Commissioning Success Sept 12

Supporting excellence in healthcare

sept/oct 2012

Prescribing optimisation Why ‘medicines optimisation’ is now the name of the game

Get engaged

When patients become customers

Sharing the load

Specialising through integrated care

commissioningsuccess.com

Editor’s letter

CONTENTS COMMISSIONING UPDATE

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he whole point of putting clinicians into the driving seat under the commissioning agenda is to ensure that no decision about a patient is made without a patient. So it’s disconcerting to hear that the NHS Alliance is having to remind the Government to reinvigorate their commitment to their favourite mantra.

Patients need a dose of reminding as well, because with all the bad press the changes to the NHS have been getting, patients are left not very much the wiser, and since they are, as Roger Hymas says on p12, essentially customers, it’s important to get them on board.

Shared decision making sits at the heart of commissioning, and runs through as a theme to this issue. On p8 we look at the area of medicines management, which, as Richard Seal, programme consultant in medicines management for NHS West Midlands, points out should be called “medicines optimisation”. He believes that, much like a consultation, medicines are often left to the last minute in the commissioning agenda, and he is adamant that this should change. Managing medications in the right way could be a godsend to saving money and improving patient care. A lot of it comes down, quite simply, to communication. Although doctors are prescribing, pharmacists dispensing, there is little guarantee patients in the community are taking the medications – and this can result in the exorbitant amount of wasted money.

We also interview the clinical director at The Practice, which is running an ophthalmology service at a surgery in Croydon that seeks to bring services like cataract surgery into the community and closer to patients. This is particularly welcomed in the case of ailments like cataracts, which can be so debilitating if left untreated.

As long as commissioners continue to keep the patient at the heart of everything they do, it’s unlikely they can go wrong – albeit they don’t break the budget.

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News and updates The latest news, comments and views on clinical commissioning

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NHS Confederation Conference A rundown of hits and highlights from the NHS Confederation annual conference

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‘Medicines management’: old news The buzz phrase is now ‘medicines optimisation’. We look at why it’s essential

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Get engaged: patients as customers Speak up! Your customers (read patients) need engaging now more than ever COMMISSIONING IN ACTION

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The collaborators Clinical commissioning groups in the southwest find strength in numbers

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Vision in the community The Practice opens a new cataract service in Croydon – closer to patients’ homes COMMUNITY CARE

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Sharing the load CCGs that have opted to specialise specific practices within their group

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Rest and recuperation We look at ways patients are recovering in the community INFORMATION AND TECHNOLOGY

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Digital outreach Reaching out to patients – from social networking to surveying MANAGING COMMISSIONING

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Softly softly approach Is the ‘soft’ skills approach necessary for successful healthcare commissioning

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Top tips Managing diabetes – ways you can help put a curb on the healthcare crisis

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Commissioning Success is published by Intelligent Media Solutions Suite 223, Business Design Centre 52 Upper Street, London, N1 0QH tel 020 7288 6833 fax 020 7288 6834 email info@intelligentmedia.co.uk web www.intelligentmedia.co.uk web www.commissioningsuccess.com Printed in the UK by Buxton Press www.buxtonpress.co.uk

Update news

NeWS gP practices Commissioning Board: KeY direCtors aPPointed want to be The two operations directors of the NHS Commissioning Board Authority’s national leadership team have been named.

Ann Sutton, currently chief executive of Kent and Medway PCT cluster, has been made director of NHS commissioning (corporate) and will be responsible for devising and overseeing the national framework for the NHS Commissioning Board’s direct commissioning responsibilities,. including specialised services, primary care, public health, healthcare for military personnel and their families and for offenders.

While Lyn Simpson, currently NHS director of operations in the Department of Health, has been appointed director of NHS operations and delivery (corporate) responsible for NHS planning and performance, assurance of delivery by CCGs and national lead for NHS emergency preparedness, resilience and response.

Ian Dalton, chief operating officer and deputy chief executive of the NHS Commissioning Board Authority, commented: “These two posts will provide the strategic leadership and oversight to ensure that we have a strong, innovative and patientfocused commissioning system that improves outcomes, tackles inequalities and supports the NHS in England to be the best it can be.”

FIRST LOCAL AREA TEAM DIRECTORS The first round of appointments to the 25 local area team director posts has also been made as follows: North • cheshire, warrington and wirral: Moira Dumma • merseyside: Clare Duggan • greater manchester: Mike Burrows

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• south yorkshire and bassetlaw: Andy Buck • north yorkshire and humber: Chris Long • durham, darlington and Tees: Cameron Ward.

Midlands and East • essex: Andrew Pike • hertfordshire and the south midlands: Jane Halpin • leicestershire and lincolnshire: David Sharp • derbyshire and nottinghamshire: Derek Bray • shropshire and staffordshire: Graham Urwin • birmingham and the black country: Wendy Saviour.

• London • london: Simon Weldon South of England • surrey and sussex: Amanda Fadero • wessex: Debbie Fleming • devon, cornwall and isles of scilly: Ann James.

BIT OF BACKGROUND There will be 27 local area teams with staff working from a number of office bases across their geographical area. All local area teams will have the same core functions around CCG development and assurance, emergency planning, resilience and response, quality and safety, configuration, system oversight and partnerships and stakeholder engagement, with the senior leadership of the local area team participating as a full partner on health and wellbeing boards.

more involved

A Family Doctor Association survey of 100 commissioning GPs showed that GPs want to be consulted at every stage of commissioning in a genuine two-way dialogue with CCGs. The study also found there to be a wish for democracy and genuine representation of practices and protected time for doctors to increase their involvement.

Over 50% of GPs questioned felt able to influence their CCG’s decision making, but one in eight (13%) felt unable to do so and felt disempowered.

There was also a clear desire for a fresh start. National chairman Dr Peter Swinyard said: ”The message to CCGs is clear. Talk with your member practices and listen to them.”

Poor hospital data threatens commissioning Hospitals in England are not supplying accurate patient data to the wider NHS, which could undermine GP commissioning, a report published by the NHS Information Centre claims.

The report found that up to a fifth of data returns by hospitals and councils contained errors in patient records and cited the ‘reorganisation and reconfiguration of services’ as a factor leading to poor returns.

On average, hospital trusts made errors in seven per cent of all data submissions, likely to have affected millions of patients’ data.

Update news

local news

clinical corner

Clinical engagement drives major savings at Essex trust

Significant savings were made at Mid Essex Hospital Services NHS Trust by clinical and non-clinical teams working together to reduce procurement costs in the areas of reconstructive and trauma orthopaedics.

Over £300,000 was saved in three months on hip products alone, with the final savings across all categories, including upper and lower limb, trauma and pulse lavage, forecast to be £500,000, representing a 28% saving.

A cross-functional commercial and clinical team was formed that reported directly to the clinical director, CFO and COO. Bill Martin, consultant orthopaedic surgeon and lead clinician on the procurement project, said: “The initial worry that financial pressures would lead us towards accepting substandard implants or major inventory changes has not been borne out, and it was reassuring to be involved in the process as a surgeon.”

The work is part of a wider programme of procurement cost reduction, led by procurement consultancy Inverto.

UK MD Richard McIntosh said: “The results clearly demonstrate the power of clinical engagement and what can be achieved when you combine specialist procurement expertise, clinical and commercial expertise and the backing of the trust board.”

