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practicebusiness + inspiring business solutions for practice managers

september 2012

Take a chill pill Become a less stressed manager

Going‌ going‌ gone The rise and fall of the small practice

CQC in the hot seat

A word with the CQC’s GP registration lead

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

CONTACT US intelligent media solutions suite 223, business design centre 52 upper street, london, N1 0QH | tel: 020 7288 6833 | fax: 0207 979 0089 | email: info@intelligentmedia.co.uk | web: www.practicebusiness.co.uk | web: www.intelligentmedia.co.uk | twitter: twitter.com/practice_biz

It’s a dog-eat-dog world of general practice There are so many things to think about these days. Some practice managers face mergers, others contract changes, while most are becoming more involved in commissioning and all are preparing CQC applications. With the decline of the small practice, which we explore both in an interview with Sheinaz Stansfield in the Provision section (p18) and in our legal feature on p36, and everything else going on, it is important general practice does not lose sight of what it does best – or what is expected of it in these changing times. The NAPC has come out in defence of PMS contracts as essential to the future of the NHS. In a recent column in Pulse, Maggie Marum was adamant that the tailor-made aspect of personal medical services in general practice made these type of contracts better suited for commissioning – where services are expected to move from secondary to primary care. This comes in the wake of news that practices are being pushed from PMS to GMS contracts due to lack of funding. Surely a better funded PMS practice will be more cost-effective than expensive secondary care in the long run and moving away from this is precisely what commissioning is about? We’re keen to hear from practice managers going through contract changes and any PMS practices that feel pressure to go GMS, so please do get in touch. In other news, with CQC registration ahead of you, on p24 we interview the man representing GP practices at the CQC and his colleague, the registration design team leader, about what practices can expect from the process. They debunk debilitating myths making the rounds, like the rumour that you have to tear up your carpets or ditch waiting room toys. Looks like you can avoid throwing your toys out of the pram after all. This autumn brings with it busy times for practices and their managers. Practice Business is by your side through thick and thin. If you want to discuss any issues, have a story to tell or want to submit a diary page, please get in touch on editor@practicebusiness.co.uk. We are always open to suggestions and practice manager perspectives.

editor


Contents sector 06 news Top news for practice managers this month 08 executive editor comment The latest from controversial columnist Roy Lilley

PRIMARY PROVIDER 10 12

provider news An update for practice managers on providing for commissioning

legal Going to tender As contracts for Darzi centres come to an end, we look at whether to make the bid for the contract

18 analysis Going‌ going‌ gone The rise and fall of the small practice

PEOPLE IN PRACTICE 24 31

CQC CQC in the hot seat A word with clinical lead on GP registration, David Haslam

case study All change at the Old Exchange One Cambridgeshire surgery switches software

MANAGEMENT 36 motivation All aboard! How to get your practice team on-board with commissioning 40 42

clinical QOF This month: Epilepsy

legal Bigger fish to fry An update on GP merger law

Work/life 44 46

advice Take a chill pill How to become a less stressed manager

diary One PM talks moving premises


sector

06

LMC practice levies set to rise GP LMC levies are set to rise due to increased LMC workloads and staff costs from dwindling PCTs. An LMC representative told GP Online that with less support from PCTs, practices would turn to them for support and to cope, LMCs would have to take on more staff. This, along with the need to ensure they are adequately represented on clinical senates and have a good working relationship with commissioning groups and local NHS Commissioning Board teams, means LMCs may need to increase their levy with GP practices. One way LMCs say GP practices could avoid

Ten minutes is ‘not enough time’ RCGP honorary secretary Professor Amanda Howe has

your monthly lowdown on practice management

called for longer GP appointments to allow enough

news

time to deal with patients with multiple conditions. She admitted such a move would need robust workforce planning, but it was an unavoidable consequence to managing more LTCs in primary care. In an interview with Pulse, the GP and professor at the University of East Anglia said 10 minutes was not enough time for clinical staff to do their job properly and can result in patients having to come back. “We need to be making the case, within the workload planning, for quarter of an hour or even half-hour appointments,” she said. “To do [complex patients] justice.” This follows on from a Pulse survey that found that a minority of practices were adapting their appointment bookings to suit patients with more complicated conditions – with the vast majority still only providing 10-minute slots.

september 2012 | practicebusiness.co.uk

increased levies is by federating to pool resources (see p42 for legal advice on this). GP practices that balk at the cost should look at the price for similar professional services like lawyers or consultants, says Dr Peter Holden, GPC negotiator and GP. “GPs may feel they can’t pay an increased levy, but you should understand the cost of employing a lawyer or whatever on the high street, it will make LMC subs look an absolute bargain,” he explained. He added that LMC levies are recognised as a practice expense, and so therefore can be offset against tax, where other services may not.

Practice loses PMS funding dispute

A GP partner who has been fighting for funding from PMS growth on his practice since March 2009, has been denied £60,000. Dr Brian Golden of Ravenscroft Medical Centre in Golders Green, London, has been trying to obtain PMS funds he claims his practice is owed. NHS Barnet has refused to make the payment on the grounds that the funds claim form was not returned before the deadline, GP Online reports. The practice says a claim form was never received. The BMA confirmed last month that it would not take the matter any further. Golden alerted Health Secretary Andrew Lansley and the High Court after failing to receive support from the NHS Litigation Authority. Dr Golden said: “The PCT knew which practices would be eligible for the funding so we thought we were getting the money and we had no reason to think that we would be getting a claim form. It was only when I called the PCT to ask when we would be getting the money that I found out about the claim form.” A spokesperson for NHS Barnet has said that the matter is now closed.


07

SECTOR | news

clinical news scottisH gPs call for Bigger PreMises GPC Scotland is calling for investment in GP premises following the news that the country’s population is at its highest point since records began. A report published last month showed that in mid-2011, Scotland’s population reached 5.25 million, its highest point ever, after continuous growth since 2002. Dr Andrew Buist, deputy chairman of GPC Scotland, said increasing list sizes were making access to primary care services difficult for patients and felt this should play a part in local health planning. “If we are to improve access and provide the range of services that patients need, then we have to make sure we have the capacity to deliver,” he said. Scotland’s register general, George MacKenzie, said the growth was likely to continue, with an anticipated increase of 63% in people aged 65 and over by 2035.

