow emerging CCGs to assess their corporate structure, financial model and staffing to decide whether they will be able to function as statutory bodies from 2013– offering them “better value” on commissioning support. While this is not intended as a budget-setting mechanism, it is a tool to help the smaller CCGs decide if they are financially robust enough to act as a statutory body.

A robust clinical system “I think it’s excellent that EMIS is constantly enhancing EMIS Web”

Kate Appleyard This month we talk to Kate Appleyard, EMIS Web project manager at the Victoria Medical Centre in Barnsley about how switching to the new generation system has helped streamline the practice

www.emis-online.com

A practice in Barnsley is one of the latest practices to upgrade to EMIS Web, and not only did staff find switching easier than they had expected, but they are already reaping the benefits of the award-winning system. Kate Appleyard, EMIS Web project manager at the Victoria Medical Centre, which serves 8,500 patients, says for some staff the worst part was fear of the unknown, but EMIS Web’s Familiarisation Service smoothed the way. “We were able to set up and configure almost everything we needed in preparation for going live. I created a ‘buddy’ system, so staff that were not as quick to pick up parts of the system could work with a staff member who was.” She added: “The data checking part of the upgrade was really useful as a training tool. We even involved our note summarisers, who not only sped up the data checking process, but learned to navigate around EMIS Web at the same time.” On go-live day, the technicians were on site from 8am, and the practice went live halfan-hour later. “We logged straight on to the system with no problems.” Fourteen weeks on, EMIS Web is already improving working practices at the surgery. “Modules are more streamlined and easier to navigate around. The appointment book is great – especially how you can configure it, making it easy to identify appointment types. Prescribing and linking medication is very easy and workflow manager is good, as everything sits together making it easy to deal with tasks and file information.” And the conclusion? “I would recommend EMIS Web – not only for the robust clinical system but for the fundamental support that is essential when running a GP practice. I think it’s excellent that EMIS is constantly enhancing EMIS Web. You can really see it work.”

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

october 2011 | practicebusiness.co.uk

GP-led commissioning

COMMISSIONING | news analysis

part 1

What it will look like in the early days? In the first part in a two-part series, Roger Hymas looks into the crystal ball and asks: Where exactly will the changes take us?

I guess most of us are now reconciled to the fact that we are on our way to GPled commissioning. But exactly where will this journey take us and what will the destination look like? We’re now well into the second year of this initiative, but I wonder if you, like me, still don’t have any real sense of exactly what the strategy is. Or whether, in fact, there is a strategy at all, behind what is a very ambitious idea. Certainly, there have been times when you might have thought, quite reasonably, that somebody (and it’s difficult to identify exactly who) is making this up as they go along. The real danger is that the initiative might find itself the victim of unintended consequences, which was what happened to Andrew Lansley back in the spring with the Health Bill when suddenly out of nowhere popped a huge number of unforeseen developments that required him to radically change course. My view is that we are headed to a radically different future for primary care, one that will be unlike today’s, which still looks like a cottage industry. We can expect unprecedented turbulence, a really rocky ride for a number of years while the sector adjusts to the changes that are just starting. But first, the regulatory and organisational framework will need at least a couple of years to settle. So, for GP-led commissioning to succeed, the DH needs to break out of its reorganisation log-jam.

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COMMISSIONING | news analysis

What we know We do know a few things for certain. All GP practices must be part of a clinical commissioning group, which all have to be authorised. The current number of ‘pathfinder’ CCGs is just over 250. The period when the really big decisions about GP-led commissioning get made – and potentially the time of maximum angst – is the few months running up to April 2013, when CCGs are due to start commissioning – taking over from PCTs and SHAs, which will then go forever. We all have been watching the turmoil that has been going on with these NHS organisations over the last year, as they have gone through a restructuring process. It started in summer 2010 with the significant downsizing that led to up to 40% of PCT staff being made redundant, and then came ‘clustering’, as 152 PCTs merged to become just 51. The 10 SHAs have also since been grouped to become four. The next milestone will be the creation of the National Commissioning Board (NCB), which will need to be got going while the PCTs and SHAs are disestablished. The DH estimates that around 3,500 people will work in the NCB, 2,500 in regional positions – that’s 10 NCB people for every one of the current 250 CCGs. My analysis says that nearly all the surviving staff currently working in PCTs and SHAs will be likely to get a job in the NCB regional organisation. But all of them will have to go through another rehiring process sometime over the next six months or so, involving more job descriptions, recruitment ads, interviews, all the panoply

PCT and SHA executives will assume responsibility for many localities where they are likely to have had little or no prior knowledge of what has been happening on the ground of modern day employment law, at a time when CCGs will need huge support to get their authorisation process through. NHS business will still need to be conducted as usual. One of the big issues will be that ‘clustered’ PCT and SHA executives will assume responsibility for many localities where they are likely to have had little or no prior knowledge of what has been happening on the ground. The new South SHA, for example, stretches from Penzance to Dover. During this time, PCTs and SHAs will have to carry on delivering the up to 300 separate current responsibilities, many required by Act of Parliament. And then the new Health Act will change a lot of these, bringing another dimension of disruption. The big question is whether PCT staff have enough time to support CCGs, just when they need it most. The complexity of the task of GP-led commissioning can’t be understated: for a start, it’s probably the biggest single change initiative for the NHS in its history. The 250-plus CCGs have got to get authorised by the NHS Commissioning Board by April 2013 (but starting as soon as April 2012 in ‘shadow’ form – just six months from now). The next potential stumbling block is the way in which the authorisation programme will be executed – in both strategy and style. I can’t see that there will be any significant behavioural change as SHAs and PCTs morph into the NCB. It’s the same people at the top of the DH/NHS who will stay in charge and it will be the senior management of SHAs and PCTs who will prevail in the regional jobs. This means the same old faces, same working style, same behaviours. Because of their cultural differences, PCTs haven’t always enjoyed the best relationships with the GP rank-and-file (who are certainly not going to change), which means there is the strong possibility of even more organisational friction, nationally and locally.

october 2011 | practicebusiness.co.uk

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Prescribing Information DECAPEPTYL® SR 3mg, DECAPEPTYL® SR 11.25mg and DECAPEPTYL® SR 22.5mg Presentation: Powder for suspension for injection. Vials for all preparations contain an overage to ensure the licensed dose is administered. Decapeptyl SR 3mg: Triptorelin acetate 4.2mg. Decapeptyl SR 11.25mg: Triptorelin acetate 15mg. Decapeptyl SR 22.5mg: Triptorelin pamoate 28mg. Triptorelin acetate and triptorelin pamoate are bioequivalent. Uses: Treatment of locally advanced, non-metastatic prostate cancer, as an alternative to surgical castration, and treatment of metastatic prostate cancer (Decapeptyl SR 3mg, 11.25mg and 22.5mg). As adjuvant treatment to radiotherapy in patients with high-risk localised or locally advanced prostate cancer (Decapeptyl SR 3mg and 11.25mg). Dosage and Administration: Decapeptyl SR 3mg: One intramuscular (i.m.) injection every four weeks (28 days). Decapeptyl SR 11.25mg: One i.m. injection every 3 months. Decapeptyl SR 22.5mg: one i.m. injection every 6 months. Additional dosing information: No dosage adjustment necessary in the elderly. The injection site should be varied periodically. Inadvertent intravascular administration must be avoided. Contraindications: Hypersensitivity to LHRH, its analogues or any other component of the medicinal product. Precautions and Warnings: Long-term use of LHRH agonists is associated with an increased risk of bone loss and may lead to osteoporosis and increased risk of bone fracture. Particular caution in patients with risk factors for, or established osteoporosis is necessary. Rarely, LHRH agonist treatment may reveal the presence of a gonadotroph cell pituitary adenoma. Mood changes, including depression have been reported. Patients with known depression should be monitored closely during therapy. Initially, Decapeptyl SR, like other LHRH agonists, causes a transient increase in serum testosterone levels. As a consequence isolated cases of transient worsening of signs and symptoms of prostate cancer (tumour flare) and cancer related (metastatic) pain may occasionally develop during the first weeks of treatment and should be managed symptomatically. During the initial phase of treatment, consideration should be given to the additional administration of a suitable anti-androgen to counteract the initial rise in serum testosterone levels and the worsening of clinical symptoms. As with other LHRH agonists, isolated cases of spinal cord compression or urethral obstruction have been observed. Careful monitoring, is indicated during the first weeks of treatment, particularly in patients suffering from vertebral metastases, at risk of spinal cord compression, and in patients with urinary tract obstruction. After surgical castration, Decapeptyl SR does not induce any further decrease in testosterone levels. From epidemiological data it has been observed that patients may experience metabolic changes (e.g. glucose intolerance), or an increased risk of cardiovascular disease during androgen deprivation therapy (ADT). Patients at high risk for metabolic or cardiovascular diseases should be carefully assessed before commencing treatment and their glucose, cholesterol and blood pressure adequately monitored during ADT at appropriate intervals not exceeding 3 months. Administration of triptorelin in therapeutic doses results in suppression of the pituitary gonadal system. Normal function is usually restored after treatment is discontinued. Diagnostic tests of pituitary gonadal function conducted during and after discontinuation of therapy with LHRH agonists may therefore be misleading. Interactions: Drugs which raise prolactin levels should not be prescribed concomitantly as they reduce the level of LHRH receptors in the pituitary.