National award for NHS Nottingham City CCG

Macclesfield GPs receive faster A&E updates

NHS Nottingham City Clinical Commissioning Group (CCG) was named BMJ Clinical Commissioning Team of the Year.

Dame Barbara Hakin, national MD of commissioning development at the Department of Health, sat on the awards panel and said of the judging process: “We, as judges, were unanimous in our decision that the winners should be Nottingham City. They showed strong leadership, great organisational development and were really looking at an enormous number of areas where they could effect change. But most of all, what stood out for us was that they were already making changes and delivering better outcomes.”

East Cheshire NHS Trust’s A&E department can now collate and send clinical patient information to GPs electronically for all patients that attend the department.

This development complements the eDischarge Notification Forms (eDNF) to GPs – a system that has helped them achieve an 84% compliance for meeting the NHS 24-hour communications delivery target.

Patient information is input into Extramed (the operational management and coding system for all A&E attendances) this automatically generates a discharge letter, which is then stored and delivered electronically to GP practices across Cheshire, streamlined by Medisec Trust eDelivery software.

Customer service delivery manager Debi Lees said: “Patients visiting their surgery after being discharged from our A&E Department the previous day can now rest assured their GP will be fully up-to-speed with their condition and any emergency treatment they may have received. This marks another significant step in our continuing drive to improve patient care.”

Trusts denying treatment are breaking the law

Patients who are denied approved drugs by their local health trust should take legal action, Sir Michael Rawlins, chair of the National Institute for Clinical Excellence (NICE) wrote in the HSJ. He said “numerous trusts” were unlawfully denying patients drugs approved by NICE or were employing “delaying tactics” to save money and that this should not be tolerated.

He gave the example of patients with retinal vein occlusion who would benefit from dexamethasone intravitreal implants, but many trusts have been refusing the treatment for financial reasons.

There is also sometimes dispute between the PCTs and hospitals on who should pay for the treatment – often at the expense of the patient’s sight.

Sir Michael called on campaign groups like RNIB to seek judicial overview to ensure rightful provision of the treatment. He also called on clinicians to “whistle-blow” on trusts failing to provide the drugs and treatments patients are legally entitled to.

DIARY 16-17 October Four Nations, One Challenge – Improving Patient Outcomes Manchester Central FMLMconference.com

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sept/oct 2012 | 05

UPDATE NHS CONFEDERATION CONFERENCE

Nicholson pulls no punches This year’s NHS Confederation Conference tackled the major issues affecting the NHS. Sir David Nicholson took to the stage on day two and set the world to rights. GEORGE CAREY reports

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s usual there was plenty to take in over Lansley had addressed the conference the day before and the three days of the NHS Confederation had clashed with Stephen Dorrell, the Conservative chair of the Conference last June, with an impressive range Commons’s Health Select Committee and himself a former health of expertise on offer discussing a wide range secretary, over the issue of hospital closures. While Lansley argued of topics. But it was NHS chief executive Sir that ministers should stand back from debate and decisions over David Nicholson who stole the show as he changes to services, which were a local matter, Dorrell called on offered a fascinating insight into life under the coalition and his them to take a lead. plans moving forward.

Nicholson was in agreement with Dorrell on this issue and In an extraordinarily candid address, Nicholson confessed joined him in citing a speech in 1961 by Enoch Powell, then he had been incredulous when Lansley first outlined his plans health minister, in which he proposed the wholesale closure of for the structural NHS shake-up now long-stay mental hospitals. Referring to being implemented. He spoke of his fury Powell’s speech, Nicholson said: “In lots “I felt angry every time the at ministers’ repeated criticism of public Government came in, starting of ways, it’s the sort of speech we need sector management: “I felt angry every our national politicians to make at the to denigrate and criticise time the Government came in, starting to moment. It’s being honest with the public public sector leaders” denigrate and criticise public sector leaders about the nature and scale of change that’s – people like ourselves who have spent our required in order to live in a world where whole lives trying to improve public services.” we have great outcomes for patients, universally available, but Nicholson told the audience that the NHS reorganisation had within the resources that we have.” felt like going through a bereavement. He had shared their feelings of He urged NHS leaders to have confidence in their ability denial, anger and depression before moving on to acceptance of the to make the new system work, based on what they’d already inevitability of the upheaval taking effect next year. On the subject achieved, saying: “In my 35 years in the NHS, I have never known of Lansley informing him of the plans, he said: “My immediate a time like it. Thank you for your hard work, it’s been genuinely response was that they couldn’t possibly be wanting to do that.” remarkable.”

SEPT/OCT 2012 | 07

Update Medicines ManageMent

Medicines management is old news. The phrase of the day is ‘medicines optimisation’. But what does this change of wording mean for CCGs and how they incorporate prescribing into their plans? JULIA DENNISON finds out

The opt mal dose

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he phrase ‘medicines management’ is one many general practitioners and their commissioning partners will have heard, but what does it actually mean? NHS Local puts it simply as ‘enabling people to make the best possible use of their medicines’, while the National Prescribing Centre describes it slightly more opaquely as ‘a system of processes and behaviours that determines how medicines are used’.

Whichever definition you prefer, the main crux of the philosophy is ensuring the population gets the best outcomes from the medications it’s prescribed for the lowest cost. With the Nicholson Challenge hanging like the sword of Damocles over commissioners’ boardroom tables, cost-saving of any kind is very much top of the agenda. When prescribing and the management of drugs accounts for 12% of the overall NHS budget, the King’s Fund is right to highlight the area for potential efficiencies. Without excessive bureaucracy holding them back, CCGs have the power to implement these quickly.

Medicines management is about more than just medicines. Shailen Rao, MD of medicines management firm Soar Beyond, believes that many areas that CCGs will be trying to tackle – such as long-term conditions and hospital admissions – can

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be directly impacted by medicines. “They’re a very integral part of the pathway,” he says. “If you look at pathway and service redesign, you have to consider the medicines aspect.” Historically, medicines have sometimes sat in a different budget category to that of, say, long-term conditions, and Rao hopes with the umbrella of commissioning there will be the opportunity to bring them together. eDUCating the Masses Two major areas to address first on the path to better value medicines is prescribing errors and patient adherence. It is estimated that £100m a year could be saved from patients taking medicine correctly, while £40m could be retained by reducing errors in prescriptions. Throughout the country PCTs have been working hard to reduce excessive prescribing costs, and this will now fall onto the lap of the CCG boards.

As part of its recent focus on medicines management, NHS West Midlands made a list of priorities. It included reducing the number of people being admitted to hospital due to problems with their medicines; improving medication safety by reducing the number of medication errors and, lastly, echoing the National Prescribing Centre’s definition of medicines management, supporting people to make

Update Medicines management

the best possible use of their medicines through shared decision-making and better patient education.

Programme consultant in medicines management at NHS West Midlands, Richard Seal, believes it is this active support for patients that will really make the difference. He highlights the importance of speaking to patients about the medications they take and ensuring it’s not just a last minute add-on to end a consultation. Up to 50% of prescription medicines are not taken as directed and around 20% are thought to be never taken at all. In his experience, the more patients understand how a medication will benefit them, the more likely they are to take that medication in the long-term.

“Medicines management has become really a population-based bean-counting exercise, though that wasn’t its intent; whereas optimising medicines is more about the individual and the outcome” Of course, these are just estimated percentages, as it is often difficult to track the true numbers.