CQC WATCH

Practices resist nonotice inspections

GP practices are demanding at least one month’s notice for regular CQC inspections, after proposals hinted at the possibility of no notice at all. The Care Quality Commission has been testing its options by considering no-notice, 48-hours’ notice, four days’ notice or 10 days’ notice routine inspections of GP practices (see p24). However, a survey of 100 practices by the Family Doctor Association found that GPs would prefer at least one month’s notice, with 10 days’ notice being the preferable option proposed by the CQC. The membership organisation reminds the CQC “that general practice is not like the hospital or nursing home”, asking: “What happens if they demand to inspect a single handed practice and the doctor has just left for holiday? What effect will it have on patients who have pre-booked a doctor appointment if at very short notice the CQC demands that the registered manager – usually a GP – is available for them?” The Family Doctor Association is therefore demanding a minimum notice period of one month for routine inspections with the right to negotiate a date. However, the organisation accepts that no-notice inspections will be necessary for practices that are a “cause for concern”.

“”

Can we cope with vaccs? The Joint Committee on Vaccination and Immunisation (JCVI) has changed the vaccinations GPs give to children, adolescents and the elderly, which, without additional funding, could impact practice workloads. New schemes include giving DTaP/IPV/ Hib at six weeks in some cases, meningococcal C booster jabs for adolescents ‘as soon as practicable’ and shingles vaccines to the elderly. Dr Richard Vautrey, GPD deputy chairman, told GP Online that the issue of practice remuneration and logistics still had to be addressed. “If practices are expected to do extra work, they need to be remunerated for it,” he commented, adding that practices needed time to plan for extra staff. He also recommended that new vaccines be accompanied by publicity campaigns to help practices get patients in.

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

diary 19 September

NHS INFORMATICS: DELIVERING A SUCCESSFUL INFORMATION REVOLUTION

They said…

The Barbican, London

“GPs’ manner and approachability is crucial to making patients comfortable to disclose their sexuality.”

4-6 October

Dr Siobhan Macintyre from Bodey Medical Centre on the landmark meeting of the RCGP, BMA and GMC on LGB health

THE RCGP ANNUAL PRIMARY CARE CONFERENCE Glasgow

practicebusiness.co.uk | september 2012


08

SECTOR | comment

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

Gone, baby, gone

NHS staff are dropping like flies. More than 12,000 posts have not been filled after colleagues have left or retired. ROY LILLEY says: get ready for the slew of leaving parties

The current £20bn savings target is wristslashing territory. The toughest in the NHS’s 60-plus year history september 2012 | practicebusiness.co.uk

Have a look around. Is there the same number of coffee cups on the shelf? The same number of cars in the car park? Have you been writing a note and fixing an envelope to it: “Sally is leaving; we want to buy her something, please pop a donation into the envelope”? “We’re having a night out at Giovanni’s; Helen is leaving, please try and come. It’s Friday.” Do you go to meetings and find the people you have been working with on this or that project are missing? The NHS isn’t what it was. More than 12,000 posts have not been filled after colleagues have retired or shoved elsewhere. These figures, based on NHS hospital and community health service staff, tell us that the overall headcount of NHS employees has reduced by almost 20,000 people since September 2009. The health trade mag HSJ reported: “The number of people classed as ‘NHS infrastructure support’ workers fell by about 20,000 from 236,000 to 216,000 from 2009 to 2012. Managers and senior managers lost 5,000 and 2,000 positions respectively.” Health minister Anne Milton said: “There are 2,400 more clinical staff working in the NHS than there were two years ago in May 2010, including over 3,700 more doctors, and over 900 extra midwives. In contrast, the number of admin staff has fallen by over 17,500, creating savings that will be reinvested into frontline patient care.” These data are interesting and very revealing: qualified nursing, midwifery and health visiting staff posts have reduced by almost 5,000 in the last two years. We know times are tough; saving £20bn by 2015 is no easy task. Get to 2015 and relax? I don’t think so. It’s just the beginning. All we are thinking about is the current spending review. What happens next? Look at growth rates, tax revenues and economic development; savings become a much bigger figure – around £50bn if you look at it over the two spending review periods. This is very bleak. The current £20bn savings target is wrist-slashing territory. The toughest in the NHS’s 60-plus year history. The calculations are based on demand, inflation and costs; set against possible funding. The reports on economic recovery are getting worse. The money available for public services is getting smaller and smaller. Get ready for more people to leave. Get ready to party!


Empowering practices in a commissioning landscape

primary provider

10

Practices exempt from Monitor license

Financial regulator consults on whether NHS providers should hold a license, but says GP practices would not be included GP practices will be exempt from holding a license with Monitor, according to a government consultation on licensing with the NHS’s financial regulator. The consultation outlines a legal framework that would enforce rules for NHS providers in the interest of patients. The paper says GP practices would be exempt, putting the responsibility with the NHS Commissioning Board to ensure they meet a certain financial standard. While it said stakeholders had raised concerns about GPs compling with patient choice in their role as gatekeeper to secondary care, there was ‘no compelling evidence’ that they were restricting patient choice against the wish of commissioners. ‘On this basis, we are recommending that providers of primary medical and dental services should initially be exempt from the requirement to hold a licence,’ the consultation, which runs until 22 October, reads.

