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september 2011

Saving the NHS

Is it actually decommissioning we’re after?

Clock watching

Ready your time management skills for commissioning

Partner in time

When a practice manager should become a partner

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YOUR GUIDE tO managing commissioning!

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

Adults and children from 36 months should receive one 0.5 millilitre dose. In children aged 6 months to 35 months clinical data are limited and dosages of 0.25 or 0.5 millilitre have been used. Children who have not been previously vaccinated should receive a second dose of vaccine after an interval of at least 4 weeks. Doses should be administered intramuscularly or deep subcutaneously. Contraindications: Hypersensitivity to the active substances, to any of the excipients, to eggs, chicken protein, neomycin, formaldehyde, and octoxinol 9. Immunisation should be postponed in patients with febrile illness or acute infection. Warnings and precautions: Do not administer intravascularly. Medical treatment should be available in the event of rare anaphylactic reactions following administration

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

include, allergic reactions (in rare cases leading to shock, angioedema), convulsions, transient thrombocytopenia, vasculitis with transient renal involvement and neurological disorders such as encephalomyelitis, neuritis and GuillainBarré syndrome. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic NHS cost: Single dose prefilled syringes in single packs, basic NHS cost £6.59; packs of 10 single dose prefilled syringes, basic NHS cost £65.90. Marketing authorisation holder: Sanofi Pasteur MSD Limited, Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP. Marketing authorisation number: PL 6745/0095. Legal category: POM. Date of last review: July 2007.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk Adverse events should also be reported to Sanofi Pasteur MSD, telephone number 01628 785291. uk15224 08/11

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

How much participation is enough participation? The new patient participation directed enhanced service (DES) is proving to be a challenge for practice managers across England. Many are unsure exactly what they have to do to meet its requirements, with PCTs giving conflicting advice about how much of a practice’s patient population need be involved. Practice managers are starting to feel like it’s too much work for the £1.10 per patient it pays, particularly when the funding for the service came out of a reduction in payments for extended hours. It’s understandable that there has been frustration. However, there are other practice managers who are already doing a lot with their patients. Michelle Webster of Woodseats Medical Centre (interviewed on p18) told me of a community outreach programme she holds for carers, as well as evening sex-education events the practice hosts for young people, reminiscent of The Sex Education Show on Channel 4. She plans to hold these events at a local community centre or youth club – basically anywhere that’s not the surgery itself – so the young folk won’t be spotted going to the clinic by the nosy neighbour next door. Because it’s difficult getting young people involved – and working professionals, and busy single mums… the list goes on – it’s easy to see how an adequately diverse demographic is very hard to achieve. Most people are just too busy to get involved in the goings on of their local GP practice. It’s hard enough for people to make an appointment a lot of the time. So what can a practice manager do – bar going out onto the street and literally dragging people in by their earlobes and forcing them to participate in a group? And once you have them participating, are the ones who shout the loudest and want to participate always the best ones to be participating? It’s a complex issue. We’re interested in what practices are doing in conjunction with the DES. Who’s participating? How have you found it? Good experiences? Bad experiences? Not doing it? I want to find out why. Please get in touch on editor@practicebusiness.co.uk with your story.

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SEE INSIDE FOR YOUR GUIDE TO MANAGING COMMISSIONING

P.10

Contents SECTOR 06

news Top news for practice managers this month

executive editor comment Latest from our columnist Roy Lilley

COMMISSIONING 10

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

comment Saving the NHS Is decommissioning or commissioning the priority?

interview Knowledge power Michelle Webster from Woodseats Medical Centre

PEOPLE 24

interview Economies of scale Practice manager Julie Coakley on group buying

MANAGEMENT 28

clinical The big issue Is Britain’s obesity epidemic the GPs’ problem?

technology Goal in site How good website design is better for patients and practices

legal Howdy, partner Should a practice manager become partner?

clinical QOF This month: Depression

WORK/LIFE 36

time management Clock watching Are you making the most of your nine to five?

diary Our ninth diarist of the year takes to the page

practicebusiness.co.uk | september 2011

SECTOR

NEW 2012/13 QOF MENU PUBLISHED NICE has published a set of new proposed indicators for the 2012/13 QOF, including three new indicators on offering support and treatment for smokers, and two new indicators to assess levels of physical activity and provide a brief intervention to people with high blood pressure who score ‘less than active’. There is also an indicator to improve care for people with asthma and a set of indicators on fragility fractures in osteoporosis patients. NICE also makes recommendations on which existing QOF indicators should be retired or amended. The selection of the ﬁnal indicators for inclusion within the 2012/13 QOF will be decided by NHS Employers, on behalf of the UK health departments, and the General Practitioners Committee (GPC) of the British Medical Association (BMA) and the new QOF indicators will be published by NHS Employers (NHSE) in winter 2011.

CONCERN FOR MENTAL HEALTH

your monthly lowdown on general practice

The new QOF proposals could mean the removal of three indicator measures for depression. The NHS Confederation’s Mental Health Network director, Steve Shrubb, said: “Mental ill health costs the UK about as much as the entire NHS budget every year. It is vital to good quality mental health care that problems are identiﬁed early so they can be treated before they require more intensive support later on. “We are extremely concerned about proposals that, if enacted, would remove any ﬁnancial incentives to identify the most common form of mental illness in GP surgeries.” Shrubb added that one third of GP appointments are related to mental health issues.

Practices struggle with PPG DES

GP practices are struggling to meet the terms of the new patient participation directed enhanced service (DES) introduced in this year’s GMS contract. Only four months since its launch, practice managers have questioned whether the terms of the DES were too rigid, requiring what one practice manager called “massive amounts of paperwork”,

september 2011 | practicebusiness.co.uk

Key points  Clinical areas recommended for QOF piloting include asthma, atrial fibrillation, cardiovascular disease, diabetes, osteoporosis, peripheral arterial disease and hypertension  Clinical areas with QOF indicators recommended for retirement include asthma, atrial fibrillation, BP, CHD, CKD, depression, diabetes, epilepsy, smoking, stroke and hyperthyroid  For details on the recommendations, visit http:// www.nice.org.uk/media/717/D1/QOF_Advisory_ Committee_June_2011_summary_recommendations_ for_menu_and_retirement.pdf.

leaving many practices despondent over meeting the targets. “You do all of this and you end up with £1.10 per patient, which is nothing compared to the time and resources you put into all of this,” Sheila McLean, an Essex-based practice manager. There has also been confusion over what exactly practices have to do to meet the targets. The Family Doctor Association, whose chief executive Moira Auchterlonie has been meeting with practice managers confused about the DES, has put together support for practices on their website, www.family-doctor.org.uk. Six in 10 GP practices are reported to have taken up the DES.

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 The DNA code New research carried out in GP surgeries shows that in some environments, specific behaviour-change interventions can lead to a dramatic reduction in did not attends (DNAs), or patient no-shows. In any 12 month period, up to six million GP and hospital appointments are missed at an estimated cost of more than £700m country-wide. In addition to the cost implications, GPs often cite DNAs as a major problem that can lead to longer waiting lists, early signs of serious illnesses being missed and reduced patient satisfaction overall. However, In the case of NHS Bedfordshire research, behaviour-change techniques resulted in a reduction of 30% in the number of did-not-attends (DNAs). Researchers feel that if replicated throughout England, this approach could deliver savings of up to £250m a year. Participant Nadia Shaw, a practice manager at Toddington Medical Centre, commented: “In an attempt to reduce DNAs we have previously published how many people have not attended in the past month and have also tried sending letters to people reminding them that they have missed an appointment. “Neither has been successful so we were pleased to take part in this study. Given how simple the interventions were we weren’t too sure how successful they would be but they proved to be an amazing turnaround for us.” The techniques used in the study, which are outlined in the Institute for government’s 2010 ‘Mindspace’ report involved:  Getting patients to confirm their appointment by verbally repeating the details to the receptionist  Getting patients to write the appointment down themselves (rather than a receptionist doing it for them)  Placing positive messages around the GP practices confirming that attending appointments is the ‘social norm’. Steve Martin, the MD of training consultancy Influence at Work, which led the study, said that even though behavioural approaches alone are insufficient in addressing serious health issues such as obesity, they are important as part of potential overall solutions. “For relatively straightforward problems, such as encouraging people to turn up to health appointments, small changes like these can make a very real difference as we have shown in the NHS Bedfordshire studies,” he said. “In fact research has shown behavioural interventions can play a significant part in addressing challenges not just in health but in other areas too.”