Why this happens often comes down to two factors: intentional and unintentional non-compliance.

Reasons for not wanting to take medications can be attributed to anything from cultural preference to hearsay or taking the wrong advice. Meanwhile, unintentional non-compliance can derive from forgetting to take it to side effects standing in the way. Both types of non-compliance can be somewhat rectified through better communication and information at the point of consultation, but wider education at a locality level can only be of further benefit.

Management v. optimisation In our conversation, Seal introduced me to the phrase “medicines optimisation”. The slight change in wording belies the significant change in culture that he believes needs to occur throughout the health professions as we move into the commissioning landscape. Rather than thinking reactively about the management of medications, commissioners should be thinking proactively about optimising their use to improve patient outcomes as well as reduce spend on conditions in the long-term. Using the right medications in the right way could hold the answer to many of our financial woes. “In philosophy, the shift is to making it more outcomes driven

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and patient-centred,” Rao explains of the difference.

“Medicines management has become really a population-based bean-counting exercise, though that wasn’t its intent, whereas optimising medicines is more about the individual and the outcome.”

‘Optimisation’, he believes, gives commissioners more freedom to find the right solutions for different patients and take a more bespoke approach to their care.

Partnership working It is important that CCGs take as much support as they can when managing medicines. Pharmacists, for example, play an important role with medicines reconciliation – where they check and amend errors in the clinician’s prescription – and act as an important safety net in the prescribing process.

By working closer with pharmacists, hospitals, patients and even pharmaceutical companies where appropriate, GPs and commissioners will come that much closer to optimising the medicines.

Raymond Lee, chairman of Central Lancashire’s Local Pharmaceutical Committee, says it makes sense to include community pharmacy at the earliest opportunity when considering care pathways. “There are nationally commissioned services such as the New Medicine Service (NMS) and Medicine Use Reviews (MURs),” he explains. “By joining these services to the care pathways, it reinforces the messages of taking medication appropriately and helps to promote healthy lifestyle interventions such as smoking cessation, alcohol awareness and weight management.”

Putting clinicians in the driving seat looks to prove favourable for medicines management. It is now up to the CCGs to take the opportunity, see the medicines budget as the investment it should be and ensure patients have the right tools to treat their conditions responsibility and sustainably. “In order to achieve the level of cost savings that CCGs need to deliver, a whole systems approach is required,” concludes Lee. “Adopting previous QIPP savings will simply not be enough. Having an integrated care pathway approach whereby all clinicians have input and are able to work together, particularly at the interface between services is where the real savings can be realised. Clinicians need to have the moral courage that services may be better served by utilising the skills of others rather than trying to protect existing services and income streams.” Commissioners, medicines management is in your hands. Use it wisely.

Update comment

Get eNGaGed When patients become customers Speak up! Your customers (read patients) are having trouble hearing you. ROGER HYMAS looks at what clinical commissioning groups could do better in terms of patient communication and engagement

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he other day I read an interesting piece on the Guardian website about the NHS having difficulty dealing with the word ‘customer’. The general thesis was that a lot of well-meaning and systemchanging DH initiatives would have a greater chance of success if patients and public were co-opted into the decision-making process. Engaged patients would then help co-create solutions for both their medical advisors and institutions in the same way that many other industries now manage their customers. It’s the phenomenon we see every day in the way we use the internet to buy goods and services. Healthcare is different, of course, and needs a special approach. To start with we need to deal with three extraordinary cultures that act as powerful barriers to progress.

AUTHOR BIO Roger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is also the founder of the Commissioning Community website, www.commissioningcommunity.co.uk

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1. doctor KNoWS BeSt The first and possibly the easiest one to deal with is that ‘doctor knows best’. A huge amount of effort has been made globally to provide information about conditions and reduce the knowledge asymmetry between patient and clinician. This has principally been the result of the ubiquity of information on the internet.

The Department of Health has spent hundreds of millions

Update comment

through its investment in NHS Direct and NHS Choices. They now get hundreds of thousands of hits and calls a year. Inevitably there are positive benefits from these programmes, though nobody seems to be in a position to tell us what the impact is on health outcomes or patient engagement yet. This is, of course, the challenge for all communication activity. How much does it cost, what parts of it work and what is the financial (and non-financial) return on the investment? Also, we need to know whether each part of the communication mix is being optimised. Do we know if it’s reaching and engaging the audience at a personal level and persuading them to change their behaviour? Often, it’s communication style, but sometimes the choice of medium, that makes the difference. Let me give you just one example: I put “bunions” into the NHS Direct website and WebMD, the leading US healthcare site. Which do you think gets its message across better?

2. NHS: A commissioning organisation The second cultural barrier that needs attention is persuading the NHS that it is now essentially a commissioning organisation and this is where the bulk of its management effort needs to be applied.

Tinkering with the provider landscape is the NHS establishment’s natural inclination, but it will not save the day. I’m not sure the penny has dropped yet that going flatout with commissioning is the only way we can affect the changes that will transform and modernise the NHS and make a real contribution to delivering the financial savings that have been targeted.

System redesign in any complex organisation starts with a focus on culture change. Until we have built a position where experienced commissioners occupy senior positions on the most important bodies, particularly the NHS Commissioning Board, then we will not make the progress we need.

Imagine a bold leap like the appointment of a senior executive from a US health plan to the NCB board so that he or she can bring his or her insights and experience. The King’s Fund came very close to recruiting a US chief executive a few years ago, and it has always struck me that NHS healthcare policy in this country might have moved quite differently if he had taken up the position.

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3. Let the GPs lead The third culture is dealing with a topdown NHS. With the arrival of GP-led commissioning, this is potentially going to be much easier to change. The great benefit is that GPs who see thousands of patients, face-to-face, every day are the best placed to make proper commissioning decisions. Just this move to a micro-managed environment presents the opportunity to change the NHS from an institutionally-oriented provider organisation into a consumer-centric, customer sensitive, delivery organisation.

Consumer-facing industries exploit these contact benefits and the data they produce to develop increasingly effective

“A lot of well-meaning and system-changing DH initiatives would have a greater chance of success if patients and public were co-opted into the decisionmaking process”

customer relationship programmes, enabling them to stay in touch and improve the customer experience. These involve a mix of techniques, including media selection, behavioural targeting, data about previous contact/purchasing history, learning style and response analysis, to build algorithms to optimise communication and, most critically, influence behaviour change. All of these programmes are designed to meet the specific needs of a single individual, a target of one.

Getting the NHS to this point would mean we would have a much greater chance of delivering ‘No decision about me, without me’. There are huge benefits for better engagement with patients. Improved involvement by the individual in selfcare, better compliance with treatment programmes are just a couple examples. What a lot of this adds up to is a lighter version of case management built on communication preference rather than traditional case management, where a care worker is assigned to supervise the patient’s treatment.

All this means that effective contact strategies should be matched to the patient.

My advice, though, is not to attempt to fix what’s not broken. If a personal visit to the GP is preferred, it should happen. But other patients will be happy with the phone, text and emails. Many of these are still relatively untried and tested media for the NHS. But there is the potential of significant efficiency gains if unnecessary consultations – both with GPs and specialists – are avoided. Many US healthcare systems are already relying on telehealth solutions, Skype, and even email.

As my best ever boss always told me: “Strategy is execution.” What the DH needs to do is move its considerable resources to focus beyond strategy to implementation.