Commissioning GPs seek communication

A Family Doctor Association snapshot survey of 100 commissioning GPs showed that GPs have an overwhelming desire to be consulted at every stage of commissioning by their CCGs. The survey, undertaken at the Commissioning Show 2012 in June, identified a wish for democracy and genuine representation of practices. Of those questioned, more than 50% felt able to influence their CCGs decision making but 13% felt unable to do so and felt disempowered by the system. The survey also indicated a clear wish for a fresh start and avoidance of the reinvention of PCTs with the same faces and policies as before. National chairman Dr Peter Swinyard, said: “The message to CCGs is clear. Talk with your member practices and listen to them.”

september 2012 | practicebusiness.co.uk

However when the Government carries out its review of how the licensing regime is operating during the next Parliament, it will reconsider this matter. ‘It may be that in the light of that review, it would be appropriate to license providers of primary medical and dental services in future,’ the paper concluded. Monitor and the Department of Health plan to introduce licensing to foundation trusts from April 2013 and providers of other NHS services – except GPs and dental surgeries – the following April.

clinicalnews Fifty per cent rise in diabetes prescriptions

Diabetes prescriptions have, for the first time, topped 40 million in year, a rise of nearly 50% on six years ago, according to Health and Social Care Information Centre (HSCIC) figures. The net cost of diabetes drugs also rose by just under 50% in the same period, according to ‘Prescribing for Diabetes in England: 2005/06 to 2011/12’. This growth is a faster and greater than for prescriptions overall, where items increased by 33% and net ingredient cost rose by just under 11% in the same period. The report shows diabetes drugs are taking up a bigger share of both total drugs dispensed and the total net cost to the NHS each year. It also shows that while the overall cost of all drugs to the NHS fell last year by just over one per cent, the diabetes drugs bill increased by nearly five per cent.


Help at hand for commissioners The NHS Confederation has released two new guides to commissioning called ‘Top tips for GP commissioners’ and ‘Top tips for councillors and officers’. The two documents promise to help health and wellbeing board members understand the structural and cultural differences between the NHS and local government. They discuss the role of health and wellbeing boards and how they will bring together NHS, local government and Healthwatch representatives to improve the lives of their local populations. Here are some top tips for commissioners highlighted in the reports: • Develop an understanding of how local government works and your local context by speaking with councillors and officers in your local authority • Focus on building relationships with elected members before trying to tackle specific (especially contentious) issues. • Engage equally with all councillors with different functions – members of the HWB, the overview and scrutiny committees, neighbourhood forums and the cabinet, wherever possible, so that all are kept informed. • Understand their personal constraints – councillors often have full-time jobs away from council and receive little in return for the time they put into being a councillor. • Tap into the local knowledge of councillors – their primary role is to represent their local ward and they often know their communities very well through councillors’ surgeries, neighbourhood forums and case work.

GET SUBSCRIBED TO OUR NEW COMMISSIONING MAGAZINE

While we will still cover commissioning-related topics from a primary care provider point of view, practice managers heavily involved in clinical commissioning will want to refer to our bi-monthly commissioning magazine that launched in April, called Commissioning Success. It targeted at decision-makers and is participants in commissioning, from board members to commissioning support units and supporting groups. Because of our background in practice management, the magazine will focus on the management and strategy behind effective commissioning, as well as keep readers up to date with all they need to know in terms of news and updates. If you’re interested in receiving a free copy, please email your details to subscriptions@intelligentmedia.co.uk with the subject line “Commissioning Success”.


12

provision | legal

r e d n te The

hook

Many of the five-year contracts for the so-called open-all-hours GP-led ‘Darzi centres’ and alternative provider medical services (APMS) are drawing to a close. Primary care lawyer Katharine Mellor offers a step-by-step guide for GPs considering going to tender with their PCT

1. Find your tendering opportunities Supply2Health.nhs.uk lists all tenders, but it should be noted that there’s often a short timescale between the announcement and the first deadline.

2. Consider your capabilities Carefully analyse your strengths and weaknesses to ensure you have the internal capacity to take on the additional work before tendering.

3. Clearly identify the bidder The contract can only be awarded to the GP, partnership or company specifically named on the bid, so it’s essential to make sure that the wording used is accurate and precise.

4. NHS Pensions Scheme If you wish to make NHS pensions available to those engaged on the contract, it is crucial that you ensure your organisational structure complies with the strict requirement of the scheme regulations. september 2012 | practicebusiness.co.uk

5. Ensure you are well prepared and organised Commissioners are keen to hear from highly organised bidders, so it’s important to plan ahead and undertake as much preparatory work in advance as possible. Make sure you have all of the relevant policies and procedures in place, and in a suitable state to be presented to the tendering body. These may include health and safety, human resources, information governance, clinical governance and disaster recovery policies and procedures.

6. Dot the ‘i’s and cross the ‘t’s It is imperative that the advertised process is followed to the letter. There is likely to be no leeway on deadlines. The usual process includes: A. Advertisement B. Completion of a pre-qualification questionnaire (PQQ) to demonstrate bidder suitability C. Invitation to tender for those shortlisted at the PQQ stage. Detailed information about the

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14

provision | legal

contract and other important terms and conditions will be issued at this stage D. The commissioner will usually hold bidder information events, where bidders can ask questions in person or submit them in writing E. Submission of the final technical proposal for how the bid team plans to deliver the services in accordance with the Commissioner’s requirements. This will effectively indicate agreement by the contractor to be bound by the terms of the proposed contract in the event that the bid is successful. After the contract is awarded there will only be scope for minor fine-tuning of the contract terms – extensive negotiations will not be entered into F. The commissioner will then evaluate the bids and make a decision based on objective criteria such as price. G. Once a decision has been made the contract will be awarded and the successful bidder will be informed and the contract fine-tuned and completed.

7. Due diligence The prospective bidder should undertake due diligence via formal enquiries and proper investigation in order to identify problems and liabilities that it may be taking on, particularly in relation to premises and staff.

8. Premises for the services Where will the services be provided from? Will you have to take on a lease? If so, take legal advice before signing anything. Each tender will be different, so it’s important to know whether you will be expected to provide services from your own premises, from commissioner-provided premises, or from the existing third party premises (in which case a lease may have to be taken on from the existing provider or a new lease may be required from a third party).

In some cases it may be possible to obtain indemnities from the existing service provider or the commissioner in respect of employee liabilities, although this is unusual in the case of health service contracts. The prospective bidder may find it has existing and transferring staff on different terms and conditions which may cause concern with its existing workforce. The successful bidder will also be required to inform and consult with ‘appropriate representatives’ – which may include a trade union – not only in relation to the transferring of employees, but also to its own employees who are affected by the transfer. Legal advice should always be sought.