When Decapeptyl SR is co-administered with drugs affecting pituitary secretion of gonadotropins, caution should be exercised and it is recommended that the patient’s hormonal status be supervised. Pregnancy and Lactation: Not applicable. Undesirable effects: Very common: Asthenia, hyperhidrosis, back pain, paraesthesia in lower limbs and hot flush. Common: Nausea, fatigue, injection site erythema, injection site inflammation, injection site pain, injection site reaction, oedema, musculoskeletal pain, pain in extremity, dizziness, headache, erectile dysfunction and loss of libido. Rarely, cases of anaphylaxis and hypersensitivity have been reported. Prescribers should consult the Summary of Product Characteristics in relation to other side effects. Overdosage: No human experience of overdosage. Pharmaceutical Precautions: Do not store above 25ºC. Reconstitute only with the suspension vehicle provided. Decapeptyl SR is a suspension, therefore once reconstituted, it should be used immediately. Legal Category: POM. Basic NHS cost: Decapeptyl SR 3mg £69.00 per vial. Decapeptyl SR 11.25mg £207.00 per vial. Decapeptyl SR 22.5mg £414.00 per vial. Marketing Authorisation Numbers: Decapeptyl SR 3mg: PL 34926/0002. Decapeptyl SR 11.25mg: PL 34926/0003. Decapeptyl SR 22.5mg PL 34926/0013. Marketing Authorisation Holder: Ipsen Ltd., 190 Bath Road, Slough, Berkshire, SL1 3XE, UK. Tel 01753 627777. Date of preparation of PI: May 2011. Ref: UK/DEC08521a (Adjuvant licence). Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to the Ipsen Medical Information department on 01753 627777 or medical.information.uk@ipsen.com 1. Parmar H et al. Br Med J 1991; 302(6787): 1272. 2. Botto H et al. 3rd International Symposium on Recent Advances in Urological Cancer Diagnosis and Treatment. 1992. Paris. 107-110. 3. Heyns CF et al. BJU Int 2003; 92: 226-231. 4. Heidenreich A. J Urol 2008; 179(4) Suppl: Abstract 513. 5. Mounedji N et al. ASCO Genitourinary Cancer Symposium. 2011. Poster. 6. Parmar H et al. Br J Urol 1987; 59(3): 248-254. 7. Data on file DEC/014/APR09. 8. Lepor H. Reviews in Urology 2005; 7(Suppl 5): S3-S12. 9. MIMS, August 2011. Date of preparation: August 2011. DEC08548a

COMMISSIONING | news analysis

Nobody has got round to admitting that 250-plus CCGs is far too many, meaning that funding ‘pots’ will mostly be too small. In certain years, because of the way the risk comes through, they will ﬁnd themselves with insufﬁcient funds to cover their care costs Does siZe MaTTeR? YoU BeT iT Does As the parties involved start to work things through, the issue that will emerge will be the management of the financial risk associated with the size of individual CCGs. Nobody has got round to admitting that 250-plus CCGs is far too many, meaning that funding ‘pots’ – their individual care budgets – will mostly be too small. In certain years because of the way the risk comes through, they will find themselves with insufficient funds to cover their care costs: the extreme example is the East Cliff CCG in Ramsgate, Kent with a population of just 14,600 souls and a likely annual budget of no more than £25m. A few high-cost patients in any one year will create a real financial challenge for them. The DH has yet to spell out what will happen to CCGs if they don’t balance their books. And over the years ahead, the pressures on NHS funding will mean that it becomes a struggle year after year. I think the system might just get away with 100 CCGs with a population of around 500,000 and a budget of about a half a billion pounds each. Arguably, a maximum of 50 CCGs would be a much better number, as the actuaries (yet to enter the NHS scene) will tell DH executives. This would bring us to the current total for ‘clustered’ PCTs. Somebody will then think that this makes for an easy and convenient organisational jump.Why don’t we have CCG organisations mirrored to the clustered PCTs? In this situation all that needs to be done is take down the PCTs’ signage and put up the NCB’s and run CCG administration with the rump of PCT staff. Job done, business as usual. The real issue about CCG scale is that in about 18 months, the majority of them, and certainly the smaller ones, could be given a ‘refused authorisation’ notice. In this scenario, practically every one of the current 250 CCGs would need to have their expectations managed because even the big ones would be impacted as smaller ones are integrated. Pathfinder CCGs that have been told to prepare for a radical transformation of the system putting them in charge of commissioning, and creating a brave new world unfettered by the old PCT dogma, might come to a conclusion that the promise is not being delivered. I really hope that GPs are not being misled and that practices, having invested huge resources – time, money and emotion – into the authorisation process, are going to see what was proposed actually happen. Of course, the people who will deliver the news will be the staff from the PCTs, part of the current support process, who in the meantime, have metamorphosed into the local NCB organisations. Now forgive the evil thought, but as the NCB is to be given the role as back-stop commissioner, will these people decide, in all the circumstances, that commissioning might be safer staying in their hands? Already, the NHS Alliance/NAPC coalition is making noises about barriers being put up to frustrate CCGs and the issues that could reduce their willingness to engage as they were swamped with ‘guidance and bureaucracy’, which means there are all the ingredients for the mother of all rows to break out. There is the possibility of a real falling out between the rump of the PCTs and SHAs, reconstituted as the NCB, and those who are to be authorised (or, as it happens, not), the CCGs. If my view of the direction of travel is right, there’s no way GPs are going to put up with local NHS managers hijacking commissioning just as the finishing post comes into sight. This is the event that could bring Lansley down when GP pressure groups line up together to say that the deal’s off. I’m sorry if I’m making this sound all too Machiavellian, but it just feels very plausible. It may not be what’s intended right now, but has the strategy been thought through, or are we again going to see the spectre of unintended consequences? If I were on a CCG board, I’d be keeping a very close eye on the progress to authorisation. october 2011 | practicebusiness.co.uk