My recent experience with GPs and CCGs has convinced me that they are ready to deliver. The missing piece is professional communication advice for CCGs. I read that both the district general hospital and the doctor’s surgery are now at least 150 years old, but are still the main contact points for hundreds of millions of patient encounters every year. We live in a digital world where ‘clicks’ replace ‘bricks’.

Isn’t it time to consider them as part of our healthcare future?

MEDICINES OPTIMISATION WITH FDB

THE CHALLENGE

THE SOLUTION

McKinsey’s 20091 report to the previous government identified changes in drug spending could deliver 10 to 15 per cent of the overall savings and indicated this might be achieved by reducing variation in prescribing practice and increasing the use of generics over branded products.

In 2011 The King’s Fund ‘The quality of GP prescribing’2 report highlighted the need to address variation in prescribing practice variation and encourage adherence to best practice.

Earlier in 2012 the GMC PRACtICe3 study into the prevalence and causes of prescribing errors in UK general practice revealed prescription drug errors for one in six people, with the elderly and young being almost twice as likely to experience an error.

Bruce Guthrie’s recently published study in The Lancet4 found that the number of morbidities and the proportion of people with multimorbidity increased substantially with age so that by age 50 years, half of the population had at least one morbidity, and by age 65 years most were multi-morbid with physical and mental health comorbidities.

In 2011 First Databank (FDB™) undertook extensive independent research to drill deeper into the current suite of clinical decision support available to understand: • why GPs reject the clinical decision support alerts available, • why GPs don’t always adhere to best practice, and • what extra support is required to assist the new CCGs and their component GP practices to achieve their saving targets?

The research showed that currently available technology and tools did not specifically address the issue of deviation from best practice and most importantly none were clinically sensitive at a patient level – making recommendations without reference to current ‘problem’ and comorbidities or polypharmacy issues.

FDB has developed its new Medicines Optimisation solution specifically to help CCGs and GP practices manage their medications budgets and improve patient outcomes through better quality prescribing and adherence to best practice guidelines such as NICE. FDB’s Medicines Optimisation at the point of prescribing helps GPs and patients by providing

sales@fdbhealth.com References 1. ‘Achieving World Class Productivity in the NHS 2009/10 – 2013/14: Detailing the Size of the Opportunity’, McKinsey & Co, March 2009.

2. The Kings Fund – ‘The Quality of GP Prescribing’ A study by Dr Martin Duerden, Professor David Millson, Professor Anthony Avery and Dr Sharon Smart, 2009 3. ’Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a cross-sectional study’ Karen Barnett, Stewart W Mercer, Michael

•

patient specific drug recommendations (with polypharmacy and comorbidities taken into account), • timely, evidence based best practice (prompts to follow relevant guidelines, with links to source documents), and • price comparisons for the drugs that are safe, in line with best practice for a specific patient.

FDB’s Medicines Optimisation analytics provides a current view on prescribing behaviour across CCGs providing access to: •

population level analytics, which can be drilled down into the individual patient record to allow interventions, • best practice guidance – reducing prescribing variations, and • the information required to build condition specific formularies.

These tools will free up Medicines Management team time for direct clinical care or local initiatives.

The next generation of medicines related active clinical decision support is here now, complemented by unique patient level analytics capabilities. For more details on FDB’s Medicines Optimisation solutions email sales@fdbhealth.com or visit fdbhealth.co.uk

fdbhealth.co.uk Norbury, Graham Watt, Sally Wyke, Bruce Guthrie www.thelancet.com Published online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2 4. ‘Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study’, May 2012 Professor Tony Avery1, Professor Nick Barber2, Dr. Maisoon Ghaleb3, Professor Bryony Dean Franklin2,4, Dr. Sarah Armstrong5, Dr. Sarah Crowe1, Professor Soraya Dhillon3, Dr. Anette Freyer6, Dr Rachel Howard7, Dr. Cinzia Pezzolesi3, Mr. Brian Serumaga1, Glen Swanwick8, Olanrewaju Talabi1

IN ACTION CASE STUDY

THE C O L L A B O R ATO R S

IN ACTION CASE STUDY

Clinical commissioning groups in the southwest have found strength in numbers. POLLY ELLISON looks at how federating has helped their smaller practices survive

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he GP federation model adopted by Somerset Clinical Commissioning Group, although still evolving, must be one of the most successful approaches to commissioning being carried out around the country.

A nominated GP from each federation sits on the CCG board, ensuring that each federation has equal representation, in the well-organised over-arching structure of the CCG. The key to the CCG’s success is in its recognition that the nine GP federations in Somerset differ from each other geographically, and that they have very different patient populations. In order to tackle this, each federation has adopted a different way in which they operate; a different working style and their aspirations vary tremendously from federation to federation. Recognising this, and supporting it, by allowing the appropriate management funds to flow through to local level, the CCG has empowered its GPs to become actively part of the commissioning process.

One example of this is the South Somerset Healthcare Federation. The federation is made up of 17 practices serving 108,000 patients across a region from Langport to Yeovil, through to Wincanton.

As Len Chapman, treasurer of South Somerset Healthcare Federation, explained: “What we have developed is a federation of the South Somerset practices, with our focus on the commissioning agenda, with a view to interacting with the Somerset CCG in order to do that.” Aiming to provide effective, coordinated commissioning and healthcare provision via existing and new services, the group is used to working together, having originally been a co-op providing out-of-hours services and part of

WyvernHealth, delivering practice-based commissioning. Those involved have a wide range of skills and local knowledge.

They are also establishing close working relationships with other stakeholders in the area, such as Yeovil District Hospital Foundation Trust, Somerset NHS, Somerset County Council and Somerset Partnership.

POWER TO THE PM The federation currently has a monthly evening meeting for GPs and practice managers plus a monthly steering group meeting to facilitate the implementation of agreed work plans. They are proposing a change to regular meetings of a smaller GPand practice manager-led working group, bi-monthly federation evening meetings and task groups as required for specific subjects.

The federation holds educational workshops, such as a recent reablement programme, which gives the group more information on the new reablement service and telehealth and provides it with an opportunity to learn more about the aims of the joint NHS/local authority programme.

Another development has been to assign practices to one of three working sub-groups to cover important areas of work, such as paediatric emergency admissions, zero- and short-length-of-stay admission, as well as identifying local commissioning priorities.

The close working of the GPs with their practice managers is the key to success, as practice managers are involved in all that is going on. In some areas of the country, practice managers would not necessarily know who the GPs on the CCG board were, never mind being involved in working with them and assisting with the development of services. Tapping into the expertise of practice managers is so important as they form the essential link

SEPT/OCT 2012 | 17

IN ACTION CASE STUDY

between GPs and practice staff and their wealth of expertise should not be allowed to go to waste. Somerset CCG has clearly recognised this and is benefitting hugely from this management resource.

“The close working of the

GPs with their practice managers is the key to success, as practice managers are involved in all that is going on” PROJECTS IN ACTION A variety of PCT projects to improve patient services have already been supported by the federation.

One example is an urgent care GP pilot at Yeovil District Hospital (YDH), where a GP and practice manager have created and delivered a service to provide GP expertise to patients in the emergency admissions unit. The aim is to help identify people whose healthcare could be managed in the community. A small group of local GPs deliver the service with the support of healthcare assistants Monday to Friday between 1.30 and 6.30pm. An experienced GP works with the on-call medical team.