“” fact

They said… GPC chairman Dr Laurence Buckman has condemned the “vast majority” of Darzi centres as a “millstone around the neck of the NHS”. He said the GPC position is that all Darzi centres must be closed. “We all believe they are a complete waste of money. I won’t be sorry to see them go,” he said.

CQC has officially been extended. GP practices will not need to register with the Care Quality Commission (CQC) until April 2013, after the Department of Health held a consultation on the extension of the 2012 deadline.

Stop-smoking The number of attempts to quit smoking and the number of attempts that have ended in success has trebled in the last 10 years, according to the NHS Information Centre. In 2010/11 there were almost 788,000 quit dates set and nearly 384,000 successful quit attempts; compared to 227,000 quit dates and just fewer than 120,000 successful attempts in 2001/02. Spending on stop-smoking services in the NHS has increased by £60m since 2001, now standing at £84.3m per year.

Prescriptions A new watchdog is to be set up to reduce the ‘avoidable’ £300m lost within the NHS each year due to medical wastage from unused medication. Health Minister Lord Howe said it will help make the £20bn efficiency savings the government expects the NHS to make by 2015.

Flu vaccine Centralised procurement will not increase uptake of the seasonal flu vaccine, say leading pharmacists. Instead, the Pharmaceutical Services Negotiating Committee (PSNC), Pharmacy Voice (PV) and the Royal Pharmaceutical Society (RPS) believe access could be improved by a wider network of flu jab providers.

diary PROCUREMENT IN THE NHS 2011: EVERY PENNY COUNTS Manchester Conference Centre 13 September

CLINICAL COMMISSIONING IN ACTION London 14 September

COMMISSIONING FORUM NORTH 2011 Manchester 27-29 September

practicebusiness.co.uk | september 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.

Reality check

ROY LILLEY talks sovereign debt and Cheryl Cole and asks: why is the government treating the NHS like it’s in a reality show? I’m going to write about the economy – no, don’t flip the page. It’s important. Make a cuppa builder’s, get a packet of Hobnobs, sit down and join in. I know the economy is not as absorbing as the riots. I confess it is not as fascinating as the fact that the wife of the Speaker of the House of Commons is so desperate for money or fame (or both) that she joined a TV reality show; the objective of which is to humiliate, belittle and have sex on the screen. It is not as extraordinary as a French actor piddling into a bottle, in full view, on an aeroplane. Neither is it as intriguing as whether or not Simon Cowell will be casting his dark shadow over the next series of The X Factor. That said, recent events, including stock market avalanches, escalating sovereign debt crises and growth figures as flat as the Serengeti, do have to be put into some sort of context. The parlous state of the world economy is really serious. The problem is governments, right across the developed world, have done what governments can seldom stop themselves from doing: they’ve spent money they haven’t got. They financed their spending splurge from taxes and borrowing. Taxes are tricky; when the economy is doing well the temptation is to put taxes down (when they should be putting them up). When the economy is doing badly, the temptation is to put taxes up (when they should be putting them down). Borrowing is arranged through ‘sovereign debt’ (sovereign being accountantspeak for government) – effectively government IOUs regarded as uber-safe. Except that they are not. Well, not any longer. The people who ‘buy the debt’, effectively lending governments money, are no longer sure that governments will be able to raise the taxes or cut their expenditure enough to pay the money back. Hence the US has just lost its triple-A credit rating and the value of the Euro is going down the toilet. Now, you may not think this as interesting as JK Rowling discovering her French ancestors, Richard Gere selling off his guitar collection or Kate Middleton and Reese Witherspoon becoming friends. On the scale of things, the fact that the Amy Winehouse Foundation is stalled because someone has registered the name, pales into insignificance. Stock markets around the world are close to melt-down. The FTSE100, the DAX, the CAC 40, the Dow Jones, NASDAQ and the BBC Global 30 have all plunged. Reason? Every piece of economic data published recently has been weaker than expected. This makes the people who buy shares very nervous. Why? The expectation is that companies will grow, employ people and pay taxes; helping governments to pay their debts. If it looks like it’s not going to happen, the worry is: who is going to pay back the sovereign debt and will I get a dividend from a company I invest in? Are you getting this? It’s a circle – a bit like all the palaver with the Cheryl Cole break-up. She left him. Now she’s gone back to him. Groan. Why does this matter? Reach for another Hobnob and I’ll tell you. The government funds the health service. Already the NHS is looking to save £20bn by 2015. We know that the coalition is fudging NHS funding. In truth, it is flat lining at a time when demand is growing at just under four per cent a year. There is not enough money, too much demand and a duplication of facilities. If you think the NHS has troubles now; you ain’t seen nothing yet. There is a new reality game to play: “I’m in the NHS, get me out of here!”

Who is going to pay back the sovereign debt? It’s a circle – a bit like the Cheryl Cole break-up. She left him. Now she’s gone back to him. Groan september 2011 | practicebusiness.co.uk

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ways Decapeptyl® SR can ways Decapeptyl® SR can

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Efficacy equivalent to the gold standard, 1-7 Efficacy equivalent gold standard, surgical castration, for to thethe management 1-7 for the surgical castration, of advanced prostate cancer. management of advanced prostate cancer.

Predictable control3,8 minimises Predictable control3,8 minimises the need for additional care the need for additional care

Choice of 1-, 3- or Choice of 1-, 3- or 6-monthly formulations 6-monthly formulations

Value for money Value for money Decapeptyl®® SR 11.25mg Decapeptyl SR 11.25mg and 22.5mgare are19% 19%less less and 22.5mg ® expensive thanZoladex Zoladex ® LALA expensive than 9 10.8mg peryear year9 10.8mg per Fewer injectionvisits visits Fewer injection with the with the6-monthly 6-monthlyformulation formulation than 3-monthly LHRH than 3-monthly LHRHagonists, agonists, providing an providing anopportunity opportunityto… to… …streamline the …streamline thepatient patient care pathway care pathway NEW Licence Extension NEW Licence Extension Decapeptyl®® SR 3mg and 11.25mg now licensed Decapeptyl SR 3mg and 11.25mg now licensed as adjuvant treatment to radiotherapy