10. Scrutinise contract terms Contract terms must be carefully checked when it is issued at the invitation to tender stage of the process. Some common issues frequently arise, including: A. Service specification and key performance indicators – these must accurately describe the services to be provided and the standard to which they must be provided B. Termination clauses – the contract should clearly set out the grounds on which the commissioner can terminate the contract C. Provider break clause – it is rare for such contracts to include a provider break clause, so even if the contract proves not to be economically viable for the successful bidder, it won’t be able to get out of the contract without the commissioner’s agreement D. Entire agreement clause – this will stipulate that the written contract constitutes the entire agreement between the parties, thereby excluding matters agreed in pre-contract negotiations unless they are expressly incorporated in the written contract.

11. Have the courage to walk away 9. Employees and the effects of TUPE If the successful bidder will be taking over an existing service or part of a service, the Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE) will probably apply. Employment contracts of the employees providing the service are transferred to the new service provider. Any liabilities relating to the transferring of employees or arising from the acts and omissions of the existing service provider also transfer to the new service provider. september 2012 | practicebusiness.co.uk

Be prepared to walk away from the process at any stage prior to the submission of the bid if you have serious doubts about the financial viability of the contract or your capacity to deliver it.

It is imperative that the advertised process is followed to the letter

Katharine Mellor is a partner and head of primary care services in DWF’s healthcare group.


16

provision | vendor profile

A good call A practice’s phone system can make or break its relationship with patients. But in these cash-strapped times can surgeries afford to improve? Companies like Atech Systems think so. Practice Business finds out what they have to offer Despite government pressure to go online, the majority of patients still feel comfortable using the telephone to book GP appointments. Add to this the fact that patient communication has become more important than ever – with patients able to choose their practice and rate it on nHS Choices – and it becomes obvious that surgeries will feel pressured to have adequate telecommunications facilities. Fortunately for the many cash restricted, time-poor practice managers out there, there are companies that will help you get the most from your telecoms. one such firm is Atech Systems.

ON YOuR SIDE Atech is a UK-based telecoms company that has been delivering voice and data solutions to the healthcare sector since 2001. Thanks to specialist expertise in telecommunications for general practice, Atech is fast becoming the name for communication in the healthcare market. Through a UK-wide network of consultative sales staff and technical field engineers who work to your hours, Atech is able to help with anything from a simple handset or headset to a comprehensive telephone system with CRM integration. Better still, they run a free consultation hotline for practices in need of a little advice. Supporting Atech’s skills in the field is a raft of products and services from the world’s most respected manufacturers and service providers, including names like Samsung, giving practices that extra peace of mind required to know they have chosen the right telephony partner.

A GOOD DEAl BETTER In these financially challenging times, the idea of changing telephone systems can seem daunting. However, economies can be found in scale. A trend in the field of primary care is federating to create buying power. Practices are partnering across localities for better prices. one such partnership is the LMC Buying Groups Federation. Any GP practice that is a member of an LMC Buying Group is eligible for a group discount with Atech, the only approved telecoms partner with the LMC Buying Groups Federation. Atech has worked with the LMC Buying Groups Federation to develop telephone system solutions specifically designed to meet surgery requirements and members of the federation can take advantage of a special discount on a range of Atech’s products and services, from telephone systems and maintenance to special call tariffs. This means that even standalone practices can get a group discount just for being a member of an LMC Buying Group. Get in touch on the Atech hotline today to find out if your practice is eligible for the discount. september 2012 | practicebusiness.co.uk

Atech, the only approved LMC Buying Groups telecom provider


17

provision | vendor profile

What’s on offer? When it comes to telecoms, Atech offers whatever your surgery requires – from two to 100-plus handsets, integration with EMIS, Vision and (shortly) System One, new call and line rental tariffs or telephone system maintenance. Atech’s LMC System Connect solution can be tailored to include anything from voicemail and auto-attendant to call recording, call reporting, call queuing and music on hold. Atech also offers seamless integration with CRM systems. Its new LMC Patient Connect service, developed by partner Oak Telecom, is the latest communication functionality enhancement for EMIS and VISION. It is a next-generation call recording solution that utilises the award-winning RecordX and Smartphone PC software to link your telephone system to your patient records (see box). LMC Patient Connect can also be used with Vision systems and Atech’s partner developer Oak Telecom is currently working to create a similar offering for System One customers. Atech is currently offering a free-of-charge 30-day trial of the main software. In terms of call tariffs, Atech is able to offer a range of packages, including LMC Connect, available exclusively for members of the LMC Buying Groups Federation. It consists of a choice of three main tariffs, which have been put together to ensure practices benefit from the most amount of savings possible. Furthermore, for practices looking to move away from 0844 numbers, which puts many patients off, particularly those ringing from mobiles, Atech has extensive experience helping surgeries switch back to a local number.

Benefits of LMC Patient Connect n Save time on every call n Instant caller recognition n Enhanced customer service n Verify patient identity n Increase productivity n Instant access to EMIS n Overview of all communication with

the practice

n Audit trail of communication n Regulatory compliance n Training and monitoring n Business protection n Prove who said what n Never misdial n Increased staff performance n Save time n Meet QOF targets