There is also the facility to manage DVT patients where there is a problem with the timing of blood collections. The aim is to provide safe, good quality care for patients while reducing the workload of the DGH. During the shift, the GP receives all requests for medical admission. One good idea in this scheme is that in order to support a rural community, a dedicated transport service has been set up to bring people in quickly, so that they can have the appropriate assessments and tests. Patients can also be returned home promptly in the early evening if it is agreed that they are safe to be managed at home. A recent audit on this service highlighted the fact that 38% of patients have been discharged from YDH the same day. Twenty per cent of patients have been transferred out of YDH where prior to the service being set up, they would have spent at least one night in the hospital. There is now a plan to implement increased ambulatory care for patients where they can be seen, assessed and

18 | SEPT/OCT 2012

discharged the same day. An effective link to primary care will be crucial to this.

CARING FOR THE COMMUNITY On a smaller scale, but no less important for the elderly, is a toenail cutting service that has been set up in five different locations. This is being advertised widely across the practices but it is hoped that eventually more practices will decide to host a service so that services are available across South Somerset. The federation is also helping facilitate the centralisation of leg ulcer services by September, which were previously provided by individual practices.

The group has also done some excellent work for its region’s carers. It has set up South Somerset Healthcare Federation Carers’ Champion Resource Packs to support carers in their caring role. Primary and secondary carers’ packs are available at GP surgeries and contain a mass of information to help support the carer.

These initiatives are examples of what each federation is doing within its own locality. Dr Helen Kingston, the CCG GP delegate from East Mendip Federation, is equally enthusiastic about the process as Dr Chapman is, seeing federations as ideal ways of taking commissioning forward.

Though the process is evolving, the results are positive. Dr Kingston is a partner at the Frome Medical Practice, which also has a branch surgery in Warminster.

This has meant that she has a wealth of expertise not only in Somerset but also in Wiltshire and continues to work across both health communities as joint chair of the West Wiltshire, Yatton Keynall and Devizes Clinical Commissioning Group as well as the Somerset Clinical Commissioning Group. Such expertise and exchanges of information are invaluable to the CCGs in their evolution. The solid, step-by-step approach of the federations will undoubtedly prove to be beneficial in April 2013, as will the local engagement of GPs. One of the most important aspects of the federation work is not just GP engagement, however, but the engagement and utilisation of the expertise of practice managers. While in some areas of the country PMs will have little or no information on their CCGs, in Somerset their active role makes all the difference.

DR HELEN KINGSTON AND LEN CHAPMAN

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Whether you’re on a the board of a clinical commissioning group, participating in commissioning, a provider or interested from the side-lines, stay one step ahead of the Government’s plans to give clinicians power over £60bn of the NHS’ budget. This magazine is aimed at GPs, practice managers, secondary healthcare clinicians and nurses – anyone who has an active role in commissioning. It will provide them with the must-have tips and tools to make a success of clinically-led commissioning.

IN ACTION CASE STUDY

A community vision Independent primary care provider, The Practice has launched a cataract service in the Croydon community.

JULIA DENNISON speaks to locality manager KIRSTY HARBORNE and clinical director DR JEREMY ROSE to find out how it’s helping patients

I

was given the opportunity to see just how cataract treatment had progressed last month when my mother underwent a corneal transplant. It was an in-and-out job that required only local anaesthetic and a course of drops for a short period afterwards. The speed at which she was treated came as a relief since, as a costume designer, her eyes are essential for her line of work. As someone who edits a magazine for commissioners, I was curious as to the kind of opportunities there must be for moving this kind of less invasive surgery out of hospitals and into the community.

22 | SEPT/OCT 2012

IN ACTION CASE STUDY

I was therefore interested to find out about a new community cataract service in Croydon, which was promising a high quality service closer to patients’ homes while aiming to limit waiting times to less than eight weeks. The service, led by Mr Nick Jacobs, a fellow of the Royal College of Ophthalmologists and an experienced consultant ophthalmic surgeon, was commissioned by NHS Croydon, provided by The Practice and run from a newly built day case theatre at Parchmore Medical Centre in Thornton Heath.

SEEING EYE TO EYE With the aging population and cataracts being an age-related condition, their incidence, alongside other vision problems, is set to be a growing issue for the NHS. With this in mind, The Practice’s cataract service is part of a larger community-based ophthalmic service. “I think a great deal of conditions related to eyes traditionally seen in a hospital setting are actually equally, if not better provided out in the community, closer to patients’ homes,” says Dr Jeremy Rose, clinical director for The Practice.

This, in his experience, makes the service more convenient, faster and to a much higher level of patient satisfaction.

One of the reasons, historically, that ophthalmology was banished to a hospital setting was because of the associated specialist equipment – such as a slit lamp or visual field machine – which most GP surgeries don’t have. “I’m a GP and if someone comes to me with an eye problem and I can’t cure it with some eye drops, I would refer them to the hospital where they could be examined,” says Dr Rose.

That was until he set out on the project of establishing a community-based service with this machinery in practice. “The machines you can easily bring out into the community setting; you can train GPs to use them and do a proper assessment and examination of someone’s eye in their own locality,” he explains. This, in his view, could reduce eye-related hospital referrals by at least 70%.

The benefits of such a reduction are plentiful: “It’s better for patients because it’s quicker, nearer to home, a more personal service, and they like being seen in a GP surgery; it’s better for the health

“Community-based services are more cost-effective; more

patient-friendly; and deliver better patient outcomes – why wouldn’t you be doing it?” economy because it is cheaper and in terms of the pressure of living within our £100bn NHS budget whilst improving the scope and type of services we deliver, this is a real opportunity,” Dr Rose says. “Communitybased services are more cost-effective; more patient-friendly; and deliver better patient outcomes – why wouldn’t you be doing it?”

OPERATION IN THE COMMUNITY Once they had seen how beneficial community-based eye services could be on referrals, the team at The Practice decided to look next at minor operations.

Offering corneal transplants was one of the first steps towards offering slightly more invasive types of eye surgery. “If you look across the world – at places like India – they will do cataract surgery on a patient who walks in, gets done and walks home in a village setting,” he explains. “So it is possible to do cataract surgery safely – I’m not suggesting in a village setting but in the right setting, choosing the patients carefully – so someone who is essentially well but has cataracts.” Dr Rose believes around 80% of cataract surgeries occur on this kind of patient. In other words, the need for using hospitals for certain eye treatments could never be eradicated completely, but could certainly be reduced by taking these kind of minor ops into a primary care setting.

In terms of continuity of care, a GP setting is also an ideal place to manage patient expectations before and after the surgery. “General practice is quite good at informing patients,” says Dr Rose.

“Sometimes better than hospitals are.” Of course, there are other benefits, as locality manager Kirsty Harborne can attest to: “Patients feel nervous and apprehensive going into hospital and being in a community setting feels like going to see their GP, so they’re more comfortable.”

From a patient’s perspective, the main benefit of a community-based service such as that in Croydon is a reduction in waiting times. Where in a hospital waiting

DR JEREMY ROSE AND KIRSTY HARBORNE OF THE PRACTICE

SEPT/OCT 2012 | 23

IN ACTION CASE STUDY

times for services like cataract surgery have been known to be up to 18 weeks for an assessment and another 18 weeks for treatment, the length of time between assessment and treatment at Parchmore averages at only eight weeks.