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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 When Decapeptyl SR is co-administered with drugs affecting pituitary secretion of gonadotropins, caution Prescribing Information licensed ®dose administered. Decapeptyl SR® 3mg: Triptorelin acetate Decapeptyl SR®11.25mg: Triptorelin should be exercised and it is recommended that the patient’s hormonal status be supervised. Pregnancy SRis3mg, DECAPEPTYL SR 11.25mg and4.2mg. DECAPEPTYL SR 22.5mg DECAPEPTYL acetate 15mg. for Decapeptyl SR 22.5mg: Triptorelin 28mg. Triptorelin acetate triptorelin pamoate and Decapeptyl Lactation: Not Undesirable Very common: back pain, Presentation: Powder suspension for injection. Vialspamoate for all preparations contain an and overage to ensure theare When SR isapplicable. co-administered with effects: drugs affecting pituitaryAsthenia, secretionhyperhidrosis, of gonadotropins, caution bioequivalent. Uses: Treatment locally non-metastatic prostate cancer,SR as an alternative to surgical should paraesthesia in lower hot flush. Common: Nausea, fatigue, injection site erythema, injection site licensed dose is administered. DecapeptylofSR 3mg:advanced, Triptorelin acetate 4.2mg. Decapeptyl 11.25mg: Triptorelin be exercised andlimbs it isand recommended that the patient’s hormonal status be supervised. Pregnancy castration, and treatment of metastatic prostate cancer (Decapeptyl SR 3mg, 11.25mg and 22.5mg). As adjuvant inflammation, injection site pain, injection site reaction, oedema, musculoskeletal pain, pain in extremity, acetate 15mg. Decapeptyl SR 22.5mg: Triptorelin pamoate 28mg. Triptorelin acetate and triptorelin pamoate are and Lactation: Not applicable. Undesirable effects: Very common: Asthenia, hyperhidrosis, back pain, treatment to radiotherapy in patients with high-risk localised or locally advanced prostate cancer (Decapeptyl SR dizziness, headache, erectile dysfunction and loss of libido. Rarely, cases of anaphylaxis and hypersensitivity bioequivalent. Uses: Treatment of locally advanced, non-metastatic prostate cancer, as an alternative to surgical paraesthesia in lower limbs and hot flush. Common: Nausea, fatigue, injection site erythema, injection site 3mg and 11.25mg). Dosage and Administration: Decapeptyl SR 3mg: One intramuscular (i.m.) injection every have been reported. Prescribers should consult the Summary of Product Characteristics in relation to other castration,four andweeks treatment of metastatic prostate cancer One (Decapeptyl SR 3mg, 22.5mg).SR As 22.5mg: adjuvantone inflammation, injection siteNopain, injection site of reaction, oedema, musculoskeletal pain, pain in extremity, (28 days). Decapeptyl SR 11.25mg: i.m. injection every11.25mg 3 months.and Decapeptyl side effects. Overdosage: human experience overdosage. Pharmaceutical Precautions: Do not store treatmenti.m. to radiotherapy in patients high-risk localised or locallyNoadvanced prostate cancer (Decapeptyl SR dizziness, headache, erectile and loss vehicle of libido. Rarely,Decapeptyl cases of anaphylaxis and hypersensitivity injection every 6 months.with Additional dosing information: dosage adjustment necessary in the elderly. above 25ºC. Reconstitute onlydysfunction with the suspension provided. SR is a suspension, therefore 3mg and 11.25mg). Dosage and Administration: Decapeptyl SR 3mg: One intramuscular (i.m.) injection reported. Prescribers the Summary of Product in relation to other The injection site should be varied periodically. Inadvertent intravascular administration must be every avoided. have oncebeen reconstituted, it should beshould used consult immediately. Legal Category: POM.Characteristics Basic NHS cost: Decapeptyl four weeksContraindications: (28 days). Decapeptyl SR 11.25mg: One i.m. months. Decapeptyl 22.5mg:product. one side Overdosage: human experience overdosage. Pharmaceutical Do not Hypersensitivity to LHRH, its injection analoguesevery or any3other component of theSRmedicinal SReffects. 3mg £69.00 per vial. No Decapeptyl SR 11.25mgof£207.00 per vial. Decapeptyl SRPrecautions: 22.5mg £414.00 perstore i.m. injection every 6 months. Additional dosinguseinformation: No dosage adjustment in ofthe elderly. Reconstitute only with the suspension vehicle provided. Decapeptyl SR is a suspension, therefore Precautions and Warnings: Long-term of LHRH agonists is associated with an necessary increased risk bone loss and above vial. 25ºC. Marketing Authorisation Numbers: Decapeptyl SR 3mg: PL 34926/0002. Decapeptyl SR 11.25mg: The injection site toshould be varied periodically. intravascular administration mustrisk befactors avoided. reconstituted,Decapeptyl it should SR be 22.5mg used immediately. LegalMarketing Category:Authorisation POM. Basic Holder: NHS cost: may lead osteoporosis and increased risk ofInadvertent bone fracture. Particular caution in patients with for, or once PL 34926/0003. PL 34926/0013. IpsenDecapeptyl Ltd., Contraindications: to LHRH,Rarely, its analogues or any other component of the medicinal product. SR190 3mgBath £69.00 vial. Berkshire, Decapeptyl 11.25mg per vial. Decapeptyl SR 22.5mg £414.00 establishedHypersensitivity osteoporosis is necessary. LHRH agonist treatment may reveal the presence of a gonadotroph Road, per Slough, SL1SR 3XE, UK. Tel £207.00 01753 627777. Date of preparation of PI: May 2011. per cell pituitary adenoma. Mood changes, including depression have been reported. Patients with known depression Ref: UK/DEC08521a (Adjuvant licence). 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Date offorms preparation information can be found at www.yellowcard.gov.uk symptoms of prostate cancer (tumour flare) and cancer related (metastatic) pain may occasionally develop during cell pituitary adenoma. Mood changes, including depression have been reported. Patients with known depression Ref: UK/DEC08521a (Adjuvant licence). Adverse events should also be reported to the first weeks of treatment and should be Decapeptyl managed symptomatically. Duringagonists, the initialcauses phaseaoftransient treatment, should be the monitored closely during therapy. Initially, SR, like other LHRH Ipsen Medical Information on 01753 forms 627777 should belevels. given to additional administration of aofsuitable anti-androgen Adverse events should bedepartment reported. 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Date of preparation: August 2011. DEC08548a 02/08/2011 11:56

commissioning in context

COMMISSIONING

practicebusiness.co.uk/cs

EMPOWERING PRACTICE MANAGERS IN CONSORTIA

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

CCGS TO BE PUT TO THE SAVINGS TEST GPs are to be assessed on their performance in providing savings for the NHS efficiency drive before they are given commissioning responsibility by the NHS commissioning board. The clinical commissioning groups (CCGs) are to have their efficiency performance assessed alongside their ability to undertake functions previously conducted by PCTs, with assessment process taking place from October to December this year and CCGs able to apply for commissioning responsibility from the summer of next year. Evaluation is to take into account the ability of CCGs to deliver their services efficiency, quality of patient and clinical care and the actions they have undertaken to implement recent NHS changes. The DH released the draft government document, Developing clinical commissioning groups: Towards

authorisation, which outlines the criteria the CCGs will have to fulfil if they are to receive approval for commissioning autonomy. “This will support emerging clinical commissioning groups in their development and enable them to be as prepared as possible for authorisation as well as taking on responsibility for healthcare budgets and improving services for their local communities,” said a DH statement.

REFORMS FAIL TO WIN OVER GPS

NHS Alliance launches commissioning site

The government’s planned changes to the Health and Social Care Bill have failed to reassure many GPs, according to a new survey by Medeconnect. Over half (57%)of GPs surveyed said discussions on GP commissioning during the listening exercise had a ‘negative impact’ on their confidence in the bill.

The NHS Alliance has launched a new website for leaders and practitioners of clinical commissioning. The website (www.nhsace.com) offers resources for those involved in commissioning. Julie Wood, NHS Alliance national lead for clinical commissioning, commented on the launch: “Since its inception, the NHS Alliance has been a consistent champion of locally-driven, clinically-led commissioning, which has been the ‘promised land’ for the NHS for over two decades now. “Yet, all too often, that promise has been accompanied by crossed fingers behind the system’s back. As the NHS faces ‘The Nicholson Challenge’ of £4bn annual efficiency and productivity gains over the coming four financial years, clinically-led commissioning has become more crucial than ever before.”

fact

september 2011 | practicebusiness.co.uk

49% of GP principals think opening up commissioning to other groups will have a negative impact on patient care (Source:Medeconnect)

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

Patients get their commissioning voice Seventy-five Local HealthWatch pathfinders were announced last month by Health Secretary Andrew Lansley as part of the government’s plans to give patients a stronger voice under commissioning. These new learning networks will champion patients’ views and experiences, promote the integration of local services and improve choice for patients through advice and access to information. Local HealthWatch will provide a collective voice for patients and carers, and advise the new clinical commissioning groups on the shape of local services to ensure they are informed by the views of the local community. Visiting a new HealthWatch pathfinder in Cambridgeshire, Lansley said that putting patients and the public at the heart of health service is central to the government’s vision of modernising the NHS and called the introduction of these pathfinders “a huge step forward”. “Local HealthWatch will give patients and carers a real say over how their local health service is run,” he said. “They will act as patient champions, drive local involvement in the community and ensure patients understand the choices available to them.” Councillor Catherine Hutton, portfolio holder for adult services at Cambridgeshire County Council, commented: “Cambridgeshire’s HealthWatch Pathfinder will build on the strong joint work that is happening in health and social care services across the county. The County Council is working together with local GPs, the local health service and Cambridgeshire Local Involvement Network to make sure that people have a voice in health and social care services.” Mike Hewins, chairman of Cambridgeshire Local Involvement Network (LINk), a new pathfinder, added: “Cambridgeshire LINk has always worked hard to put patients and service users at the forefront of its work. As a HealthWatch Pathfinder, we’ll be able to reach out and work with many more people in Cambridgeshire and ensure that they are fully involved in health and social care in the county.” The 75 Local HealthWatch pathfinders established this week will pioneer plans ahead of their full establishment across the country in October 2012.