A Samsung solution A UK telecoms market solutions leader, equipment manufacturer and global brand is Samsung – and Atech is one of Samsung Telecommunication’s longest standing direct UK partners. Samsung has a wide range of telephone solutions to suit any size of surgery and budget. For practices with multiple sites/remote branches that wish to benefit from convergence technology, for example, Samsung has their unique SPNet service, which enables practices to have multiple Samsung telephone systems linked together, acting as one networked system. This means that all calls routed between sites using SPNet will be free of charge and calls can be transferred between sites by dialling extension numbers. In short, all sites operate as if they are working from one system – wherever they are. Many surgeries have multiple lines with different numbers to allow for incoming and outgoing calls – often called ‘Bypass’ lines. If you have two incoming main lines and two outgoing ‘Bypass’ lines, it often means you are not always using all of the lines when you could be – at busy times, for example, the two incoming lines would be in use, so patients would then get an engaged tone, while the Bypass/outgoing lines remain free. When using the Samsung system range, Atech has created a unique feature called Line Usage Preference that lets the user switch automatically between incoming/outgoing calls on all the lines, giving you greater flexibility and increased efficiency, so all four lines can use one number. For example, if you have four lines, restriction can be changed automatically by the system so that, say, between 8am and 9:30am patients have access to three of the four lines and at 10am it changes to two of the four lines – leaving two lines free for doctors to make outbound calls. Another useful feature on all Samsung sytem handsets is called ‘Listen’. It lets people hear a call using the hands-free speaker, without the irritating echo. Samsung achieves this by making the ‘hands free’ speaker on the telephone work only one way. This can be particularly helpful for staff training. For practices looking to get more from their telecoms solutions, Atech Systems is a name you can trust, whether you are looking for a full system overhaul or just some good advice. Atech offers very competitive finance rates through its funding partner BNP Paribas. The company’s motto is ‘honesty, integrity and transparency’, which are all things Atech’s surgery telecoms specialist, Mark Horton stands by. “We have a special focus on delivering high quality service levels to doctors’ surgeries,” he says, encouraging practices to get in touch. “If you would like some free, no obligation advice, then give us a call. That’s what we’re here for.”

n Keep up-to-date with changing patient

contact numbers

n General and business contacts n Maximise benefits from caller preview n On-screen extension status n Internal instant messaging n Improved internal communications n Call logs, including missed calls.

Contact details

Contact Atech’s specialist healthcare team today on 0844 854 0054 or e-mail sales@atechns.com practicebusiness.co.uk | september 2012


18

provision | Interview

Size matters

GP practices have got a lot to grapple with as health reforms change primary care forever. CARRIE SERVICE speaks to practice manager and ex-PCT worker SHEINAZ STANSFIELD to ďŹ nd out how small practices can weather the storm Âť september 2012 | practicebusiness.co.uk


20

provision | Interview

General practice is going through some major alterations in light of the reforms, and no one knows this better than smaller practices that have fewer resources to cope with them. Sheinaz Stansfield is a practice manager with 30 years of experience in the NHS, having worked as a nurse and health visitor. Following this, she worked in commissioning at primary care trust and strategic health authority level, where she focused on developing integrated community services outside hospital. She is well accustomed to working with practices of all sizes and is currently in the process of coordinating a merger between her own practice in Gateshead and a smaller surgery nearby. Stansfield believes that the biggest issue small practices are faced with at the moment is commissioning. “And that’s not about becoming actively involved in the commissioning process,” she explains. “The biggest thing is going to be around peer review.” She recommends that small practices that are struggling to cope with the extra work either merge with a larger practice in the local area, or alternatively, federate: “In Gateshead we’ve actually set up a social enterprise: our provider federation. What we’re intending to do is support small practices to help them with the extra work that needs to be done.” The federation has employed salaried GPs and managers so that smaller practices that are struggling to cover their hours due to being heavily involved in the commissioning process can be supplied with temporary staff at a low cost. The federation is also coordinating statutory mandatory training for its practices, meaning they can negotiate better prices than a small practice operating completely on its own due to economies of scale.

accreditation. Around 17 indicators within CQC have always been carried out by practices, including those that target health and safety and workforce and premises, because they are core parts of employment law and have been for a long time. The reason why this now presents a challenge for practices is because they simply aren’t used to being scrutinised in this way. “We haven’t been heavily performance managed in the past,” explains Stansfield. “And we’re going to have to provide evidence to prove we’ve got policies and procedures in place.” For smaller practices this could be an issue, as procedures such as employee appraisals are often very informal. Another hurdle is around information management. Practices will be expected to be pretty nifty with their data management skills, despite being presented with unfamiliar software packages as commissioning changes the way data is used. Many will not be accustomed to having such formal clinical IT systems and so will require a whole new skill set in order to cope with that. By federating, small standalone practices can develop standard policies and procedures that can be used across the board, something that Stansfield is keen to see happen in Gateshead. “We have to operate in a competitive environment,” she explains, “but we are collaborating with all the practices in Gateshead to ensure that all patients have good quality of care.” It is this balance between competition and collaboration that could be key to surviving the CQC process.

By federating, small stand-alone practices can develop standard policies and procedures that can be used across the board

Changes to QOF CQC SOS Something that has been looming for a while now is, of course, CQC september 2012 | practicebusiness.co.uk

The three new QP indicators on A&E attendance, which are now part of the QOF, could cause difficulty for all

»


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provision | Interview

practices, regardless of their size. The QOF now requires a lot more active involvement from clinicians, whereas in the past a large part of the process could be managed by administrative staff. “In a small practice where there are only one or two GPs this is going to be a huge struggle,” warns Stansfield. This is one issue that can’t really be addressed by federating, as the responsibility to meet these indicators falls on the individual practice itself. However, some issues can be overcome by sharing knowledge across the CCG instead. Each individual practice within the Gateshead federation, for example, completes their own audit, and then the practices come together to discuss where improvements could be made and share best practice techniques with one another.

Practices will be expected to be pretty nifty with their data

Losing out on a piece of the pie Changes in the provision of enhanced services could also pose a major threat to the small practice. With primary care no longer having a monopoly over these services, practices will be missing out on a considerable amount of funding if they are taken over by someone else: “Over the last two years we have actually lost three enhanced service contracts, and there is nothing new that is coming to replace those enhanced services,” says Stansfield. Larger practices will be better equipped to bid for services through Any Qualified Provider, however, there is a high risk that many smaller practices simply won’t have the capacity to do this. “I think in terms of practice income that’s going to be a massive issue,” she reflects. “If you think about the NHS health checks, that was one of the first contracts that went out to Any september 2012 | practicebusiness.co.uk

Qualified Provider and now we’ve got pharmacies and all sorts of people providing that. There is talk of flu jabs now being provided by alternative providers, and a lot of the [other] services we provide automatically in primary care.” Again, federating could be a viable way of securing these enhanced service contracts. Stansfield believes that as the Any Qualified Provider process develops, federations themselves will be able to put out the bid to win a contract, and will then be in a position to select practices within their group to provide that particular service.