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COMMISSIONING

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Commissioning, consortia, and clotted cream Until now, little research has taken place around the impact of commissioning in a rural community. Certainly, piloting exercises based on what happens in London appear to have little relevance to an average GP practice working in Cornwall, with problems of deprivation and limited access to choice within healthcare. In an attempt to redress this balance, Michelle Pratley looks at the proposed changes at an individual practice level The NHS and general practice were thrown into turmoil by the publication of the NHS white paper, ‘Equality and Excellence – Liberating the NHS’ and the reality of the challenges that the reforms present to primary care has yet to be fully understood. Research at national level by organisations like The King’s Fund and The Nuffield Trust has reiterated that leadership and management within clinical commissioning groups (CCGs) will be key to success, however there had been little previous research at ‘grass roots’ practice level to establish GP perceptions of the proposed changes, nor any analysis of how practices plan to move forwards. The results of the listening exercise in June suggest that clinical advice and leadership should involve multiprofessional input with a strong role for clinical and professional networks: ‘clinical senates’ should advise local commissioning groups, providing strategy and innovation. The recommendations within the report that followed do not fundamentally change the fact that GPs will become responsible for commissioning services, holding budgets, and taking financial responsibility for patient care.

practicebusiness.co.uk | september practicebusiness.co.uk | october2009 2011

COMMISSIONING

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A review of relevant literature reveals the main concerns that face general practice in this transitional period relate to GP leadership skills, motivation, and the management of change; with scepticism about GPs’ attitudes to the reforms in general. No assessment had taken place within a rural community like Cornwall, and certainly piloting exercises based on the capital appear to have little relevance to an average-sized GP practice, working within the parameters of a peninsula with problems of deprivation and limited access to choice within healthcare. Add to this an ageing population, increased incidence of long-term conditions, and the poor economic outlook within the county and it starts to become clear why this community did not appear within the government’s initial list of ‘pathfinders’. In an attempt to redress this balance, this research set out to look at the proposed changes at an individual practice level, considering the views of GP partners and practice staff. It also assesses the views of GPs working within North Cornwall to establish a cross-practice view on CCG size, competition within the NHS, and GPs’ capacity to lead. The data collected revealed concerns regarding the lack of clear information and accurate data for practices, the need to establish structured leadership to facilitate commissioning involvement, and a belief in the need for improved collaboration and communication between primary and secondary care. The way that services have been commissioned has been highlighted as a potential weakness within the current system in a King’s Fund report. Previous trials at GP commissioning, in the form of fundholding and practice-based commissioning, have not matched expectations, and this is clearly demonstrated by subsequent research. Questions have been raised about the motivation and commitment of GPs and their ability to achieve the scale of change required. The key questions incorporated in this research were: n What were the perceptions of GPs and practice staff to the proposed reforms? n GPs attitudes to leadership within the consortia n How do people feel about the change process? n What motivates GPs and practice staff to achieve results? A smooth transition is an imperative management goal if future success is to be achieved and sustained. The study looked at general practice at a micro level and in particular concentrated on GPs within Cornwall as no other research had been carried out at this level or within this geographical area. october 2011 | practicebusiness.co.uk

GPs are doggedly determined to defend their businesses and will do everything necessary to protect the future of the NHS Cornwall in focus Cornwall has a unique identity incorporating problems with deprivation, transport and population spread. It has one main hospital provider with significant problems of patient access. The primary care trust also has responsibility for the Isles of Scilly, which adds additionally to the geographical restraints faced by the community. The research encompassed qualitative and quantitative data collection methods, and included individual GP interviews, a staff focus group, and a GP survey incorporating the views not only at GP partners, but of locums and salaried GPs. One of the interesting aspects of the interviews was that along with the establishment of key themes (see p22) partners’ ideas for potential management solutions and changes to working patterns also emerged. The GPs remain wary and uncertain of the proposed reforms; the lack of clarity of vision and direction by government is adding to this unease. However, data also confirmed that GPs are doggedly determined to defend their businesses and will do everything necessary to protect the future of the NHS. They are motivated to provide the best possible patient care, and relish autonomy to act. There is a general acceptance that for the NHS to be sustainable, change is clearly necessary. If well-directed and planned, this could have positive results.

Management in CCGs Concerns were highlighted about the components of the CCGs and how management decisions would be communicated. Clearer information and consistency of data will be imperative to success. Generally it was concluded that GPs would be able to lead the commissioning groups: skills, knowledge and previous experience were all considered to be essential components for any CCG member. Excellent financial and management skills were highlighted as an essential part of commissioning. Reductions in bureaucracy and a cessation of unnecessary auditing could help to free up resources, and if politics could be removed from the agenda it would be easier to concentrate on patient care. Closer productive relationships with secondary care colleagues, and collaborative working, were confirmed as a key component for future success.

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COMMISSIONING

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The staff focus group reiterated the feelings of individual GPs with regard to the reforms, viewing them with some concern and fear, in particular in relation to job roles and security and workload. Issues related to patient care and whether the NHS would continue to be free at point of service. Staff were concerned about rationing or reducing services and whether the ‘postcode lottery’ would increase, with reducing budgets. Involvement in the change process and in decision-making were emphasised as important objectives for all staff. It was felt that staff at all levels within general practice should have involvement in the decisions related to commissioning with representatives from practice teams being considered when formatting boards. The GP survey element of the project was the first time GPs in Cornwall had been specifically questioned on their attitudes to the NHS white paper and this makes the result of interest, adding significance of the findings. The practice list size of those questioned varied from fewer than 2,000 patients to over 15,000, with the majority of GPs (76.2%) working in practices with lists of between 5,000 and 12,000 patients. Concerns were raised about the effect of the reforms on patient care, with the majority of those surveyed (69%) believing care would be adversely affected. The results in relation to the use of private providers triangulated with the qualitative data with the majority of GPs (61.9%) opposed to this.The survey concluded that potential savings could be made through reductions in staffing, a review of services and working practices, and through moving patient treatment outside of hospital settings. Consensus on CCG patient list size was unclear, with surveyed GPs suggesting patient numbers of between 60,000 and 250,000. Previous commissioning experience, for the majority of GPs, was at practice level, although in accordance with the qualitative data there was demonstrated belief that GPs have the capacity to lead. Positively, almost a third of GPs surveyed would be willing to become involved as a CCG board member.

Conclusions Reiterating the findings of this NHS Future Forum Report, the primary data within the project concluded that the speed of the reforms and the lack of piloting at ‘grass roots’ level is a cause for concern. The data highlights the need within practices and CCGs to have a clear management strategy and defined objectives; there should be a clear focus for the practice in the short term. With this structure in place and given the appropriate level of autonomy, it was universally felt that savings could be made and waste minimised. The infrastructure has to be right, with reduced bureaucracy and clarity of vision. CCGs need to be accessible, relevant and not remote. Concerns were expressed about ‘who should lead’ and what skills and attributes will be required. The research concluded that the reforms could be motivating if packaged appropriately, with GPs generally relishing autonomy and above all wanting to continue as the patients’ advocate. All members of the practice team gave job satisfaction as a key motivator, with the provision of excellent patient care being top of the list. It would be easy to forget outreaches and smaller communities when considering large scale reforms, but these research results create a picture of a determined and defiant workforce, which believes that quality patient care should be at the heart of any reform process. Perhaps there is a message to be found in this localised study that rural GPs still believe in the future of the NHS, and far from being removed and remote from the challenges set by government, they can be seen as advocates for their patients and protectors of a vital community service. This article is based on research carried out as part of an MA in management through Cornwall College and Coventry University october 2011 | practicebusiness.co.uk

ANALYSIS OF KEY THEMES EMERERGING FROM PRIMARY RESEARCH INTERVIEWS Thoughts on NHS Reforms n Increased Government expectations n Threat to secondary care n No rural studies – only London based n Personal crusade by health secretary n Free but can be run by anyone n Unrealistic deadlines – GPs ‘fall guys’ n Disincentive to staff n Favour large countywide consortia n Mini hubs to work under consortia. GP Leadership n GPs have varying skills, volunteers may not be the best choice n Some good clear vision with leadership skills n Need to work as team member/elected n Politically motivated/ good negotiator n Require financial and management skills n Uncertainty of whom will be empowered n Previous commissioning had limited scope. Relationships and Communication n Avoid ‘bigger brother’ style n Encouragement not beatings n Practice representative with good reporting n Local hubs with open communication including patients n More information and clearer data.