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COMMISSIONING | news analysis

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

Saving the NHS

Roger Hymas asks: Is it decommissioning rather than commissioning that is the real priority for GP practices and clinical commissioning groups? The NHS is so big that often I find myself looking for a biblical metaphor to describe what’s going on. But looked at over the long-term, it does feel like feast or famine. We’ve just had 10 years of extraordinary feasting (2000-2010) as NHS budgets have doubled. But we now know that the famine is upon us. Increasingly, we’re beginning to read in the local or healthcare press of a hospital or PCT coming under new financial pressure. Despite government promises that front-line services are going to be protected, we are constantly reminded that £20bn has to be saved by 2015. And with the advent of GP commissioning, it’s practices who have now been given the responsibility for getting us out of the hole. At first sight, the challenge does look daunting. I’ve spoken at a few conferences recently where I have paraded my favourite new slides (see page 16). Slide 1 shows the historic growth of healthcare spending in America. Slide 2 predicts what will happen if this trend is extrapolated at the current rate. The prediction is that at some time towards the second half of this century, the whole of the US economy will be spent on healthcare, which I think we all know is not going to happen because America will go bust first. But there are lots of indicators of the trouble ahead. Take every motorcar made in America. The second biggest component after the steel is the private health insurance payments that companies like Ford and General Motors make for their employees and pensioners. But probably the most staggering statistic of any that I have heard is that Starbucks now spends more on employee healthcare than it does on coffee. UK health expenditure is a long, long way behind the US – we’re about 10% of GDP if you add together what’s spent on the NHS, private healthcare and nonprescription drugs, compared with the US equivalent of about 18%. And the experts say that it’s just not going to happen here and that everything’s under control. Slide 3 just published by the UK Treasury’s Office for Budget Responsibility suggests that we won’t hit the current US GDP proportion before 2060. I’m sorry, but I just don’t buy into this. We know what drives healthcare spending, starting with demographics and the ageing population (apparently somebody born in this country this year will live to be 150). Then we add medical technology advances – extrapolate where we are with biomechanics, the human genome, etc., at just an ordinary pace of development. Finally, consumer expectations are rising – the NHS will deliver whatever seems to be the public’s belief that it should. My view is that healthcare costs won’t stop spiralling unless we find a way of re-setting the cost baseline. Somehow we have to cut back on the waste and the irrelevant and that is essentially the agenda for GP-led commissioning. It’s GPs, practices and consortia who will have to save the NHS and here are my suggestions on how we might get started:  There’s ample proof that a lot of what is being done clinically shouldn’t be done because it brings no benefit to the patient.  Practices where referrals/prescribing rates are higher than the national average need to be brought into line.  Millions of pounds could be saved by treating patients appropriately and efficiently in the right setting, that’s generally out of hospital.  Provider contracts will need to be enforced by commissioning groups to drive productivity and quality.

september 2011 | practicebusiness.co.uk

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COMMISSIONING | news analysis

GP practices and consortia will be judged by their effectiveness at commissioning to deliver excellent patient care. But it will be their skill at decommissioning that will save the NHS

So, yes, in the future, GP practices and consortia will be judged by their effectiveness at commissioning to deliver excellent patient care. But it will be their skill at decommissioning which will save the NHS, and maybe the UK economy as well. Decommissioning involves taking out services that are unnecessary, wasteful, duplicative or just plain dangerous. We need to focus on decommissioning because so much of the healthcare resource – people and real estate – isn’t appropriate any more, when judged by the test of best, modern clinical practice. Let’s face it: the NHS infrastructure deployed today is the consequence of multiple strategies, politics and decisions that have been made, for good or bad, during the past 60 years of NHS history. It’s just grown like topsy. Arguably, parts of our health system go back literally hundreds of years. Barts Hospital in London is probably the most extreme example. Founded in 1123, it’s still going strong after at least three decades of attempts to close it down. The Tomlinson report of 1991 recommended its closure well over 20 years ago, as London was reckoned to have too many hospitals. Looking on Google, I even found that there is an academic paper on it: ‘Closing Barts – community and resistance in contemporary UK hospital policy’, Moon and Brown, published in the Environment and Planning Journal in 1999. Health authorities, and more recently PCTs, have been woefully bad at not taking out surplus or redundant provider capability. Largely, this is the result of local politics where a kind of reverse nimbyism seems to take over. Back in June, there was an excellent piece on the phenomenon by Philip Stevens in the Financial Times titled ‘The way to save the NHS – close hospitals’: ‘[Nimbyism] decrees that the NHS offers an “everything, everywhere” service. Local hospitals are deemed sacrosanct. One thing frightens politicians more than placards demanding they save the NHS – constituents campaigning against closure of accident and emergency or maternity units.’ So what’s the FT’s solution? ‘For the health service to have any hope of sustaining standards in the face of shrinking resources, a radical reshaping of Britain’s hospitals is required. District hospitals built for another era will have to transfer some services to primary care facilities and others to regional centres of excellence and patients will sometimes have to travel further to secure the best treatment.’ Financial Times, 28 June 2011 Nearly every healthcare practitioner recognises that there is excess or redundant capacity in the system. But if you’re ever faced with the decision to try to deliver a hospital closure – as I was a few years ago – just count to 10 and wait and see what happens next. Radical change just doesn’t happen. You have to find a way to manage the politics. I’m pretty certain that GPs won’t want to be dragged anywhere near these. This means that what the DH is now advocating as an interim solution – which has all

september 2011 | practicebusiness.co.uk

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COMMISSIONING | news analysis

september 2011 | practicebusiness.co.uk

Slide 1 U.S. healthcare spending 1960 to 2007 % of GDP (gross domestic product) 16% in 2007

%GDP 16 14 12 10 8 6 4 5.2% in 1960 2 0

1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2007

Year Source: OECD Health Data 2009

Slide 2 Projected spending on health care under an assumption that excess cost growth continues at historical averages % of GDP (gross domestic product) 100 90 80 70 60 50 40

All other Health Care

30 Medicaid

20 10

Medicare

0 2007

2022

2037

2052

2067

2082

Source: Congressional Budget Office

Slide 3 Projected health spending: alternative real spending per person growth 20.0 18.0 16.0 14.0 12.0 % of GDP

the appearance of a private sector insolvency plan – might just have a chance to succeed. Existing services will be protected, subsidised by a special DH fund to protect a hospital’s financial position while it re-configures to the new operating format. This might just be the pragmatic solution that will accelerate the transition and one which will get buy-in from the local population and GPs. It may be worth the try. So with cover in place, GPs are then able to get onto the decommissioning agenda. Now, this is where we get to the bottom line. Politicians and bureaucrats will not close down redundant health care services or facilities. But effective commissioning could. What I’ve found from my time as a commissioner is that it’s extremely difficult to push through change without the evidence that is needed to justify decisions to the public. Success only comes by piling up robust, almost bomb-proof evidence. You’ll need to know all about costs – by patients, disease or condition, procedure, episode of care and care pathway. You will also be required to evidence quality, outcomes and mortality rates. All of this data is now much more freely available, so it is becoming easier to build the case. But, there is an easier way to shrink hospital activity. For only the second time in its history – fundholding was the first – GPs acting as commissioners are going to sit opposite their patients every day of the week. GPs will then have literally 300 million opportunities each year to work out whether the care plan they are about to determine for their patients can be delivered by the health care status quo or whether something needs to be changed. Last November I wrote a piece for Practice Business called ‘Power to the PM: how practice managers can play their part’. The point was that if you could find a way of reducing hospital referrals by one a week per practice, hospital activity across the country could be reduced by nearly 10%. This is because of the 20 million first outpatient appointments made by practices every year, nearly 30% are referred back to the GP immediately with no recommendation for hospital care. In the process, of course, a lot of money is spent on unnecessary, invasive and sometimes dangerous interventions. The Payment by Results (PBR) process puts huge pressures on hospitals to deliver as much care as possible to make the money to keep them viable. But if GPs determine that the services are unnecessary, poor quality, expensive or dangerous, that is when they will get re-designed and decommissioned. Pretty exciting stuff, eh? Let’s get started.