Bigger isn’t always better One area in which small practices do have the upper hand though is integrated care, particularly when working in conjunction with other organisations. “The smaller practice I’m working with at the moment has just over 2,500 patients, and knows every patient individually,” says Stansfield. “They have really good relationships [with the patients] and also with other organisations that are working with that family, such as social services and community services. Because it’s a small practice and because it’s not too complex, it can actually integrate better. I think in terms of providing personalised care, small practices have a real advantage there.” Stansfield’s own practice of over 11,000 patients has a highly mobile population, including asylum seekers and refugees needing very complex care, making it hugely difficult to have a personalised approach. Smaller practices on the other hand can actually target their patient population as a whole, rather than having to target individual conditions that are particularly prevalent in the area. It could be this idiosyncrasy that will help keep the small practice going, after all, there aren’t many things that can compete with a practice that knows exactly what its patients’ needs are.


one-to-ones with the people making a difference

people

24

and carry on Having started your CQC registration, you’ll no-doubt have plenty of burning questions. Julia Dennison covers the hot topics with the CQC’s David Haslam and Vicky Howes. Their advice? Keep up the good work

september 2012 | practicebusiness.co.uk


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people | CQC

When I meet David Haslam, the CQC’s clinical lead on GP registration and Vicky Howes, GP registration design team leader, they are a little over a month away from the first round of application submissions. Just under 7,000 of the 8,500 practices that need to apply have registered to do so. Meanwhile, the CQC is undertaking a pilot inspection programme. In this crucial time for general practice, the CQC is on hand for questions and queries. I direct a few practice manager-related ones their way. So what happens if a practice does nothing? VH: If they don’t complete this registration set-up, they won’t be able to do their online form; they won’t be registered by the first of April, therefore they could be subject to prosecution because they won’t be registered as per the legislation. This is the first stage to get there. We’re trying to help them as much as possible because we don’t want anyone to be in that situation. So we are sending out multiple reminder letters; we are getting in touch with PCTs and LMCs to let them know who in their region might still need some support and help because they haven’t done it. We’re trying to work with as many people as possible to help people get through this process. DH: We’ve got no evidence that the people who haven’t applied are conscientious objectors or digging their heels in. I think it’s a mix of things. Who at a practice should be the registered manager? VH: Our guidance has always been that you’ve got to think incredibly carefully about it and we are suggesting that it should be a partner because they have that legal responsibility. We think people need to think very carefully before someone else accepts that role. DH: There are some managers who are partners and for them it may well be appropriate. That may be the ideal scenario. When you get around to completing all the online documentation, we think it is important that all the partners should be involved in the discussion and ratify that they have agreed to sign it off. Don’t just push it to one side as somebody else’s responsibility, because it is a major legal undertaking. VH: All the partners are held jointly legally responsible so [if you were a partner], you would want to know what you are signing up to.

Should the wider practice team be involved too? VH: We’ve given them tools so that they can do that. On our website there is a resources section with template agendas, slide packs, checklists and the ability to print out the application form, so that you can have a practice meeting and everyone can get involved. Because some of the standards are about things like: ‘Does everybody know what you should do with a safeguarding issue?’, everybody should be involved in it, but the people who take legal responsibility are the partners. How long should an application take? VH: It depends. If you’re a very good practice; you’ve got all your governance, data quality and contract-monitoring information already there, you’ve probably got all the evidence you need.

We spotted a debate on Twitter a month or so back on waiting room toys. A PCT had said the CQC was going to demand that all toys are thrown away because they don’t match our hygiene code. There’s absolutely no truth in that at all Filling in the form when we did the testing in the field, it took between 40 minutes and an hour and a half. Actually filling in the form is a very small part – it’s the preparation you do beforehand. If you’re a good practice, that shouldn’t take too long. Is that preparation something they should be doing now? DH: Pretty well all practices want to deliver high quality care for their patients. They care about the safety of their patients, their staff, environment, etc. and will have addressed all these issues. If they have, then there’s very little else that we require. If they haven’t, well maybe they should have done, so there will be work to be done. Are there any problem areas uncovered with dentists, who had to be registered a year and a half ago? VH: Infection control is something that has come up with a few of the dentists and we’ve also identified instances where improvements could be

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practicebusiness.co.uk | september 2012


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people | CQC

made to record-keeping, training and issues around safeguarding. Would you recommend GP practice managers speak to dental practice managers about their experience? DH: No, it’s totally different. If dental practice managers say they had not a terribly easy time of it, then medical practice managers can thank them for the experience which has taught CQC a lot and given us an opportunity to revise our processes quite dramatically. Can practices that feel they are doing things well afford to be blasé? DH: There’s a balance between being blasé and taking it seriously. We are a regulator with strong legal powers and it’s important that people recognise that. But, also, if they have been assuring themselves, they will almost certainly be assuring us. There are all sorts of myths that we want vast box-files of protocols for everything under the sun. That is absolutely the last thing we want. We have no particular interest in such things. You’ve been considering your options with inspection notice periods. Have you made any decisions? DH: Part of our piloting is looking at the impact of different notice periods. I chair a stakeholder group, which has representatives from the BMA, the Royal College of GPs, the Family Doctor Association, the GMC, the Royal College of Nursing, the National Association of Primary Care, the MDU, the MPS, and the LMCs. We’ve been meeting regularly with that group for over a year and discussing all these issues and taking onboard all the views. As far as the notice periods are concerned, in pretty well every other sector we work on an unannounced visit basis, because I think that’s what the public would expect. They don’t want organisations to get the paint brushes out and tidy everything up just because [we’re coming]. We absolutely recognise the impact of our inspectors descending on a Monday morning in the middle of a busy surgery when someone’s on holiday – it could be damaging to patient care september 2012 | practicebusiness.co.uk