Motivation n Job satisfaction n Profit and finances n Better patient care n Local services n Ambition and new opportunities n Self-employed/autonomy n Targets n Increased efficiency. Perceptions of Change n Necessary to evolve n More threat than challenge n Needs planning and collaboration n Creates new opportunities n Change-averse/enjoys ‘status quo’ n Can appear rushed/too much too quickly n Lacks financial incentives/ funding n Knowledge not always utilised n Organisation is change fatigued. Potential Solutions n Reduce bureaucracy and red tape n Local pilots/collaborative working n Simple model with local based services n Remove the politics/ concentrate on patient care n Redefine the core values n Encourage self-reliance for patients.

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PEOPLE

DEBBIE GLADWELL of West Hampstead Medical Centre is fairly new to the practice management profession, working her way up diligently after starting out in the music business and moving to the NHS when she had a career change of heart. JULIA DENNISON finds out a bit more about this ambitious womanâ&#x20AC;&#x2122;s hopes and aspirations

october 2011 | practicebusiness.co.uk

people | interview

For Debbie Gladwell, practice manager of the West Hampstead Medical Centre, preparation is everything. She is diligent and sharp-witted, and ensures she makes her best attempt at anything she puts her hand to. Being the best she can be runs through everything she does, especially when managing her busy north London practice. As she took me around the surgery, where she started working about a year and a half ago, she made sure everything was just right: straightening the pictures on the wall, pushing in boardroom chairs and grumbling at the flickering of a faltering florescent light. “I’m one of those people for whom two A-levels wasn’t enough,” Gladwell says. “I had to do more and more.” A self-proclaimed perfectionist, she sees little point in being half-hearted in anything, yet prides herself in her ability to adapt quickly to change, something she sees as essential to the practice manager’s role – particularly in these changing times. It is little wonder she keeps a ‘Keep Calm and Carry On’ postcard Blu-Tacked to the wall behind her computer monitor.

Career aspirations Gladwell’s career began about as far away from a GP practice as you can get – as a director of a record company (something she doesn’t even put on her CV, because she feels it would only distract from her recent work under the NHS). She enjoyed the music business, but she wanted to move to a profession where she could make a difference. A job came up at Adelaide Medical Centre in Swiss Cottage as a senior administrator, specialising in IT. She went for it and it was here that she met her “mentor”, then practice director Monika Cleaver, who has since retired but is now working as a practice manager consultant. Cleaver’s influence and guidance inspired Gladwell to venture down the path towards practice management. Other reasons for Gladwell wanting to become a practice manager included a head and heart for management. “I like to manage things; I like to organise things; and I like to lead on things as well,” she explains. “People have said to me that I see the bigger picture of things, I have huge determination and I like to make changes.” It’s this ability to embrace change that she sees as central to the role. “You have new types of people coming into the practice, new trends going on, and it’s good to move with the times,” Gladwell explains. “If you’re not really for change and you’re not flexible enough to take on changes, then I don’t think practice management’s for you.” With her eye on the prize of becoming a practice manager and never one to do things by halves,

Fact Box Practice: West Hampstead Medical Centre Patients: 10,455 Partners: Four Clinical staff: Seven GPs (four partners, three salaried GPs), one practice nurse, one locum practice nurse and one HCA Administrative staff: 12 PCT cluster: NHS North Central London

Gladwell pursued a Diploma in Primary Care and Health Management with Cherith Simmons while she worked at Adelaide, which she passed with a distinction (not an easy achievement). But even after qualifying with the diploma in practice management, which gave her an academic grounding for the profession, Gladwell felt she still had a lot to learn. “I went through a huge learning curve,” she explains. “Though the Cherith Simmons course was very good in terms of management theory, I realised I needed to up-skill myself and take on a few more roles in terms of the practical side of things.” After Adelaide, Gladwell’s next job was as a practice manager at another practice, but she didn’t feel ready and wanted a bit more mentoring, so she quickly moved on to become an assistant practice manager at West Hampstead Medical Centre, where she learned more about the finance and accounting side of the role. The practice manager there eventually left and Gladwell had to step up as acting practice manager and eventually practice manager in full. Though daunting at first, she now loves her career choice. “My favourite thing is probably now accounts and finance,” she laughs. Gladwell still scratches her head when she considers why Cleaver hired her in the first place. “I keep asking why she gave me the job at Adelaide Medical Centre – yes I had been a PA before and I’d used IT, was able to explain what I’d do in a situation if everything went wrong etc, but I hadn’t worked in the NHS,” she comments. “But Monika always says: ‘When I came for the interview they just knew I was the one,’ and they certainly did not look back.”

Pathfinder: Camden Clinical Commissioning Group Practice manager: Debbie Gladwell Time in role: A year and a half Background: Gladwell started her professional career in the music industry as the director of her own record label. She moved into healthcare in 2003 as a senior administrator specialising in IT at Adelaide Medical Centre. She then pursued a Diploma in Primary Care and Health Management with Cherith Simmons, which she passed in 2008 with a distinction. She became assistant practice manager at West Hampstead Medical Centre shortly thereafter, and later became practice manager.

practicebusiness.co.uk | october 2011

people | interview

My goal here is to make sure West Hampstead Medical Centre becomes one of the best performing practices in the whole of Camden CCG A support network

When asked what she thinks is the hardest part of her job, she responds with “fitting it all in” – she’s been known to answer emails at 2am. (“If I don’t do it then, I’ll forget about it,” she protests.) “As a practice manager, you never switch off,” she continues, proud of the fact that on her last holiday she only checked her work e-mail once. “Having one of these little lifelines is probably the worst thing possible [for my work/life balance],” she says, pointing to her iPhone, “but I love it!” When people outside the medical profession ask her what a practice manager’s job is like, she gives the analogy of spinning plates: “It’s like keeping them all spinning, while thinking ahead and making sure you know when a plate’s about to go, and it’s adaptability – you really have to be flexible.” Gladwell feels it is important that she has worked her way up from the bottom – as a result, no job is beneath her. “I know how to clean up sick and unblock the toilet if I need to,” she explains. “If I know how to do it, then I feel happier telling somebody else to.” While she used to have difficulty delegating, her busy schedule allows her little choice. “For me, good delegation is not just telling people to do things, it’s also following it up and making sure everything went OK for them – then you find peace of mind, and I have peace of mind now,” she adds. october 2011 | practicebusiness.co.uk

Gladwell gets a lot of support from her fellow practice managers. “I’m lucky to be in Camden because the practice managers here all talk to each other,” she says. Practice managers within West Hampstead Medical Centre’s pathfinder, Camden Clinical Commissioning Group, hold monthly meetings under the leadership of Jacqui Tonge, practice manager at Abbey Road Medical Group. Within the CCG, West Hampstead Medical Centre is a member of a local North-West Cluster, which comprises seven local GP practices, and this smaller group gets together regularly to support each other too. These meetings, Gladwell says, are “just fantastic” and a “huge lifeline”. “There is never a question that is too stupid to ask,” she adds, “and everyone is just so honest with each other because we’re all going through the same things.” For someone so fastidious in everything they do, Gladwell is surprisingly levelheaded about the chaos that surrounds the impending Health Bill. “My goal here is to make sure West Hampstead Medical Centre becomes one of the best performing practices in the whole of Camden CCG,” she says. “I am very proud of the changes I have helped implement, along with the partners at the practice, and I am very blessed to have the best partners I have ever come across, who listen to what I say. We’ve moved from being a practice on the sidelines to one in the middle of it all, alongside practices like Adelaide Medical Centre, which has had Monika Cleaver move it to the top.” She cites the idiom: ‘Look after number one’. “For me, I’m looking after my number one – the practice,” she says. “Once my house is in order, then I will feel happier about opening the doors and saying: ‘Come in, see my place.’” In terms of what’s next for Gladwell’s career, she’s more than happy to stay put as she gets to grips with the practice manager’s role in the foreseeable future, but eventually, it’s impossible to know what the future holds for the profession and therefore her future job prospects. Undoubtedly, commissioning will play a large part of it. Whatever it may be, this practice manager says bring it on: “Because I’ve worked so hard to become a practice manager, it’s about strengthening that and really becoming focused on practice management, dealing more with finance and maybe, who knows, after that, the world’s my oyster.”