10.0 8.0 6.0 4.0 2.0 0

2010-11

2020-21

Central projection

2030-31

2040-41

2050-51

2060-61

Alternative projection (real spending per person growth of 3%)

Source: ‘Fiscal sustainability report’, Office for Budget Responsibility, July 2011

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CoMMISSIoNING | interview

Finding the path MICHELLE WEBSTER is a practice manager with such passion for commissioning that she’s even training her peers on the subject. JULIA DENNISON visits her at the busy Woodseats Medical Centre in Sheffield, where she’s been working for just over a year to help it become the best GP practice it can be

When I visit Michelle Webster (fourth from the left) at the Woodseats Medical Centre on the outskirts of Sheffield, she’s in the middle of giving the practice a makeover. One year into her role, she’s decided the surgery needs to have a bit more of a “corporate feel” that includes a new logo, staff uniforms and scarves to match. It’s all part of her grand plan to make the practice as prepared as possible for a future of commissioning, when the NHS’ microscope will be focused on primary care. Webster is not new to commissioning – on the contrary – she worked as national commissioning lead for the Improvement Foundation, until it ceased trading in February 2010, sat on the practice-based commissioning (PBC) steering group at the Department of Health and now spends her free time training practice managers on how to cope with the additional responsibility that commissioning brings with it. For her, commissioning starts at the practice and works its way up – it’s for this reason that she’s inspecting every detail to ensure it passes muster – even if it means upgrading the practice staff’s accessories. september 2011 | practicebusiness.co.uk

beTTer worKing prAcTice The improvements at her practice come at a time of change. Two new partners have come on board recently where others have retired. But Webster is wary of change for change’s sake, and is adamant that anything she adds to the practice will benefit the patients’ experience whether they like it or not. One example is a recently installed telephone triage system where GPs spend the first hour of their day screening their patients over the phone. This is not a telephone consultation, but a chance for the GPs to assess the nature and urgency of the call. If the patient is presenting with straight-forward symptoms for, say, a urinary tract infection, the GP can get a prescription ready for them without having to see them. This hasn’t been entirely popular with some patients since the decision to come in to see the doctor is taken out of their hands (90% of patients who call still actually see the GP that day) anyways. But Woodseats is doing it for the greater good of all its patients, as it will mean more people who need to see the GP will get to do so in a timely fashion, and the GPs have to stand firm, resisting the urge to give appointments to the patients

people | interview

practicebusiness.co.uk | september 2011

COMMISSIONING | interview

Fact box Practice: Woodseats Medical Centre Patients: Just under 9,000 PCT: Sheffield Commissioning group: Central Sheffield Consortium Partners: Six Clinical staff: 13 Practice manager: Michelle Webster

To me, if you have a pathfinder, it’s someone who is literally finding the way and carving out that path. But what’s happened is, everybody’s a pathfinder who shout the loudest. Of course, if it’s an elderly patient or one that has trouble using the telephone, an exception can be made – but these exceptions are not taken lightly. Also part of Webster’s grand efficiency plan is cleaning up the practice’s finances. She’s put pay freezes in place across the practice, much to the chagrin of all the staff. “This is about protecting ourselves so we can be sustainable in the future, this is not about just wanting to be mean,” she explains. “We’ve got to be smart and use every bit of money in the best way possible.” Other efficiency efforts include getting the GPs to wear headsets so they can type as they take calls; changing doctors’ shift patterns so appointments are spread more evenly throughout the day; training-up the healthcare assistant role so they hold more clinical responsibility; and holding a flu vaccine ‘blitz day’ where nearly half of the patients eligible for it queued up to receive their jab on one Saturday in October. Instead of giving patients the option of a few different days or making an appointment, Webster arranged for a letter to go out telling patients that the practice would be expecting them on a day dedicated to the jab. With over 600 vaccines being administered in one day, it resulted in the practice’s best flu vaccine uptake ever.

The bigger picture It’s this almost stubborn determination to run an efficient practice that keeps Webster one step ahead of many of her peers. “NHS resources are finite,” she says. “We can’t just keep adding on more and more september 2011 | practicebusiness.co.uk

Time in role: One year

appointments with more and more doctors. What I’ve got to do as a manager is make sure my doctors are able to take on the commissioning responsibilities.” And at Woodseats, the staff are very much looking forward to taking on these commissioning responsibilities, confident in the capabilities of their clinical commissioning group – Central Sheffield Consortium, a PBC group transformed into a pathfinder. “The service redesign that has happened as part of Central Sheffield Consortium has been fantastic,” confirms Webster, who points to the progress they’ve made in clinical fields like dermatology, urology, and gastroenterology, which she says is thanks to the high standard of clinical leadership within the group, particularly the CCG’s clinical steering group. She also sings the praises of the roving GP service that Central Sheffield commissions, which means that two GPs are at the disposal of the member practices as and when the extra resource is needed. However, Webster is wary of help from the PCT. “I have concerns that what they want to do is force us into a way of working that they dictate and they lead and they drive, and we’d almost be ‘allowed’ in,” she says. “If that happens, we’ll just be another PCT by a different name.” There are elements of the PCT’s role she’d like to keep ex-PCT staff doing, however, such as the administrative details of primary care, the skills for which, she admits, don’t necessarily lie within general practice. “It’s about letting these fledging groups of clinical commissioners manage what we can,” she explains.

Background: Michelle Webster started her career in primary care in 1989 and has worked in various roles, including as a practice manager and as national commissioning lead for the Improvement Foundation, until it ceased trading in February 2010. She returned to practice management when she took the job at Woodseats Medical Centre about a year ago and has also done some commissioning training for managers through Productive Primary Care.

practicebusiness.co.uk | september 2011

COMMISSIONING | interview

We’re welcoming the challenge of commissioning, but we’re scared too. In 20-odd months, we’ll be wondering for the first time, if we don’t get it right, will our business crumble? “And, we may not get it right straight off – we’re in a transition period.” This is where she chuckles at the term ‘pathfinder’: “To me, if you have a pathfinder, it’s someone who is literally finding the way and carving out that path. But what’s happened is, everybody’s a pathfinder!” To get the PCT to back off, for lack of a better phrase, Webster believes you need strong practice managers at CCG level. At Central Sheffield, the practice managers meet weekly to share their experiences under the prowess of lead manager Paul Wike. The lead managers then meet with the clinicians once a month. It’s this “culture of sharing”, as Webster calls it, that allows the CCG to determine what will be of most benefit for the member practices and their patients. “The GPs don’t look down on the managers, which is refreshing and very important,” says Webster, “because in the new environment of commissioning, you need good managers with lots of different skills.”

Come together, right now Working in primary care has changed significantly in the two decades Webster’s been in it, and it’s set to change even more. “Being a practice manager [earlier in my career] was the usual being a practice manager – which is jack of all trades: having to do accounts, payroll, HR, health and safety or change the odd toilet seat,” she remembers. “But it was very much about working for independent contractors – or your surgery – and never really looking out to other surgeries.” All this is changing drastically as we speak. “Now we have to share some of this responsibility – at least financially,” she says. “We’re welcoming the challenge [of commissioning], but we’re scared too. In 20-odd months, we’ll be wondering for the first time, if we don’t get it right, will our business crumble?” This is why it’s important for a certain amount of risk to be shared out among the CCG’s member practices – and further afield too. Part of this lies in determining where, within a CCG, different skills lie. “We can all test ourselves and when people really want to achieve something you test yourself honestly,” says Webster. Now is the one chance practices like Woodseats have to make their mark on Britain’s healthcare system. “We only want to do things that as the result of doing them, something gets better,” she adds. The key to this is being more efficient, and if you have to start somewhere, it’s at the practice and no one can crack the efficiency whip quite like a good practice manager. “There are things we can’t do anything about,” Webster adds lastly. “We can’t put more hours in the day.”

september 2011 | practicebusiness.co.uk

one to ones with the people who matter

people

Economy of scale

Charnock Health Primary Care Centre in Sheffield has joined a buying group to save money on medical supplies. Julia Dennison speaks to practice manager Julie Coakley to find out whether there is strength to be found in numbers

september 2011 | practicebusiness.co.uk

people | interview

Fact Box Practice: Charnock Health Primary Care Centre PCT: Sheffield Patients: 5,200 Commissioning group: Hallam and South Consortium (HASC) Practice manager: Julie Coakley Time in role: Six years

In these times of tightened belts, there is more pressure than ever on practice managers to save money on supplies and medical consumables. This, on top of a busy workload, can prove overwhelming at the best of times. Julie Coakley, practice manager at Charnock Health Primary Care Centre in Sheffield, is used to managing a busy schedule, maintaining an efficient workforce and is now embracing a new trend in primary care by joining a buying group that brings together other practices from the area to save time and money on procurement. Charnock Health is one of 18 practices in the new Sheffield Buying Group, set up in partnership with distributor Williams Medical Supplies. The group uses its size to source better deals on around 30 key products. Coakley first considered a buying group for the first time last year. “It was: ‘Right, anybody interested?’,” she remembers of the group’s formation. The practices local to Charnock, most of which form the Hallam and South Consortium (HASC) commissioning group, are lucky that they work well together. But it wasn’t totally smooth sailing when it came to getting everybody to commit to the group purchasing agreement. “Some people felt loyal to a local company, but I said whoever

wants to do it, do, and whoever doesn’t, don’t,” Coakley explains. “There are some practices outside of the Hallam and South group that thought it was a good idea and they’ve come onboard.” This flexible approach means that the practices that are onboard are committed and proves it’s not always necessary for a buying group to consist of all the practices in a single clinical commissioning group (a little over half of the practices within the HASC CCG opted into the scheme).