and that’s the last thing we’d want. We’re in the business of improving. So we’re looking at the different options and it’s nowhere near as straightforward as it may seem. Whilst we recognise that some organisations have asked for a month’s notice, that might be harmful. It might actually mean [practices] waste a month preparing stats for us or employing new staff, so it’s not as straightforward as saying the more notice the better. It may actually turn out that relatively short notice, so there’s less time to worry about it, may be better. VH: And we also want to see how they work on a day-to-day basis. Not how they work if they’ve been given a month to prepare. If there were no-notice inspections and you arrived upon a practice with doctors on holiday – would you consider coming back another day? DH: We’re looking at all these issues – as I’ve said, our business is of improvement, not causing ourselves to be a problem. It’s a tricky balance because we don’t expect the inspection to take doctors away from the doctoring or the nurses away from the nursing, maybe apart from very brief interviews, practically I’m sure most of this will be with the practice manager. But it’s also important practices can function whoever’s there. Patients aren’t particularly interested in who’s in the building, they just want to have a good service and that’s what we’re looking at. Can you tell me about the GP provider reference group? VH: We’ve got about 700 representatives signed up to it. It’s been running for quite a long time. It’s an online group and people can get involved as much or as little as they want to. You could sign up for it and dip in and out as you want, or you could sign up for it and be completely involved. It doesn’t mean you have to do things. How is it used? VH: We use it in a number of different ways. We use it to answer people’s queries and

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we hold live Q&a sessions and we’ll be doing that around the end of the closing of the submission window and over the next few months as well to help people through it. we also do polls to see how it feels out there – what is worrying people, what do they need more FaQs about, where do they need more clarification. it’s where we drew volunteers to test the form and for the pilots as well. we also use it for if we’re going to do any guidance, we share it with that group to basically say: ‘Does it make sense?’

don’t match our hygiene code. There’s absolutely no truth in that at all – none whatsoever. so we stamped on that right away. There have been stories that we’re going to demand that all carpets are ripped up – no we’re not.

Can anyone in general practice get involved? VH: anyone can get involved by signing up on our website. it’s managed by a thirdparty company so we don’t actually know people’s names or anything, so if you do ask a query, we won’t know who you are. it’s anonymous, unless you volunteer for something.

DH: if people hear things like that, or are told ‘CQC is going to do such and such’, we’d quite like to know about it because chances are it may not be true.

DH: we would positively encourage people to get involved. it’s of no disadvantage to them. There’s plenty of value and advantages. Is there anything else you want to get across to practices going through the registration process? DH: There are an awful lot of myths out there which we’ve gone out of our way to bust as much as we can. some of it driven by well-meaning but unhelpful PCT staff who think they know what we’re going to do. For instance, we spotted a debate on Twitter a month or so back on waiting room toys. a PCT had said the CQC was going to demand that all toys are thrown away because they september 2012 | practicebusiness.co.uk

VH: we had one where PCTs were going around with tape measures saying the corridors were too narrow and the reception desks were too high. we’re not coming with tape measures. That’s not what we’re about.

What’s the best way of getting in touch? VH: There is a dedicated phone line, but the best way is by emailing 2012registration@cqc. org.uk because you get a written response back. Any final words to practices? DH: we know as regulators no one’s going to like us – no one’s going to say thank you – we’re not expecting that. all we’re after fundamentally is for people to feel that it’s fair and that it’s ultimately going to be to the benefit of patients. i think most people recognise that there is a very small rump of poor quality practice out there, which hasn’t really been addressed since the health service was founded and which lets everybody else down. i think if we can do something to help those patients, then that’s going to be Got more questions? worthwhile. But for the majority of practices Visit CQC.org.uk or email 2012registration@cqc.org.uk – keep calm and carry on.


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PRACTICEBUSINESS


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people | interview

All change at

The Old Exchange Greer Deal has been practice manager at the Old Exchange Surgery in St Ives, Cambridgeshire, for four years, having previously worked full time in the pharmaceutical industry. She has been trying to implement a new clinical IT system at the surgery for the past two years and finally got her wish, with an entirely new system being installed just last month. Here she tells Carrie Service about the ups and downs and her hopes for the future Âť

practicebusiness.co.uk | september 2012


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towards a paperless environment. Before we would get outof-hours messages via fax machine and then we had a system where we would write up that someone has just been admitted… now it comes through our clinical system so it’s all electronic… It’s seamless.” Many of the other practices within the St Ives locality will also be using the same system, meaning they can potentially interoperate where necessary, and they are planning to set up a support group to troubleshoot and share best practice with one another.

The Old Exchange Surgery in St Ives, Cambridgeshire is a small practice with a patient population of just over 2,600 people. Nevertheless, it faces many of the challenges that all practices face on a day to day a basis, and when practice manager Greer Deal came on board four years ago, she was determined to make her mark and improve the running of the surgery. “I’m very keen as an individual – and I think I’m conveying this to everyone else – that we should have tools that help us work more efficiently and more effectively, but make our working lives easier,” she explains. It’s clear to see that she is passionate about making life as easy as possible for her staff, and there is a strong sense of team spirit about the place – essential in a practice where everybody is part time and the lines between roles become frequently blurred. “They all wear several hats, they do lots and lots of different tasks within their job role,” she tells me of her team. Deal has a good knowledge of IT, having used many different systems in her career in the private sector. She could see that the existing clinical system was a powerful tool and had the potential to really improve efficiencies in the practice – it just needed modernising. Making improvements The practice’s old system had to be backed up every night and tapes were stored off-site, which presented security implications, and Greer felt sure there were more up-to-date systems that could do a better job. “I just felt that there was a better tool out there somewhere,” says Deal. The new system now stores all clinical data in the cloud, and is constantly backed-up automatically, almost eliminating any risk of data loss. Although still in the “honeymoon period”, as Deal puts it, the surgery has already begun to see the benefits of switching over. Its out-ofhours service has just gone live with the new system and already there has been a positive effect on paperwork levels: “We’re getting all the out-of-hours reports [via the system] and when our patients go into A&E we get notified so we can see straight away what has happened,” Deal explains. “It is really working september 2012 | practicebusiness.co.uk