business intelligence and management sense for practice managers

management

Tackling the patient DES

The patient participation directed enhanced service (PPDES) aims to familiarise practices with their patients and spearheads the drive for patient choice within the NHS – but is this scheme a blessing or yet another burden for the practice manager? Jonathan Hills looks into the repercussions for practices The £60m of investment released for the patient participation direct enhanced service (PPDES) scheme is to be used to try to persuade practice managers to listen and adhere to the thoughts and opinions of their patients within the running of their practice. The British Medical Association (BMA) and NHS Employers have laid out a six-step process that practices are

october 2011 | practicebusiness.co.uk

required to adhere to in order to be eligible for the PPDES funds, which can result in earning the practice around £1.10 per patient, a reduction from £3.01 per patient from the previous year. The policy of the document echoes changes that are currently hitting the rest of the NHS and, indeed, the country – that is to say there is more to do and less money to do it with.

29 31

management | DES

However, reservations reservations that that have have arisen arisen from from the the new However, PPDES scheme (due(due to run until March 2013) stem new PPDES scheme to run until March 2013) primarily fromfrom the clarity rather than policy of of the stem primarily the clarity rather than policy scheme, andand though everyone might understandthe the the scheme, though everyone may understand guidelinesthat thathave havetotobebe met order to qualify guidelines met in in order to qualify for for DES, DES, many are uncertain about what they specifically many are uncertain about what these specific guidelines guidelines entail. entail. Surveysare aretotobe beundertaken undertaken least once a year Surveys at at least once a year and and must comply with the standards outlined by the must comply with the standards outlined by the PCT, PCT. Furthermore, able to ensure furthermore practicespractices must be must able tobeensure and prove and these provesurveys that these surveys represent an authentic that are an authentic cross-section of their cross-section of their patient demographic. patient demographic. Trying to organise a group of patients to of come The difficulty in trying to organise a group patients together and share a process sufficiently to come together andtheir shareviews their in views in a sufficiently coherentprocess to be converted into practice policy ispolicy coherent as to be converted into practice daunting, callingfor foraaforum forum is daunting,especially especiallyifif PCTs PCTs are calling “withoutdiscrimination” discrimination”and and with choice of “without with “a“a choice of modes” modes” to be available. to be available. JulianPatterson, Patterson,director director marketing Julian ofof marketing andand communicationsfor forPrimary Primary Care Commission (PCC) communications Care Commission (PCC) outlines thethe reasons forfor, - and spoke about reasons andthe thedifficulties difficulties with adheringto tothe - the new PPDES qualifications. adhering new PPDES qualifications.

“It’snot notgoing goingtotobebepossible possible have patient “It’s to to have thethe patient representativegroups groupswithout without having at least some of representative having at least some of the the process undertaken virtually,” hereferring says, referring process undertaken virtually,” he said, to the to the difficulty in recruting busy professionals and difficulty in acquiring busy professionals and youngsters youngsters to a patient participation as part of a patient participation group, group. and some of the “It’s required quite hard, some of this stuff. I think there is software thereof. a learning curve people reallythere hadisthe “It’s quite hard,but some of thishaven’t stuff. I think a time to travelcurve it yetbut – the onehaven’t impression I getthe is time that to there learning people really had has not been anone enormous amount work travel it yet – the impression I get isof that theredone has by practices around patient participation forby one really not been an enormous amount of work done practices obviouspatient reason: practices for do one not really knowobvious how toreason: do it around participation and still do donot theknow day job.” practices how to do it and still do the day job.” ThePCC PCCrecently recently conducted a survey of over The conducted a survey of over 200 200 practicemanagers managers determine the heart practice to to determine whatwhat lay atlay theatheart of of the agenda. Themajor two priorities major priorities for it the theirtheir agenda, the two for practices, practices,was it emerged, waspatients working with patients emerged, working with (63.5% considered very (63.5% considered very ‘important’ and 31.7% as important and 31.7%this as important) and maximising income ‘important’) andvery maximising potential (68.4% potential (68.4% importantincome and 23.4% important). The ‘very important’ and 23.4%, ‘important’). Theawakened nature nature of the PPDES necessarily incorporated the ofpatient the PPDES necessarily incorporated the in awakening of opinion, but what does the DES offer terms of of patient opinion, what does the DES offer in financial incentive forbut practices? terms of financial incentive for practices?

script file

A patient’s story “The Pharmacy2U service gives me more leisure time and I never run out of my medications. I cannot fault it”

mr Dennis halford Patient

delivering health

An innovative NHS mail-order pharmacy service is saving 80-year-old Dennis Halford a three-mile train trip to his GP and ensuring that he never runs out of his prescribed drugs again. Mr Halford, a patient at Granton Medical Centre in Birmingham, is prescribed five regular medications. Despite being on the waiting list for a replacement knee, he still likes to keep as active as possible. However, when his GP suggested the Pharmacy2U service might be more convenient, he jumped at the chance of avoiding unnecessary trips to the surgery for repeat prescriptions. He commented: “It saves me time spent trudging up to the doctor’s, then waiting at the chemist. It gives me more leisure time and I would recommend it to anyone.” Granton Medical Centre 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 into a free telephone or email reminder service. UniqUE TElEphonE rEminDEr SErvicE For Mr Halford, the telephone reminder service – a unique feature of the Pharmacy2U service – is invaluable. He said: “If I’m low on supplies of a particular drug, Pharmacy2U will ring me to tell me I’m running short. If they ring me in the morning, you can guarantee a delivery will be at the door the next day. I never run out of medication now. I cannot fault the service – I find it very helpful.” www.pharmacy2u.co.uk/practice

management | DES

I think the people who are finding this especially hard are those who haven’t got a patient forum already – starting from scratch would be extremely difficult but certainly not something you can’t get your head around

“If practice managers are just focused on the PPDES then they may be able to earn around £13,000 per year, [but] they are going to miss a trick, Patterson adds “Still, it isn’t just altruism; the practice will benefit from understanding exactly what the patients want and how to deliver it most effectively, and this can translate into long-term savings that are way in excess of what you can earn with the DES.” Patterson agrees with what the guidelines were trying to achieve via a patient-centred policy, but he also acknowledges the lack of clarity of the new PPDES, stating: “Patients are at the heart of the NHS, but it’s not enough to believe it you must be able to demonstrate it. And the authorisation framework does not describe in any great detail what engagement with patients actually involves.” The assimilation of information concerning the demographic and preference of practice populations will also lead to a greater understanding of local health problems and areas of improvement – potentially driving down unnecessary expenditure and increasing awareness of previously unknown issues. Sally Pern, practice manager of Grange Road Medical Practice, has been running a PPDES forum since 2007 and advises on how to manage patient participation and the various techniques that can prove useful. “It is an awful lot of work,” she says. “I think that the people who are finding this especially hard are those who haven’t got a patient forum already – starting from scratch would be extremely difficult but certainly not something you can’t get your head around.” Pern’s optimism and support for the PPDES scheme is interwoven with hesitance however, as she emphasises the difficulty of setting up practicepatient relations in the first place. october 2011 | practicebusiness.co.uk

“We advertised in the practice, the newsletter, the website and held a patient forum leaflet and open day to encourage patients to join, and with the new DES we have set up a virtual patient forum for people that can’t get to the meetings but still want to give their feedback,” she explains. But Pern dispells the belief that the PPDES is something that can be done to bring in extra cash, stating: “I’m not sure you would break even in the financial sense, but to make a difference for the patient we must involve them – being patients ourselves, we can see ourselves where the gaps are, and if we sit there and don’t say anything then nothing will improve will it? “The demographic is difficult – we have tried to email younger patients, asking them at the desk when they come for their appointments and asking them if they want to join the virtual patient forum, how they would like to be contacted, and giving them the option – some of the virtual forum patients have now actually started to attend the practice meetings.” Despite the reduction of incentive in the PPDES scheme, there still remains a great deal of support based around the importance of patient interaction, and this is something that is set to grow as a sentiment of NHS policy in the future. Whether or not it is something that can increase revenue in the practice, and expert advice suggests that likely it is not, it remains integral to a smooth running and pragmatic practice.