This is important when you’re dealing with something as vital as someone’s vision. “It can be quite worrying for patients and having to wait up to 36 weeks is not something a patient would choose to do,” says Harborne. “They want improvement straight away.”

SEE CLEARLY NOW While The Practice is planning to roll out similar ophthalmology services beyond the confines of Croydon, investing in the right equipment to at least bring assessment into primary care is something that could easily be emulated by CCGs. Optometrists already have access to necessary equipment and many commissioning groups may well decide to work closer with them. “We like to engage quite closely with optometrists, not just because they can refer cataracts, but actually because they’ll often see a patient, send the patient to the GP and ask the GP to refer them onto us, which is an unnecessary step in the referral pathway,” explains Dr Rose. “I think in the more modern world we should allow ourselves to

24 | SEPT/OCT 2012

direct-refer them to a service when they’re happy they have the right skills to do it.”

Of course, GPs can be up-skilled to do this as well: “If you’ve got the equipment in a surgery, then GPs could take on some of the lower-level services themselves but that’s a slower roll-out service.”

Made up of a group of GP surgeries, The Practice is one of those organisations that sits on the same wavelength as the ‘Liberating the NHS’ whitepaper. Other services the group has actively moved into the community include dermatology, ENT and sexual health. Dr Rose believes the same model applies: “If you can get the kit out into the community, bring some specialist care and up-skill GPs with special interests, you can manage an awful lot of conditions in a community setting.

When we look at other specialties, we should always ask ourselves: ‘Why does that have to be done in a hospital? Are there not ways we could bring it closer to the patient in the community and hopefully run it quicker and to a higher level of patient satisfaction and, as far as the health economy is concerned, more cheaply?” For visionary clinicians like Dr Rose, the changes to the NHS certainly offer a wealth of opportunity for improving patient care, and if they save money along the way, so much the better.

“A great deal of conditions

related to eyes traditionally seen in an hospital setting are actually equally, if not better provided out in the community, closer to patients’ homes”

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COMMUNITY CARE SHARING SERVICES

SHARE

&

SHARE ALIKE

Sharing services between practices sounds like a practical way of ensuring patients have access to a range of treatments in their local area. So why aren’t we seeing more CCGs implementing the idea? CARRIE SERVICE investigates

S

haring services should be easy and effective. In theory, a GP who is trained to provide a specific treatment should be able to provide this to anyone within the local community who needs it. It should be as simple as a couple of clicks on a mouse and a taxi to take the patient to the nearest provider. However, for one reason or another, this has not been the case for many. I spoke to David Thorne, chief executive of Newcastle West Clinical Commissioning Group, about the challenges involved in sharing services.

26 | SEPT/OCT 2012

PRACTICALLY IMPOSSIBLE Newcastle West is a small but extremely proactive CCG for one of the most deprived inner city populations in the country.

Thorne explains that although the group is well engaged they have still not managed to get around some of the practical issues that prevent practices from sharing services.

One service that Thorne believes does have the potential to be shared is contraceptive implant fitting. Some patients may prefer to be fitted by a female GP and the CCG recognised the potential for the service to be made available to patients from outside practices where a female GP wasn’t

available. With this in mind, Newcastle West trained up around 30 of their female GPs in hope of allowing patients from practices in surrounding areas to use the service. However, the project didn’t achieve the level of success that Thorne believes it could have, and has now fallen by the wayside. When I ask why, he explains that there are practical issues that may seem trivial, but have a profound impact on the success of this sort of project: “The practical difficulties you always get with things like this are the clinical IT systems that practices have. We’ve only got 18 practices, but we’ve got four different systems and they don’t talk

COMMUNITY CARE SHARING SERVICES

to each other.” Not having a universal IT system across the CCG meant that medical notes could not be easily shared, creating a clumsy process that in theory should have been pretty straightforward. There was also the issue of payment and who should be acknowledged for having provided the service. “It’s always the same things that come up about systems, permission, and contractual issues around payment,” reflects Thorne. “It’s just the sheer complexity of the NHS and the arcane nature of the system.

Can you get a £25 payment for putting that contraceptive implant in, even though it wasn’t your patient?”

Another drawback that has made many wary of referring patients to a different practice is the danger of losing them altogether – do practices really want to risk sending their patients off to a GP that they might prefer? “That is a concern [of many],” says Thorne. “But in our practices it isn’t.” He puts this down to good teamwork and collaboration across the group. An issue that he believes does warrant some concern, however, is

transport: “Because most of our patients don’t own cars and they are on very low incomes, there are practical difficulties about how you get someone from one place to another. In theory, there’s no problem at all, we’ll get some kind of small contract with a taxi company to take people back and forth.” In practice though, this never quite came off, but Thorne stresses it is something that will have to be addressed for services to be successfully shared in deprived areas.

“Everybody knows what we want to do, but not how to do it” THE FUTURE Despite not seeing much success with it so far, Thorne does believe there is a bright future in sharing services; commissioners just need more time to tackle some of the practical issues involved. With authorisation taking up a great deal of time over the past six months, there has been little left over to spend on planning

new projects. “We’re frustrated,” he tells me. “We were making more progress on clinical projects last year than we probably are now. And we’re a very active group – although we’re small we have forty clinical commissioning projects going on at the moment.” As well as relaunching the contraceptive implant shared service, there are other projects that Thorne is hoping to see develop nicely after the storm has settled, including a new nursebased ENT service for syringing ears. This would work in the same way, with nurses based in peripheral sites so that if the practice nurse isn’t available that day, the patient can be referred elsewhere. What commissioners need now, says Thorne, is some success stories so that they can follow suit: “Everybody knows what we want to do, but not how to do it. It’s getting the right people together, going through it and cracking all of these permission issues and transactional-type boundary issues, and then using that in a way that you can replicate as a template for other specialties.”

SEPT/OCT 2012 | 27

COMMUNITY CARE REDUCING ADMISSIONS

H ome c o mforts CARRIE SERVICE takes a look at how patients can be encouraged to manage their health outside of the hospital setting and whether or not the NHS is prepared for the change in attitudes that this requires

O

ne of the most effective ways of reducing emergency admissions is to encourage patients to take a self-managed approach to their care. In the last issue of Commissioning Success we talked about the power of telehealth, and how giving patients the tools to manage their own conditions from home allows them to be masters of their own destiny (and subsequently, masters of the NHS as a whole’s destiny). This concept of treating long-term illnesses in the home has been flagged time and time again as a way of reducing emergency admissions and saving the NHS money in the long term. So how can patients be encouraged to recover in the community, and is the help being made available for them to do this?

28 | SEPT/OCT 2012

UNCHARTED TERRITORY Jean Lewis, professional lead for adult nursing at Central London Community Healthcare NHS Trust says that district nurses are absolutely vital to both patients’ recuperation and maintaining their health in the longer term. “This is even more important for patients in the most vulnerable groups – such as the elderly and people with long term conditions,” explains Lewis. “District nurses support patients to recover in the community by providing holistic assessments, patient centred care planning and by liaising with health, social care and voluntary agencies to meet the patients’ needs.”