Background: Julie Coakley started working in general practice 20 years ago helping with data input in the early days of computers and worked up to become IT administrator. After nine years she went to work for the PCT, helping practices with their IT and formulating disease registers. She then became practice manager of Charnock Health Primary Care six years ago.

Saving time and money Being a member of a buying group saves Coakley and her team time – particularly the healthcare assistant who was often tasked with calling three or four companies to hunt down the best price on individual items. Now the HCA can spend more time with patients. “People don’t realise how much time it takes to order supplies and chase the best deals,” comments Coakley. “Many hours are spent on price comparison because we have to get the best deal we can, without compromising quality.” Now as part of a buying group, everything comes from the one place, with one invoice, and Coakley is confident of the quality of product coming in, which is important when

practicebusiness.co.uk | september 2011

people | interview

People don’t realise how much time it takes to order supplies and chase the best deals. Many hours are spent on price comparison because we have to get the best deal we can, without compromising quality

you’re dealing with particular clinicians. “If they don’t like the couch roll and they think it’s going to rip when the patient first sits on it, they’ll tell you about it,” she says. Product confidence becomes even more important when dealing with clinical supplies like speculums or tools for minor-operations. “You have to have the quality, as well as the quantity and best price in place,” Coakley underlines. “It’s imperative because it’s a false economy if not and in the end it comes down to quality.” For this practice manager, every little really does help. “I’m a thrifty practice manager because we’re not a big practice,” she says. She admits to sometimes having had to go to the local shops for cleaning products to see what was on offer. “Because you had to cut the budget – you couldn’t just buy it from a supplier who was charging you their margin on top of delivery.” This errand was usually done in her personal time too, to which she adds: “We do a lot for the love of it, us practice managers!” Coakley now outsources her practice’s cleaning service to an external company, which also provides the cleaning supplies, saving her money there too. “The companies are all needing to be competitive and are having to undercut the prices they had years ago to get the business,” she comments.

Benefits in kind The benefits of joining a buying group are becoming increasingly clear for members of the Sheffield Buying Group; because they are a large conglomerate, the prices are negotiated up front, with loyalty discounts on repeat orders, and the supplier will price match on many items too. “It is saving us money already, I know the prices we’re getting are good and I’m hoping to see significant savings within the next six months,” she adds. Other practice managers around the country seem to agree with the concept of a buying group, as more september 2011 | practicebusiness.co.uk

than a third of GP practices are expected to form similar federations by next year, according to Williams Medical Supplies, helping to meet tough government efficiency targets. The company predicts there to be 130 buying groups by the end of 2012. There are other buying groups already in existence around the country, but what makes an alliance like Sheffield Buying Group different is its member practices have made a commitment to consistently buy through the group and not just “dip in and out” as Coakley sees elsewhere. When asked whether it ever felt too binding, this practice manager is realistic: “You’ll always look for the best deal,” she says. “If something comes through the door then you’re going to look at it.” But in the end, she feels happy to commit to the set-up while it saves her money. “It’s only if you need something out of the ordinary, like a new couch, that you would start looking elsewhere, otherwise it’s easy to stick to using the buying group to order things we use month-in-month-out.” As part of the deal, Charnock Health is required to order products on a monthly basis, which takes getting used to. “Having to order monthly does mean the HCAs have to get the stock levels right, but once you’ve cracked that it’s brilliant,” says Coakley. “It’s just a learning curve – a rolling process. It is still early days but we are happy.” In the end, Coakley fully advocates the buying group model of procurement and would recommend it to others. She feels it also helps to strengthen the bonds between local practices as they move into commissioning. “Buying groups are the way forward,” she urges. “I’ve always said for years that we shouldn’t buy alone – there’s more leverage in numbers.”.

business intelligence and management sense for practice managers

management

The NHS’ heavy burden Could practice-led obesity clinics be a solution to Britain’s weight problem? Jonathan Hills takes a look

The 2009 Health Survey for England (HSE) shows that over 23% of adults over the age of 16 and 14.4% of children aged two to 10 are obese; a statistic that, according top current trends, is set to double by 2050. For the NHS, obesity poses a huge financial problem. The £4bn spent in treating those with obesity directly (diet pills, surgery etc.) is eclipsed by the staggering £16bn that is spent indirectly for treating obesity-related or exacerbated health conditions such as heart failure, liver disease, skin problems and most significantly, type 2 diabetes. The impact of this increase in type 2 diabetes upon local practices is significant, as sufferers require counselling sessions, lifestyle advice and regular medical checkups to monitor their health from their primary health authority. Research shows that over a 10 year period, people with a BMI over 30 are 80 times more likely to develop diabetes than those with a BMI under 22 and a report published by the NHS Information Centre in 2010 demonstrated an increase of diabetics in England from 3.3% in 2004/5 to 4.1% in 2009/10. Furthermore, the progressive nature of type 2 diabetes will exacerbate and eventually patients may require insulin medication from their practice. These medicines often cause weight-gain as a side-effect and are becoming more and more expensive: in 2009/10 the NHS spent nearly £650m on diabetes prescriptions, a rise of more than 40% over five years, including over 35.5 million items of prescription medication.

september 2011 | practicebusiness.co.uk

Professor Tony Leeds of Central Middlesex Hospital hopes to instigate a political movement that will look into the scope and prevalence of obesity as a social phenomenon, how to deal with weight management, and the impact of obesity upon other health conditions. “Obesity is a global problem and few countries have found a really effective solution,” he wrote for the BBC recently, asserting that many GPs or primary care staff do not currently have the specialist knowledge of how to deal with obesity and that medical practices must adjust their traditional relationship with patients who suffer from the condition. He calls for “a fully integrated national scheme providing surgery for those who need it – but adequate support for those who are not eligible”. Dietary and exercise advice, prescribing weight-loss medication (such as Orlistat), funding schemes (such as the ‘pound for pounds’ incentive) and paying for subscriptions to weight loss programmes are the main options currently available to practices to combat obesity. It is the latter of these options that has proved to be the most effective and is essentially what Professor Leeds wishes to integrate directly into local practices working for the NHS. “If a patient asks for help with their weight problem, most GPs have little to offer beyond conventional diet for the person who needs to shed 10-15lbs (4.5-6.8kg), or referral for surgery if there is a need to shed, say, more than five stone (31kg),” he explained.

management | obesity treatment

“For the 13 million Britons in the middle – who need to lose between 15lbs and five stones – most GPs are hard-pressed to help them.” It is within this group that obesity has become “epidemic”, according to Professor Leeds. He argues for the “basic training” of nurses, pharmacists and GPs so that each general practise will run an “obesity team” who are educated in dealing with weight problems. The drive to implement specially trained primary care workers aims to utilise the two most effective solutions to obesity currently available: bariatric surgery for those considered to be extremely obese and unable to loose weight and the utilisation of weight loss clinics (which have worked so well outside of the NHS via GP referral) for the vast majority of people who have the potential to lose the weight themselves but need structure and encouragement. These obesity teams are set to replicate the support and personal advice that independent and privatised weight loss schemes currently offer to the patient outside of the NHS, but often utilised by practices to great effect.

“Britain must face the facts,” states Professor Leeds. “While prevention is vital, we don’t have the luxury of anticipating some future dilemma. It is here, and now; the immediate challenge is to help those whose health is already directly threatened.” The means by which the Professor’s proposal can be integrated into the current changes to the NHS seem quite fitting – new autonomy given to GPs and practice managers would certainly allow them to cater their practice according to the prevalence of obesity within their patients. However, there is hesitation of introducing such a scheme when budget cuts within the NHS are so rife and unrelenting, and the decision will have to be made about whether this is the time for such a vast overhaul of the treatment of obesity within the NHS. Either way, the issue of obesity and related health problems is a growing problem and the question is no longer whether practices should be utilised to combat the issue but rather how and when are these measures to be implemented.

 23% of people over 16 are obese in England  There are one billion overweight adults in the world. Some 300 million are obese  People with a BMI over 30 are 80 times more likely to develop diabetes than those with a BMI under 22  1,010,000 – The number of morbidly obese people in England  10% of six-year-olds are clinically obese, three times more than 20 years ago  £7,000 – the cost of a gastric band operation under private care in the UK.

script file

A hassle-free repeat service “The mail order service is useful for patients – and also helps to reduce the number of last-minute requests we receive”

Commy Roffey Practice manager, Pond Tail Surgery

delivering health

A busy village practice in Surrey has introduced an NHS mail order prescription service to give wider choice for patients who need repeat scripts. Pond Tail Surgery in Godstone serves 7,200 patients and is working with the UK’s leading mail order pharmacy, Pharmacy2U, to provide patients with an alternative way to order and receive their regular medications. The service allows patients to order their prescription by telephone or online. The request is then sent electronically to the practice and once the script has been approved, the medication is issued directly to the patient, either at home or work. More choice for patients The practice already offered patients the option to drop off or post their repeat requests to the surgery or order online.