ElePractice The complete solution for patient participation

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management | medicine for managers

HIV

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: HIV

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, special adviser to the Parliamentary Health Select Committee

In the UK there are around 90,000 patients with HIV, a quarter of whom do not know that they are infected october 2011 | practicebusiness.co.uk

Human Immunodeficiency Virus is a retrovirus that attacks the body’s immune system, rendering the sufferer vulnerable to infection or disease. The disease develops as the virus destroys white blood cells (CD4 cells), which fight infection, gradually resulting in immune failure. In the later stages of the disease it may be called AIDS (Acquired Immune Deficiency Syndrome) and the patient is usually suffering serious consequences of the disease. The term ‘late-stage HIV infection’ is now preferred. The disease first appeared amoung the New York gay male community in the early 1980s but has spread globally. In the UK there are probably about 90,000 patients with HIV, a quarter of whom do not know that they are infected. It is thought that the virus originally arose from a similar virus found in chimpanzees in Africa. HIV is spread by exchange of bodily fluids, such as blood or semen. It can be spread through sexual contact, homosexual or heterosexual, with infected individuals. It can also be spread by the sharing of contaminated needles by illicit drug users and by infected blood transfusion (in the UK all blood is screened for HIV but this might not be the case in some parts of the world). It is more common in people who have caught another sexually transmitted disease. The initial symptoms of HIV occur two to six weeks after infection and are non-specific and often mistaken for cold or flu symptoms. They include sore throat, fever, swollen glands, tiredness and aching and a blotchy rash. They are usually mild and resolve without treatment. There is then a latent period often of many years without symptoms but during which time the virus is multiplying and progressively damaging the immune system. In late-stage HIV symptoms may depend on the nature of acquired illness but may include weight loss, night sweats, extreme tiredness, persistent diarrhoea, cough, breathlessness, fever and lymphadenopathy. Patients may develop pneumonia, TB and some cancers. HIV is usually diagnosed by a blood test that identifies the virus. The test is not effective immediately after exposure and patients who have been potentially exposed to risk are advised to have a test after three months. The test is specific for the disease and consent of the patient is required. Any person with a positive diagnosis needs considerable support with counselling and social back-up. This could be arranged through referral to a specialist HIV clinic. Patients undergo regular blood testing to monitor the level of HIV in the blood (the viral load) and the CD4 count (the number of defence cells in the blood). This data enables medical staff to assess disease progression and the likelihood of developing an HIV-related infection. The viral load also gives a measure of the efficacy of anti-HIV medication, the purpose of which is to reduce the virus to undetectable levels. HIV is treated with anti-retroviral medication. There is no cure and currently no effective vaccine for the disease. Medication requires skilful selection. Single medicines are not used because the virus can quickly adapt and become resistant. They are therefore normally used in combination and are able to slow the progression of the disease. They can prolong life for years. There are five main groups of anti-retroviral medication, all of which attack the virus in different ways. The objective of treatment planning is to identify the best combination of medication to reduce viral load to undetectable levels while minimising the side effects, which are commonly nausea, diarrhoea, tiredness and skin rashes.

For the medication to be effective and to provide the best chance of success it is essential that the full dose is taken exactly as prescribed. It is sometimes possible to halt the development of HIV within the first 72 hours after exposure. This technique, Post Exposure Prophylaxis (PEP) can be used after, for example, having sexual intercourse with an HIV-infected person when a condom broke or following an accidental stab with an HIV infected needle, as could happen in the course of medical treatment. The course of treatment lasts for four weeks, often has unpleasant side effects such as nausea, vomiting, diarrhoea and headache, and is not guaranteed to be effective. Preventive measures are crucial if there is any risk of acquiring the disease. Because the route of transmission is through bodily fluids, precautions such as condoms are essential. Drug users should ensure that they use needle exchanges wherever possible to avoid ever sharing needles. HIV is an insidious infection that remains to be beaten and it remains invariably fatal. Healthcare workers should take care to minimise any risk of transmission through needle-stick injuries and health education programmes to reduce sexual transmission are crucial.

management | advertorial

Travel in the modern age IT drives quality and productivity in travel health

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,

october 2011 | practicebusiness.co.uk

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.

management | legal

Preparing for the bill

Amid the ongoing progress of the Health and Social Care Bill passing through Parliament, including the recent completion of the Public Bill Committee consideration, Ingrid Saffin and Phil Walton of the healthcare department at Mundays Solicitors discuss the governance, employment and property issues that have arisen as a result and their impact on practice manager The Health and Social Care Bill continues to progress slowly yet steadily through Parliament. As this goes to print, it has been through two readings in the House of Commons and completed its committee stage in the House of Commons on 31 March. Some of the content of the bill and the speed with which it was progressing through Parliament caused serious concern to certain groups involved in healthcare in the UK. The perceived failure of the government to take seriously these concerns led to of a number of pressure groups lobbying fiercely and very publicly. It looked as though the bill might be doomed. In response to this, the government announced in April that there would be a break in proceedings to “pause, listen and reflect”. Professor Steve Field, a practising GP, chaired Future Forum, an independent group tasked with making recommendations to the government. Over 29,000 people provided views to Future Forum and 16 key recommendations were made.

In light of the recommendations and in a highly unusual step for legislation in the UK, the bill was sent back to the Public Bill Committee for further scrutiny. The committee had 12 sittings to debate the bill and its consideration finished on 14 July. Since then, the bill has passed through its report stage and third reading in the House of Commons and had its first reading in the House of Lords. Its next big test is the second reading in the House of Lords, which is due to take place on 11 October and comprises a general debate on all aspects of the bill. Alongside this, Health Secretary Andrew Lansley launched the second phase of the government’s ‘listening exercise’ on 18 August, with Professor Field once again responsible for presenting a summary of findings to ministers. Four work streams are under consideration: integrated care, information management, education and public health. This unprecedented step demonstrates the uncertainty

practicebusiness.co.uk | october 2011

management | legal

Indications from the government suggest that the latest phase of the listening exercise will conclude later this year with the exercise taking “months rather than weeks”, and the bill is then likely to be sent back to the Public Bill Committee for further scrutiny that surrounds the bill in its current form. Indications from the government suggest that the latest phase of the listening exercise will conclude later this year with the exercise taking “months rather than weeks”. Although the bill and the proposed NHS reforms appear to be in a beleaguered state, the bill still remains likely to progress through the Commons and the Lords and eventually become law. However, the form and impact of the bill remain uncertain.

The impact of the bill: generally The bill will be just one part of the overall picture. As and when it becomes law, many regulations will be issued that will put flesh on the bones of what is essentially an ‘enabling act’. At each stage of the process greater clarity will be achieved and it will be interesting to see how this develops. Strategic health authorities are likely to remain in their statutory roles for the whole of 2012/13 and, subject to the passage of the bill, will be abolished alongside primary care trusts at the end of March 2013. Under current plans, the NHS Commissioning Board and the other new national bodies will take up their full responsibilities from 1 April 2013. By then, subject to the passage of the bill, all GP practices will be members of a commissioning group. This is notwithstanding the BMA’s statement of 20 July confirming that it will continue to call for the bill to be withdrawn, while still “critically engaging with the government to achieve necessary improvements”. Despite this uncertainty, healthcare professionals in all disciplines need to be prepared for every eventuality and that preparation, if it has not already started, must start now.