Ensuring patients have access to help when leaving hospital after a major operation, injury or illness can clearly reduce readmissions drastically and as Lewis points out, the role of the

COMMUNITY CARE REDUCING ADMISSIONS

district nurse in providing high quality intermediate care is essential. However, with decreasing numbers of nurses signing up for district roles, implementing care at home is going become ever more difficult.

It is understandable why fewer nurses are willing to leave the hospital environment and move over to district nursing, because, as Kathryn Godfrey from the Nursing Times acknowledges in her blog, there is enough pressure on nurses as it is: “It’s already a tough job without all the increasing pressure currently being loaded on. Working in a ‘hospital without walls’ is a challenging role. Making decisions about frail and elderly patients with multiple comorbidities in their own home takes skill and training.” At the annual Royal College of Nurses congress earlier this year Lansley received a substantial grilling in the Q&A session after his address. In answer to a question posed about how to tackle the drop in district nurses, Lansley is reported to have responded by saying that the numbers of health visitors will be increased, which Godfrey says is “a good initiative – but it’s not the same thing”. Can one really be replaced with the other? The need for health visitors and healthcare assistants in the NHS is clear, but in the “hospital without walls” environment as Godfrey puts it, isn’t training and experience even more critical?

DISTRICT COUNSEL Moira Fraser, director of policy at Carers First, an organisation that provides support and information for people caring for a loved one, held a session at the RCN congress this year. After the event she discussed in her blog the issues that had been raised by delegates during her session: “They were talking about feeling inadequate if they identify a carer but then have nothing to offer them, or not knowing the up to date information on what’s available. They also described being so rushed for time.”

Fraser suggests that a better approach to district nursing would be to allow nurses the freedom to treat patients holistically, rather than simply concentrating on the individual clinical tasks they have to

carry out on each visit, and being forced to overlook social issues due to time restriction: “Explaining to a carer how to best look after the person they care for, and dealing with their concerns about treatment – those are clinical issues in my book.

Supporting carers with their own health and stress issues – well that too, I would say, is verging on clinical – or at least will likely become so. I don’t see the problem with measuring this and counting it as a valued part of the nurse’s role.” Perhaps if nurses could be allowed the freedom to do their job in the way they see fit– in a way that seems to be in line with a holistic and patient led approach to health – then perhaps more would be willing to step out of the hospital environment and provide highly skilled care within the home. How nurses roles are shaped is key to the future of community care – nurses are going to need a wide enough skillset to work in a range of settings in order for the NHS to allow them to have a real impact.

TAKING CONTROL More and more treatments that would years ago have been restricted to the hospital ward are now taking place within the home as they become increasingly routine, and this has the potential to have a significant impact on admissions. The outcome rests on how well and to what extent this type of care is invested in over the next few years as commissioning changes hands. Nurses and other care workers need to be given the skills-training and right equipment to administer home treatment for community care to become truly integrated. Telehealth is an area which has positive results, or so the findings from the Whole Systems Demonstrator programme suggest. Allowing patients to feel empowered in their own homes could help change public attitudes towards health. By making patients feel they can actually have an effect on how their illness is managed and can see tangible improvements such as being able to spend more time at home with family and less time in hospital waiting rooms, they might start to realise that their health and happiness lies in their own hands.

SEPT/OCT 2012 | 29

INFORMATION TECHNOLOGY DIGITAL COMMUNICATION

The myriad communication possibilities opened up by the power of the internet offer a cost-effective and relatively simple way for commissioning groups to release information and gain feedback from the patient population. GEORGE CAREY finds out what options are available

D I G I TA L D I S S E M I N AT I O N

F

rom surveys to digital services and social networking, there are now more ways than ever to inform and keep in touch with your patient population. While some elderly patients may have resisted the move to disperse more information through digital channels, this method is constantly increasing in popularity and will only do so at a faster rate in years to come. So what are the best ways to harness the internet to enable your commissioning group to benefit its patients?

SURVEYS Surveys in healthcare are nothing new but the digital age has made them significantly easier to carry out.

The entire process has been streamlined and the difference in costs is huge, with no paper or expensive postage to consider. Making patients aware of the surveys is now simple through email and the increased feeling of anonymity can result in a higher rate of survey completion and entirely uninhibited answers from those who do choose to participate. Collating the data has been simplified as well, with software

30 | SEPT/OCT 2012

“New parents receive regular emails and text messages containing relevant and timely NHS -approved advice as their pregnancy develops�

available to analyse and interpret the information supplied at the click of a button and present it clearly and attractively in a range of different formats. It can then be distributed among all members of a commissioning group with ease to aid a discussion of the results.

DIGITAL SERVICES The NHS has embraced the chance to enrich patients lives with digital services and a great example of this is the NHS Information for Parents service, launched in May. It gives new parents information and advice they can trust, covering a wide range of issues related to staying healthy in pregnancy, preparing for birth and looking after their baby. By signing up to the service, parents-to-be and new parents receive regular emails and text messages containing relevant and timely NHS-approved advice as their pregnancy develops and as their child grows. Links to videos showing midwives demonstrating practical advice such as bathing babies, and parents discussing issues that affected them and how they supported each other, will also be sent at appropriate times.

INFORMATION TECHNOLOGY DIGITAL COMMUNICATION

SOCIAL NETWORKING With 50% of the UK now using Facebook and the increasing prevalence of Twitter in everyday life, social networking can be an incredibly effective tool for commissioning groups to communicate with those whose care they are responsible for. One of the biggest challenges is using social media and other digital channels without breaching confidentiality rules and regulations, when you are potentially talking about people’s very private healthcare needs. Alex Talbott is digital communications officer for NHS London and founder of NHS Social Media (nhssm.org.uk), a blog designed to help NHS staff and those interested in healthcare and the web communicate. He believes that confidentiality is not under as much threat from social media as some would make out: “It’s something we’ve discussed a lot on the NHSSM blog and time and again people try to knock social media out of the comms toolbox because of confidentiality issues. Of course there are issues around that, but we shouldn’t just throw it out because of this one concern, there are too many positives that we can get out of it.” He goes on to explain: “The standard rule applies that if you don’t want to say it in public, don’t say it through social media.”

It is important to bear in mind that CCGs do so much more than treat people and there is a duty to inform patients of vital public health messages. This is where social media is at its most useful. Already, initiatives such as NHS Smokefree are using a Facebook page as a place for people using the service to keep up to date with important information and discuss their experiences with other people trying to give up smoking. It’s these kinds of applications of social networking that use all of its strengths and avoid its potential pitfalls. While these pages can be vulnerable to trolling – perpetual posting of abusive messages – and other internet abuses, it doesn’t use any confidential information and therefore poses little threat to those using the service. Talbott concludes: “There needs to be an understanding that social media isn’t big and scary and only for big companies to mess around with. There is a possibility here for the NHS and other healthcare providers to increase the service offer that they currently have for patients.”

It’s time to digitise your interaction with patients and ensure that you are getting full value from the huge range of communication tools available. Research carried out in June by NHS Local involving 328 people found that more than half of those questioned would be happy to Skype their GP. Proof if it were needed that these advances in communication will continue to diversify. The most progressive CCGs will grasp the chance with both hands.

SEPT/OCT 2012 | 31

MANAGING COMMISSIONING ADVICE

Taking it interpersonal Communication skills, assertiveness, team-working, and delegating are just some of the challenges facing commissioners that could go overlooked.