Practice manager Commy Roffey comments: “The mail order service provides another option for patients, and is particularly useful for elderly patients and people who work during the day and find it difficult to visit the surgery or collect their medication from the village pharmacy. “Pharmacy2U are a really helpful team and worked closely with us to implement the system. It’s hassle-free and the electronic requests are easy to process.” Patients using the service are also offered a reminder service, so they don’t forget to order their prescriptions. Commy adds: “It’s helped to reduce the number of last-minute requests we receive, by reminding patients before their medication runs out.” The service is free to patients and practices and has been introduced by more than 300 GP surgeries. www.pharmacy2u.co.uk/practice

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management | websites

Catching the web Steve Dunn explains why effective website design is better for patients and practices

More than two thirds of the UK uses the internet and, for a significant majority, it is now the first port of call when searching for information. Busy practice managers often find there aren’t enough hours in the day, and demands on time will only increase under the government’s proposed changes to primary care provision. Those who embrace technology by creating a website will improve patient access to information – it is a permanent resource available to patients at their own pace, 24 hours a day, seven days a week. This empowers them and helps them feel more informed and confident in the practice. Patients can use websites to book appointments, order repeat prescriptions and find links to other useful NHS information. A website can also seriously reduce the time and energy staff spend dealing with routine, informationbased enquiries from patients throughout the day. It is effectively a public bulletin board and is easily updated. This is especially useful when practices need to communicate with busy patients, such as when a new, seasonal or specialist service is offered like flu jabs or travel vaccines, which are not offered everywhere. The government is calling on practices to encourage patients to engage more actively with their GP surgery, and websites will have a significant role to play. Patients can get the chance to give feedback with questions or concerns on their needs. What is more, they expect their practices to have a website. Conversations I’ve had with practices across the UK have only confirmed that a website is a very important tool. One example is the James Street Family Practice in Louth, Lincolnshire, which has fully embraced the internet. Positive feedback from their patient participation group shows patients find the practice website useful and easy to navigate.

A website can also seriously reduce the time and energy staff spend dealing with routine, information-based enquiries from patients throughout the day The design of the site focuses on simple, clean layouts that guide patients to the information they are looking for quickly and easily. Important information such as contact details, surgery times and out-of-hours arrangements are the key focus of the home page, which is designed to flag essential information patients may need in an emergency. Elsewhere on the website, patients can book appointments and order repeat prescriptions online via links to the practice’s clinical system. There is an overview of services provided at the practice, together with an introduction to the practice team and a library listing links to useful healthcare websites. Practice manager Jackie Rotherham said: “We use our website to showcase the practice and provide useful information to patients.” She also sang the praises of having a website with a flexible template, which allows her to build more pages when she wants to add content. “We are always looking for opportunities to promote healthcare information to patients and in this day and age being able to do this online is essential,” she added. Using website developers that offer adequate technical support is also important to Rotherham. She said: “Good support is crucial in today’s manic world.” Steve Dunn is the CEO of Williams Medical Supplies practicebusiness.co.uk | september 2011

management | legal

Howdy, partner? Oliver Pool, considers some of the issues that should be taken into account when a practice manager considers partnership Why become a partner? For the practice manager, motivation might well be the prospect of earning more money – although a properly crafted ‘bonus’ under an employment contract can often achieve the same outcome. Achieving the ‘status’ of partner may be thought to be important – appearing on the firm’s notepaper (and on the NHS website) may look good, but, such considerations have to be balanced against the commercial risk and liability that comes with being held out as a partner. From the GP practice’s point of view, with the drive to ‘commercialisation’, a ‘business’ partner may well be incentivised to manage the business more effectively, if they are sharing in the resulting increased profit. It may well be particularly appropriate if there is a major project, e.g. a surgery development in which the PM can participate.

Technical considerations Under GMS regulations, a PM can become a partner, and a signatory to the GMS contract, as long as there is at least one other partner who is a general medical practitioner. The practice, which has a non-registered medical practitioner, cannot sue, as a firm, for unpaid fees (e.g. for private non-NHS services) and, in that unfortunate event, an individual GP would have to take the appropriate action. Any PM should be aware, of course, that by becoming a partner they assume joint and several liability, alongside the GPs, for all risks and liabilities of the partnership business, including liability for claims for professional negligence. The PM should, therefore, make sure appropriate insurance cover is in place.

Legal update sponsored by Veale Wasbrough Vizards Oliver Pool is an associate at Veale Wasbrough Vizards specialising in GP partnership agreements. He can be contacted on 0117 314 5429 or at opool@vwv.co.uk.

As far as the practice is concerned, they should be aware that by making a PM a partner, they are conferring presumed authority on the PM to bind the practice for all liabilities incurred in the ordinary course of the business.

Loss of statutory rights A PM should be aware that, by becoming a partner, they automatically cease to have the many employment protection rights, and benefits, that go with employed status. While the normal anti-discrimination legislation generally applies to partnerships, rights not to be unfairly, or constructively, dismissed will not be applicable, nor the statutory rights to maternity, or adoption, leave, which should normally be replaced by appropriate provisions in the partnership agreement.

Partnership agreement issues Other amendments will be needed to the partnership agreement, e.g. the GP partners should indemnify the PM against any clinical negligence claims, and perhaps in strictly clinical matters, the PM should not have the same right to vote.

Salaried or fixed share? We would generally advise a PM not to take on either of these types of arrangement, unless as a prelude to a full equity (i.e. profit sharing) partnership. Even then, the PM should consider obtaining a release from principal creditors of the practice (e.g. a bank or a landlord) making it clear that the PM, although held out as a partner, is not responsible for those liabilities.

management | qof

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

Depression

Depression remains one of the most common presenting problems in general practice and there have been some changes made to the depression requirements in the 2011-2012 QOF revisions. Dr Paul Lambden explains what they are

You don’t function anymore. You shut down.You feel like you are in a void september 2011 | practicebusiness.co.uk

Sometimes it seems as though the whole world is depressed. With all the modern pressures of living we probably all have periods where we feel depressed, sad or miserable. Such feelings, though, tend to be short-lived and are part of the normal mood swings of life. Sometimes, however, the symptoms become more intrusive on daily living and are persistent or recurrent in nature. This is often a feature of depression in the medical sense of the term. There are a host of symptoms that may indicate clinical depression and these include feelings of negativity and fear, loss of emotions, restlessness, agitation or irritability, insomnia and early morning wakening, lack of energy, forgetfulness, repeated tearfulness, loss of concentration, difficulty in making decisions, despair, helplessness, loss of interest in sex and excessive guilt. In its most severe forms patients may feel suicidal or give up the will to live. Five per cent of patients are chronically depressed and one patient in five becomes depressed at some period in their lives. Depression is often accompanied by anxiety, which interferes with concentration, relaxation and sleep and which may present with headaches, dizziness and generalised aching. The aetiology of depression is complex. There appear to be a variety of causative or precipitating factors. It may be triggered by fear, by previous unpleasant experiences or as part of a grief reaction. It can also be induced by various types of medication and particularly by illicit drugs. Often there is no obvious cause for the depressive feelings. In general it does not appear to have any sort of clear-cut genetic background. The result, however, is a disturbance of one or more of the chemical transmitters in the brain (simple chemicals which transmit electrical messages between nerve cells). Depression was formerly classified into reactive (resulting from depressive life events) and endogenous (where the depression was not obviously associated with any specific event(s). Modern psychiatry recognises some specific types of depression including postnatal depression (occurring up to two years following giving birth), bipolar disorder (formerly called manic depression and associated with major mood swings between depression and high excitement) and seasonal affective disorder (which occurs during the winter months and which appears to be associated with insufficient exposure to light). There are a range of treatments for depression, which vary in efficacy and speed of effect depending on the individual, the degree of severity and any precipitating or persisting causes. NICE suggests that antidepressants are not suitable for mild depression because of the possible drug side effects. Suggested treatments include self-help techniques and a variety of approaches which involve patient engagement, such as cognitive behavioural therapy (CBT), various types of psychotherapy and what some have described as distraction therapies such as exercise and activities to occupy the patient. Problem solving sessions can help patients rationalise and break down what seem to be insurmountable problems and can change any negative attitudes that affect behaviour. Self-help enables patients to take control of their own problems and psychotherapy may help resolve relational difficulties. For many patients, however, antidepressant drugs are valuable and effective. They act on the brain’s chemical messengers to alleviate the mood swings. The