The impact of the bill on practice managers So what can be done now in this period of uncertainty? The key primary care providers who need to act are GPs. They and practice managers should be auditing and reviewing their practices so that they and their practices are ready and flexible enough to move forward when the time comes. This includes checking partnership deeds/ shareholders agreements, contracts of employment, that lease and leasing agreements are up to date and in good order, and taking advice as appropriate. october 2011 | practicebusiness.co.uk

Primary care providers such as pharmacists, dentists and opticians should engage with their local clinical commissioning group (CCG) to ensure that they know what is happening in their local area and they contribute to and receive the due consideration of the CCG. It will be in everybody’s interest for CCGs to operate from a position of fullest knowledge possible. CCGs will continue as previously, monitoring all developments as they arise, perhaps with particular focus on their structure. The bill, at section 22, sets out many principles expected of a CCG with respect to its establishment and structure, including the functions and make up of its governing body from which a CCG may use as a helpful checklist. However there are many clauses, in this section alone, providing for regulations and guidance to be issued at a later date. For example, one clause states that regulations may provide that there must be two lay members of the governing body of each CCG or their remuneration and audit committees. The bill, in its current form, makes provision for a staff transfer scheme in connection with the merger, dissolution or variation of CCGs. Interestingly, it makes no overt reference to a staff transfer scheme from a PCT to a consortium, so it is unclear if the staff transfer scheme provisions apply in that specific case. In practice, TUPE would in all likelihood apply on a transfer of functions from a PCT to a CCG and therefore the majority of PCT employees, where their tasks are transferring to a CCG, would transfer on the same or more favourable terms and conditions. Careful consideration will therefore need to be given to staffing levels post-transfer as redundancies may be likely. The staff transfer schemes proposed by the bill do allow additional rights and liabilities that would not otherwise be transferred, as well as criminal liabilities. A staff transfer scheme may also create or impose rights, as well as make provision regarding the continuation of current legal proceedings. Like it or not, changes are coming. Depending on how they are met by healthcare professionals, they could be the best thing to happen to the NHS for decades, or they could be the worst. Whichever side of the fence you stand on, you cannot afford not to prepare properly.

work/life

Change is good

advice for busy lives

With so much happening in healthcare, it’s important to have your practice team on board. Jonathan Hills seeks some good advice on how to motivate your team, put changes in place and assert your authority as practice manager and within the CCG As the NHS cuts start to take hold, your practice will be forced into finding more innovative means by which to keep an effective patient service running with growing costs and a reducing budget. Like in any business, this will result in you needing to find more and more innovate ways to cut spending and reduce costs. It is a time to be pragmatic and learn new skills to ensure that your practice does not suffer as a result; you will need to ensure that your staff are flexible and accommodating, ready for a challenge and prepared to move into areas of responsibility that they might be thus far unfamiliar with. Some practices particularly might have certain staff members who are extremely proficient at the job they ordinarily perform, but when asked to move into a new arena might become apathetic or reluctant to excel. Michael Wright, practice manager at Whyburn Medical Practice thinks that practices working together will be key in tackling the implementation of the CCGs. “One of the main things, and one of the things which is really going to come out of all the commissioning going on now, is working together,” he says. “There are going to be times in your locality when you can share some of the back office functions. There is going to be pressure and there is talk of a new contract, so if that means there is going to be less

october 2011 | practicebusiness.co.uk

money coming in to the practice, then you are going to have to pool your resources.” Wright believes his staff have an altruistic approach to dealing with patients, and therefore is something that can be used when reasoning with staff about taking over roles and financial changes within the practice. “I think it is seeing what appeals to staff,” he continues. “What motivates them to come in and do the work? Most, even 90%, of staff are very patient centered so they are very much dealing with the public and like speaking to them. In fact, most of them would rather speak to them than do a lot of paperwork, and practice managers should think about this when reallocating roles in the practice. “You train them up and you make sure that patient welfare is at the heart of what they do, and as long at it is then you have usually got their buy-in,” he added. The integration of technology will also have a profound effect on the running of your practice, and you and your staff will have to be prepared to learn how to use it – and with the introduction of the CCGs the role of technology looks to become more prominent. Wright states that the use of the same back office system is vital in the smooth running of a practice, and especially between consortium members: “One of the problems at the moment is that there are a lot of IT systems out there – if you have an IT system, everyone

work/life | change management

You train them up and you make sure that patient welfare is at the heart of what they do, and as long at it is then you have usually got their buy-in

should be able to use it, trained up and able to access your surgery regardless of what practice you belong to,” he said. Michelle Webster, practice manager at Woodseats Medical Centre agrees there must be a dedicated and supportive staff team to ready the practice for change. “Preparing for the new environment is daunting, because really, no one knows what it is going to be like at the moment,” she comments. Emphasising that practices need to be braced for the plunge, Webster argues that both personnel and financial steadiness are required for the transition if practices are to survive it. Her advice on how the practice can ready itself for the financial implications of the transition is quite different, however while managing staff often reuires a tailored, individual approach, managing finances relies upon uniformity. whereas in managing staff importance in management should come with individualism, when it comes to finances, the greatest importance is upon uniformity. “It’s about adjusting roles within the practice because actually, certain elements of commissioning like scrutinising data and making sure everyone’s referral patterns and prescribing habits are the same, all takes time, so you have to adjust your workload accordingly – making sure the practice finances are robust enough, in case the worst happens and suddenly you are not able to pay the wages,” she says,

mentioning that this year her staff had to deal with a pay freeze for the first time in preparation for the future. “But it’s not just about saying that we can’t afford it – because we can - it’s about preparing for their future. We don’t want people to become redundant,” Webster continues, explaining how she talked through the process of a pay freeze with staff as the only logical conclusion for the practice and opening suggestions for the floor to find an alternate solution. Her advice concerning the management of staff and how to handle personnel centres upon trust and openness. She upholds that being honest, including asking staff for their opinions on changes in the practice, leads to greater respect in her team, and ultimately, a better practice. “When you tell people why and give them the option to come back with concerns or alternative proposals they will respect the decision you make,” she says. “If people think you are just the boss in the practice, people will not go out of their way for you.” Whatever the future holds for practices in the NHS - and truthfully everyone may have an indication but no one actually knows the repercussions that will come with the introduction of the CCGs – one thing is certain, and that is it’s best to have a tight and accountable financial structure, and a solid practice team around you when you make the change. practicebusiness.co.uk | october 2011

Work/life | top tips TOP FIVE TIPS FOR

Marketing your GP practice

There’s no time like the present to work on your practice’s image. Timi Olotu looks at the various ways to get your name out to the wider world to attract more patients and beneficial attention that could help your budget in the long run While the use of the term ‘marketing’ in relation to GP practices might sound odd to many, there has never been a more appropriate time for the two ideas to be juxtaposed. The imminent advent of clinical commissioning groups means that general practitioners will now be responsible for designing local health services in England. This means that important decisions will need to be made regarding what health services, and where, deserve the most financial backing. The above development coupled with the fact that entrepreneurial GPs (like primary care firm Chilvers McRae) are managing to take over other practices, gives a clear indication as to exactly why GPs now have to be aware of how to market their practices. The following are five excellent tips that are sure to help make your practice a marketing success:

Define your practice/have a plan

It is absolutely critical to brand and define your practice properly and accurately. This is a basic but necessary step for marketing your practice successfully, as it is the foundation upon which all other marketing steps you take will be built. Writing a mission statement and describing the goals of your practice, as well as marketing efforts, should help you get started with this step.