Development and training expert MARIA KORDOWICZ discusses these ‘soft’ skills

C

ommissioning is defined by the Department of Health as a process that incorporates assessing population needs, prioritising health outcomes, procuring products and services and managing service providers.

Each one of those components, while naturally requiring high-level specialist knowledge, also demands the skills needed to build successful working relationships.

With inevitable team restructuring, new providers and the need for new CCGs to establish themselves within the wider community, now is the time to reflect on our ability to meet those demands.

Good interpersonal skills are essential to interacting with others effectively. They can be seen as the invisible glue that binds our working processes. They comprise our ability to communicate with confidence while employing active listening to make decisions and problem-solve. Most importantly, highly developed interpersonal

32 | SEPT/OCT 2012

skills help us to manage our own reactions and personal stress appropriately.

There are workshops in interpersonal skills for clinicians aplenty, and with good evidence to justify their existence. Time and time again, we hear that patients value healthcare professionals’ interpersonal skills above everything else. Indeed, the ‘interpersonal’ has become almost a managerese term akin to ‘upskilling’ and ‘co-collaboration’, ever-present in training manuals and management textbooks.

Although the ‘Liberating the NHS’ whitepaper does not use the term directly, there is no doubt that, in particular, putting patients and public at the heart of commissioning decisions requires the ability to listen, collaborate, communicate information and guide others in the decision-making process. These are all key elements of our interpersonal domain and clearly we all have these skills to a greater or lesser extent. The new challenge is to further develop and broaden those skills, through self-reflection and practice.

MANAGING COMMISSIONING ADVICE

“Listening depends on your ability and willingness to focus

and pay attention to various messages representatives of your local population are trying to impart. It is also about giving your population a platform to be listened to” ASSESSING POPULATION NEEDS Beyond the economic analyses and numerical terms, assessing need is very much a listening exercise. It is about getting to know your patient population.

Here it is apt to emphasise the oftenrepeated distinction between ‘listening’ and ‘hearing’. Listening depends on your ability and willingness to focus and pay attention to various messages representatives of your local population are trying to impart.

It is also about giving your population a platform to be listened to. This means that appropriate communication pathways need to be developed so a dialogue with your local population is facilitated. Beware of

dispute. The ability to negotiate is often listed in specifications for procurement positions, as fairness, achieving mutual gain and forging successful working relationships are the keys to a successful procurement outcome. To negotiate effectively you need to accept that disagreement will naturally be borne out of procurement processes.

Negotiating with others should, where possible, take a structured approach where goals are clarified and a mutually agreed course of action is decided upon. The aim is a ‘win-win’ outcome – this means all parties involved will feel positive and have a sense ownership over the outcome.

how your prior experience can lead you to jump to conclusions and how stereotyping can be a harmful barrier to understanding true need. Be sensitive to cultural and language differences. Avoid using jargon and acronyms. Assessing population need should be as much about statistical analyses as market research ‘at the coalface’.

Remember that in the first place, it was the genuine interest in listening to and helping those in need that got you where you are.

MANAGING SERVICE PROVIDERS The ability to manage is necessary to be an effective commissioner. With service providers potentially being more heterogeneous than ever before, commissioners need to be flexible in the way they manage others. Empathy plays a part in allowing us to be adaptable.

Commissioners need to understand that others may have different points of view and ways of working. Gain trust by showing that you can see things from the perspective of your providers. Furthermore, by opening services to a wider range of providers, we in turn become open to learning about working in new fresher ways.

These management and leadership challenges of commissioning are rarely stress free. Increased stress can have a detrimental effect on joint working. The bottom-line of high-level interpersonal skills is the ability to recognise stress in yourself and others and knowing when to take stock to reassess a project.

In sum, one should not underestimate the part that interpersonal skills play in furthering the commissioning agenda. We need to be aware that the interpersonal is the binding force behind effective working relationships. In order to nurture those skills, it is important to take time to reflect on our own strengths and weaknesses.

PRIORITISING HEALTH OUTCOMES Priorities are, in part, built on the foundations of in-depth stakeholder consultations. It is important to be clear in the way you communicate with your stakeholders, so as not to confuse the issue or be misunderstood. Feedback should be sought regularly to ensure your message has been taken on board. The consultation process should be an inclusive space to exchange views, free from manipulation.

At the same time, assertiveness is required for clear agenda setting. Being assertive is expressing views in a way that is neither passive nor aggressive, but harms no one, and preserves your rights and the rights of the organisation you are representing.

PROCURING PRODUCTS AND SERVICES Assertiveness feeds into our ability to negotiate. This is a process by which a fair agreement is reached while avoiding

Maria Kordowicz is founder of Akord People

SEPT/OCT 2012 | 33

MANAGING COMMISSIONING TOP TIPS

Diabetes has hit crisis point, so what can be done to help your population better manage the disease and bring down costs? We ask three experts what measures could have a positive impact on how diabetes is managed in the UK

Diabetes management “Diabetes is 99% managed by the individual, as it is a 24/7 disease. Without the proper tools and guidance to manage it well, complications are far more likely”

DR PAUL GRANT, DIRECTOR OF COMMUNICATIONS AT THE YOUNG DIABETOLOGISTS FORUM (YDF) “The future of diabetes relies on an investment in integrated care – ensuring that patients with difficult to manage diabetes see the right professional, be it diabetes specialist nurse, GPwSI or diabetologist, at the right time, without inappropriate delays relating to worries about short term cost savings. The YDF recommends the use of a strong IT infrastructure, with a powerful enough database to capture all the requisite information about patients, which can be shared between healthcare professionals. Patients should be empowered to know about the standards of care they should expect such as the Diabetes UK ‘15 healthcare essentials’. Whatever form a diabetes service takes; it should be open to peer review and ongoing assessment to make sure that patients are being managed effectively. On a practical basis, practices can ensure that adequate information and support are available – posters, information leaflets and details of the local Diabetes UK voluntary support group for example are crucial.”

SUE MARSHALL, TYPE1 DIABETES SUFFERER AND EXPERT AND FOUNDER OF DESANG, A SUPPLIER OF DIABETES KITBAGS AND A WEBSITE/INFORMATION CENTRE FOR DIABETICS “Action now – in terms of diabetes education and supplying blood test meters and strips – will prevent later hospitalisation of patients, yet there are often reports that GPs surgeries are restricting the prescribing of test strips. Access to strips is a basic way to improve health outcomes in those interested in their health enough to bother to use them. An interested patient should not be deterred in this, it is a trifling cost next to that of being hospitalised, although that cost will be on someone else’s budget, it still comes out of the NHS as a whole. It is a case of prevention.”

ALAN EASTWOOD FROM ONLINE DIABETES FORUM DIABETESSUPPORT.CO.UK “Diabetes is a very individual condition and people need to learn how their bodies react to and tolerate different foods, and the only way they can do this is to be able to monitor their reactions. On countless occasions highly-motivated and capable members of our support forum have been refused this facility and have had to either self-fund or simply rely on periodic HbA1c tests which, if not good, will provide no clue as to where the problems may lie. In contrast, those who are able to self-monitor had shown great improvements – often resulting in reduction in medications and non-diabetic blood sugar levels. The argument against selfmonitoring is cost, yet complications from poor management cost the NHS considerably more.

Diabetes is 99% managed by the individual, as it is a 24/7 disease. Without the proper tools and guidance to manage it well, complications are far more likely.”

34 | SEPT/OCT 2012