drugs take 10-14 days to start to work and, in cases where they are effective, patients are advised to continue to take them for 12 months to reduce the risk of recurrence. Commonly used drugs such as citalopram and fluoxetine may have side effects but probably less than the older tricyclic antidepressants such as amitriptyline. In severe cases of depression or where suicide is considered a significant risk, admission may be necessary. For less serious cases, support may be obtained through the community mental health team. In the 2011-2012 QOF revisions, changes have been made to the depression requirements. DEP2 has changed to DEP4. Patients with a new diagnosis of depression (between the preceding 1 April and 31 March) should have an assessment of severity using a validated tool. It has been reduced to up to 17 points with a threshold of between 40-90%. DEP3 has been changed to DEP5 and requires a further assessment using the validated tool between 4 and 12 weeks after the initial assessment. It has been reduced to a maximum of eight points with a threshold of 40-80%. Depression remains one of the most common presenting problems in general practice. Care should be taken only to code ‘depression’ when there is supporting evidence for the diagnosis and other cases should be coded as ‘depressed mood’ to avoid inclusion in the register. In its severe form it may be truly awful, as Marie Osmond described it: “You don’t function anymore. You shut down. You feel like you are in a void.” But there is help and success rates are improving.

work/life

Timing is everything

advice for busy lives

Improving your time management to be ready for commissioning is essential. ALLIE ANDERSON outlines simple steps you can take

september 2011 | practicebusiness.co.uk

Effective time management is essential to be successful in any career. The difference when working in a healthcare setting is that poor time management can impact not only on the working day, with the associated knock-on effect to the remaining workload and important tasks that are stacking up, but it can also affect the standard of patient care. As clinically-led commissioning and Care Quality Commission (CQC) legislation begin to make their impact felt ever more heavily on general practice, managers will see their workloads and demands on their already precious time increase dramatically. Never has the issue of efficient time management been more pressing for practice managers. The best managers can list time management as a crucial skill, which in turn is underpinned by excellent organisational skills and tends to go hand in hand with high levels of motivation – something that is arguably more important to good time management than tangible methods and processes, and addressing a lack of motivation is the most significant barrier to overcome. Becoming more efficient is best accomplished when you have a reason to do so. Setting long-term goals is the best place to start, and, if you are really passionate about them, they can in turn stimulate your motivation levels. Think about what you really want to achieve in your professional life – though for many, goals might be related to impending deadlines rather than reaching personal achievements. Either way, once established, break the long-term goals down into

work/life | time management

shorter term aims that will help to achieve the wider objective. Crucially, having your goals written down where you can clearly see them every day will help to maintain your focus. Once you have pinned down your objectives and set yourself interim (daily, weekly or monthly) targets, the most important thing is to stick to the time you have set aside to dedicate to each task. Barring emergencies that require urgent attention, be sure to protect the time you have penned in for fulfilling something on your to-do list and don’t allow yourself to be distracted. For many people, successfully managing their time relies on also managing other people’s expectations; if you find yourself devoting too many precious hours to the problems and demands of others, making them aware of your time limitations might help. Be mindful, of course, that when dealing with patients it is important not to make them feel rushed or as if they are a nuisance. If you don’t have time to deal with a patient’s queries or concerns, have a colleague handle them promptly rather than risk the patient being given the impression that they are a burden on your valuable time. Delegating is another skill closely allied to solid management, but it is important not to overload other staff for the sake of freeing up your own time, especially when jobs you’re passing on to someone else fall outside their capabilities and expertise. However, the everyday chores that eat into management time can often be given over to a member of the support team, many of whom will be happy for the opportunity to step up and be challenged. An option more and more managers are exploring is automation within the practice. There are a plethora of providers with different packages on offer that claim to ease the strain on time by streamlining processes that although essential in maintaining a smooth-running service, use up valuable resources. Basic solutions, such as document management software to simplify the processing, electronic filing and subsequent work pathway of incoming correspondence, have the potential to free up vital cashflow as well as administrators’ time. An example is The Falmouth Health Centre Practice, which saves an estimated £13,000 per year through processing 100 hard copy letters a day using automated document management. Elsewhere, The Appletree Medical Practice in Derbyshire reaped the benefits of upgrading to digital dictation equipment, the new system slashing 71.5 hours – more than eight working days – a month from the time taken to process routine patient information.

Motivation is more important to good time management than tangible processes and lack of motivation is the most significant barrier to overcome More advanced and sophisticated automated systems can even take care of health and safety, risk assessment and HR under the watchful eye and management of the PM, who is then freed up to focus on pressing issues that will no doubt continue to build up in the run up to clinically-led commissioning and CQC registration. As daunting a task as it may seem, organising yourself for the long-term purpose of better managing your time is one well worth getting a handle on.

Top ten tips for better time management   

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Don’t underestimate the time it takes to complete a task – double your initial estimate. Do one thing at a time and learn to say ‘no’. Learn to delegate and don’t be precious about completing tasks yourself – while some things can only be actioned by you, your support team is probably more than capable of shouldering some of the load. Don’t put off unpleasant or difficult tasks – set a timetable to complete them and get them over with as soon as you can. If you find yourself getting interrupted a lot, make appointments for people and set aside blocks of time where you will not be interrupted. Include telephone-free time as well – but make sure you also make time to return calls and check messages. Avoid getting bogged down in conversation – keep things short and to the point and learn how to end meetings without being rude. Open correspondence first thing and set aside time to action them. Banish unnecessary letters and mail by removing the practice from mailing lists – don’t be afraid to instantly bin or shred anything you don’t need. Always keep on top of filing. Putting documents in their appropriate places as and when they come in/ have been dealt with saves endless time later when papers have piled up. Make the most of any time spent commuting by train or bus and look for any other blocks of ‘dead time’ during your working week that you could utilise. practicebusiness.co.uk | september 2011

Work/life | diary

Practice diary Sam Clark Sam Clark sits on the Practice Management Network steering group and is practice manager at East Barnwell Health Centre in Cambridge.

If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk. For further information on access aware, including booking places on a session, contact Phil Ambler on phil.ambler@rnib.org.uk.

september 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: Sam Clark asks: Are you access aware? As a member of the Practice Management Network (PMN) steering group, I was recently approached to attend a session of sensory and learning disability access awareness – which I did and which really got me thinking: Just how much are we, as practices, access aware? Do we really know who has access issues and who these patients are? Almost two million people in the UK are living with sight loss, but only 370,000 are registered as blind or partially sighted. So while we may be aware of patients who are registered, what about those who are not? Can we begin to imagine what sight loss feels like when navigating round a practice? Have we all ‘walked the patient pathway’? And what about patients with hearing loss – do we know all these patients? Is it noted in their records that they have a hearing impairment? What are we doing to support these patients? Do communication methods in the surgery include effective processes for severe or profoundly deaf patients? There are 1.5 million people with a learning disability in the UK – a learning disability is life-long and usually has a significant impact on a person’s life. People with learning disabilities find it harder than others to learn, understand and communicate and have differing levels of need. Do we see the person and not the disability? What different levels of support do we offer? Can we all put our hands up and say: “Yep, we’ve done everything we can and understand the

needs of all of our patients.” Or is that a never-ending task? What can we do to ensure we are doing as much as is feasible? The session I attended proved to be a real eye-opener for me. Emphasis was placed on the importance of working closer with the voluntary sector to ensure all patients receive the best quality of service possible, with practical resources for practice teams. These two-hour, free sessions are now being offered across the country, starting this month, aimed at increasing the equality of access, to focus practice teams on the relevant issues of accessibility for patients with sensory and learning disabilities, to get to grips with and to promote active involvement in the development of access and communication with GP practices. This initiative is being led by the UK Vision Strategy and the PMN, in conjunction with leading charities. It’s also supported by an online tool equipped with a wealth of useful resources to signpost practice staff to further information. This online tool hosts specific patient questionnaires to assess practice accessibility which may be used to contribute to the patient participation directed enhanced service – and we could all do with a little help with that particular DES, couldn’t we? I would urge practices to attend these sessions (see side bar for details on booking), but if you can’t make it, put your thinking hats on, walk the patient pathway, make use of the resources available, liaise with stakeholder charities, and help your team become access aware.

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