Marketing to the converted

Your most fruitful marketing potential may initially lie with current patients. It is wise to take steps to keep your current patients feeling ‘cared for’ rather than merely ‘attended to’, since they are then likely to recommend you to friends and other family members. One simple and free way to do this is through social media websites such

october 2011 | practicebusiness.co.uk

as Facebook. For example, creating a fan page for your practice where you keep current customers updated and privy to certain types of ‘insider information’ may make your practice feel more personable than others.

Medical blogs

Strategic partnerships with other practices

Have an appropriate website

The emergence of medical blogs (such as KevinMD. com) by top physicians, has helped to humanise the profession. Freely disseminating valuable medical information to members of the general public, via blogs or Twitter, could go a long way in raising your profile. Furthermore, the internet tends to create a snowball effect whereby, the more people there are reading your blog, the more new people you are able to reach.

Another way to market your practice is to focus on other (possibly similar) practices. The rise of physician-only social networking sites such as Sermo.com, and SocialMD. com, are invaluable here. For instance, you could use these online communities to raise awareness in the medical community about critical issues, and potentially, increase your chances of gaining funding to tackle such issues.

Having an appropriate website is a point that ties all the others together. In an age where the internet is becoming more and more accessible in more and more ways, the first port of call for most people who hear about your practice will be its website. Make sure it is clean, clear, and full of quality information.

Work/life | diary

Practice diary Geraldine Taggart-Jeewa is business manager at the North Meols Medical Centre. She sits on the Practice Management Network steering group and is joint-honorary secretary of the Family Doctor Association.

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

october 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: Geraldine Taggart-Jeewa discusses virtual patient participation groups Another week, another piece of work to sort out. The patient participation DES needs dealing with. Each year with QOF and DES I vow that everything will be done and dusted before February. Each year in March we still seem to be chasing right up to last minute for the remaining points. It’s the autumn and I haven’t done anything about this year’s patient participation DES. I realise that, yet again, I am in serious danger of missing my own targets. Excuses such as a new salaried GP, staff on maternity leave, employee sickness, a new apprentice, appraisal month etc, will no longer wash. I need to get on with it. I confess a small part of my inertia has been due to the fact that we were one of the pilot practices for the ‘virtual patient participation group’ (ePPG). So in some ways I have already done some of the leg work – but wait, that was back in 2009. Just where have I put all those signatures from our patients to sign up to my ePPG? Thankfully they are exactly where they should be, locked up in a safe place. Now the work begins: those who signed up two years ago to a pilot of a virtual patient participation group may not want to be a part of my fully fledged official one. Are some of them still our patients? Are their email addresses still valid? This reminds me of one of the things I learned when undertaking the pilot: The maintenance of the database needs careful consideration. Should you create a local code and scan in the sign up form? It seems these days, patients medical records

are increasingly having non-clinical information attached to them. So for us, the answer is yes. Our links with our local community through the local parish council have always been very strong. We recognise, however, that we should broaden our links with our patients. During the pilot phase, to our surprise and joy, over 100 patients signed up in the first week. We were also delighted with the number of responses and the information our patients were kind enough to share with us. Now the original survey I had created needs to be altered to reflect the new changes in our practice and the proposed Health Bill. A new topic for us will be focusing on continuity of care having gone from being a one GP practice to having two. I have promised our local CCG that I will ask our patients if they would also be interested in contributing to their work with commissioning. There is no point in double handling this task. So I have emailed the staff to let them know we are doing this again. I have collaborated with my GPs in deciding on the survey questions. I have put posters up, added a link on our website and put information about it on our TV in the waiting room. I have added a local code to our patients’ records. I have created paper versions of the survey for those patients who do not have use of the internet. Finally I have amended our new patient registration forms to include the option to sign up to an ePPG. Now I am just waiting for replies to the survey – fingers crossed I get some!

VIV/094/240811/P. 08/11

Further Reading – Prescribing information Vivotif® (Live vaccine for active oral immunisation against typhoid fever). (Please consult the full Summary of Product Characteristics before prescribing.) Active ingredients: A single dose of Vivotif® contains at least 2 x 109 Salmonella typhi Ty21a in a lyophilised form. Quantities expressed per capsule. Pharmaceutical form: Enteric-coated capsule. Therapeutic indications: For active oral immunisation against typhoid fever in children aged 6 years and over, adults and elderly. Dosage and administration: One dose of Vivotif® is to be taken on days 1, 3 and 5, with lukewarm water at least 1 hour before meals. The protection becomes effective 7–10 days after ingestion of the third dose of vaccine. Under conditions of repeated or continuous exposure to S. typhi protection persists for at least 3 years. In the case of travel from a non-endemic area to an area where typhoid fever is endemic, an annual booster consisting of 3 doses is recommended. Contraindications: Vivotif® must not be administered: to persons known to be hypersensitive to any component of the vaccine or the enteric-coated capsule, to persons with congenital or acquired immune deficiency (including patients receiving immunosuppressive or antimitotic drugs), during an acute febrile illness or during an acute gastrointestinal illness. Vaccination should be postponed until after recovery. Warnings and precautions: None known. Interactions with other medicinal products and other forms of interaction: An interval of 3 days should be allowed between the treatment with any antibacterial agents and Vivotif® vaccination. If malaria prophylaxis is also required, the fixed combination of atovaquone and proguanil can be given concomitantly with Vivotif®. Doses of mefloquine and Vivotif® should

be separated by at least 12 hours. For other antimalarials, there should be an interval of at least 3 days. Vivotif® may be administered concomitantly with the live attenuated vaccines: yellow fever vaccine and oral polio vaccine. Pregnancy and lactation: Animal reproduction studies have not been conducted with Vivotif®. It is not known whether Vivotif® can cause foetal harm when administered to pregnant women or can affect reproduction capacity. Vivotif® should be given to a pregnant woman only if clearly needed. There are no data regarding administration of Vivotif® to nursing mothers. It is not known if Vivotif® is excreted in human milk. Undesirable effects: The following adverse reactions were reported commonly (<1/10 but >1/100) in clinical studies: Gastrointestinal disorders: Abdominal pain, nausea, diarrhoea, vomiting. General disorders and administration site conditions: Fever, influenzalike illness. Nervous system disorders: Headache. Skin and subcutaneous tissue disorders: Rash. The following additional adverse reactions have been reported very rarely (approximately <1/10,000) during post-marketing surveillance: Skin reactions such as dermatitis, exanthema, pruritus, urticaria. Anaphylaxis. Asthenia, malaise, tiredness, shivering. Paraesthesiae, dizziness. Arthralgia, myalgia. Overdose: Doses five-fold higher than the recommended dose do not produce vomiting, abdominal distress or fever. However overdosing can increase the possibility of shedding the S. typhi Ty21a organisms in the faeces. Special precautions for storage: Store at 2°C – 8°C. Protect from light. Package quantities and basic NHS cost: 3 x 1 dose, basic NHS cost £14.77. Legal category: POM. Marketing authorisation number: PL 15747/0001. Marketing authorisation holder: Crucell Italy S.r.l, Via Zambeletti 25, I – 20021

Baranzate (MI), ltaly. Date of last revision of Prescribing Information: June 2010. Vivotif® references: 1. Vivotif® Summary of Product Characteristics. June 2010. 2. Monthly Index of Medical Specialties. March 2011. 3. Levine MM et al. Lancet 1987; 8541: 1049–1052. 4. Dietrich G et al. Vaccine 2003; 21: 678–683. 5. Guzman CA et al. Vaccine 2006; 24: 3804–3811. 6. Salnerno-Goncalves R et al. J Immunol 2002; 169: 2196–2203. 7. Sztein MB. CID 2007; 45(suppl 1): S15–S19. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Crucell at pharmacovigilance@crucell.com