Teething problems The one thing the old system did have going for it was that everybody knew how to use it. “A lot of people don’t like change,” reflects Deal. “They were comfortable with [the old system], they knew where everything was, and it was all really easy.” Convincing people to change their approach to their work and embrace new technology proved to be quite a challenge and hasn’t been without its teething problems. The system went live in the second week of July, so was still in the throes of inauguration when our interview took place. The practice found the first couple of weeks of going live quite tough, but they got through it. “I think now we’re actually going through the painful period; the first two weeks are what I’m calling ‘the honeymoon period’ and now people are finding it really hard because they are still not up to the speed that they were used to working at with the old system,” says Deal. So can she see a light at the end of the tunnel? “I definitely can, and I think there are times with everyone else where they think ‘I wish we hadn’t done this’ – but we had no choice actually – in the end we were going to have to

go with a new system. It was a case of ‘when’, not ‘if’. I’ve been told some members of staff are saying ‘I’ve got to believe that it’s going to be worth it and it’s going to be better – but when?’ So it’s been quite a challenge to keep people motivated and engaged in the new system.” The greatest challenge was actually getting the clinical staff on board with the changes in the first place;

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where the admin staff had always been keen to have a new system, the clinical staff weren’t so enthusiastic. “It was really them that I needed to get buy-in from and that was the hardest. They were used to using [the old system], they’d used it all their careers.” A mammoth task The process wasn’t a quick-fix; all staff had to be trained, which is quite a feat when every member works part-time hours, and in the run-up to going live, all data had to be double- and triplechecked after being converted into its new format ready to be transferred onto the new system. “It’s not something that one person can do by themselves,” warns Deal, “you have to have a team, and I’ve got to say the staff here have just been absolutely fantastic.” During the go-live week, technical help was always available with trainers constantly on hand. But in the second week the practice was left to its own devices. To try and help ease the situation, four ‘super-users’ – the members of staff who had received the most training – were nominated to provide support after the trainers had left. Deal then arranged the rota so that there was always a ‘super-user’ on-hand who knew the system well enough to address any issues that occurred. To get a real feel of how the system worked on every level, she shadowed the doctors and nurses during their training sessions so that she could learn the processes from a clinical and administrative point of view.

opener to us as well… We’ve had feedback from them and we take that all on board. They come up with some really good ideas so we implement them wherever possible.” Looking ahead Deal is also in the process of coordinating a new phone system at the surgery – but wisely thought it best not to do it at the same time as implementing the new IT system. She is hoping to get this up and running sometime this month: “Again, that’s to help everyone work more efficiently, and help the patients too. Because we do have a really, really old system and it’s been quite problematic. Even in terms of support, nowadays if you need support an engineer can just dial in and fix it remotely – with our system you can’t, they have to come out, and it’s over a hundred pounds just for a call out.” These improvements are all part of a complete overhaul of the practice, which will include looking at staff hours and responsibilities. Deal is hoping to create a more formal structure for each member of staff so that they know exactly what tasks they are responsible for and have enough “protected time” to complete them. She can’t speak highly enough of her team and obviously works hard to see that they get what they want out of their job, just as much as she gets what she needs out of them. And with the plans Deal has for The Old Exchange Surgery, it’s clear to see she has all the help and support she needs to make them a reality.

We should have tools that help us work more efficiently and effectively but make our working lives easier

Patient patience Every effort was made to ensure that patients were aware the surgery’s service would be affected during the first few weeks of the new system being installed. Deal arranged for communications to be sent out to all patients; posted an advert on the website; had information on the surgery noticeboards and put leaflets in with prescriptions. Despite all of this, the practice did inevitably receive some negative feedback from patients. However, it is still very early days and Deal has every confidence that it will all be worth it in the end. She feels that a good relationship with patients is vital to the running of the surgery and the success of these kinds of improvements. The Old Exchange does have a patient participation group, albeit of only three individuals, but nevertheless, the importance of having this vital feedback is recognised by the surgery and Deal very much appreciates the two-way learning opportunity it provides: “They’ve been fantastic and we’ve kept them involved in what’s been going on. It’s been interesting to talk to them because we are pretty transparent with what goes on and what’s going on within the NHS as well as the practice… So it’s been a real eye-opener to them, but on the other hand it’s been a real eyeseptember 2012 | practicebusiness.co.uk


MEDICINES OPTIMISATION WITH FDB

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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


business intelligence and management sense for practice managers

MANAGEMENT

36

All aboard Want to get you and your team involved with commissioning, but not sure how? CARRIE SERVICE gives a run-down of clinical senates, health and wellbeing boards, and the less direct routes to commissioning

september 2012 | practicebusiness.co.uk

With commissioning probably becoming the most commonly used word in healthcare at the moment, you might be wondering how it is going to affect you as a practice. Some of you in larger practices are choosing to take a proactive approach to commissioning by actually getting involved with the local board itself. But there are less direct methods of contributing to the way services are commissioned in your area and you may even be doing it already without knowing it. As integrated care has become the main priority for the NHS in light of the reforms, a lot of the emphasis has inevitably fallen onto primary care to implement the necessary changes and new services. GP practices are at the forefront of ‘the patient experience’ and therefore are well placed to gather the information needed to help influence decisions within clinical commissioning groups. Senates, strategic clinical networks and you In order to know how you can get involved in the commissioning process, you first need to understand the structure of the NHS as it stands (for the time-being at least). To commission services that are relevant on a local level, there needs to be a lot of local input and to achieve this, the NHS Commissioning Board has created 12 areas in England to be overseen by clinical senates. These senates


37

management | commissioning

will be made up of clinicians, other professionals and members of the general public and their purpose will be to advise CCGs in their allocated area. For these senates to best advise the CCGs, they will utilise information from strategic clinical networks, which will be established and hosted by the NHS Commissioning Board. What are strategic clinical networks? Strategic clinical networks are a more formal version of clinical networks. There may already be existing clinical networks in your local area, and these can vary in terms of their size and type. Many networks are dedicated to a particular condition or disease such as cancer or stroke and are aimed at raising standards and improving services for that particular condition. In areas that present major health challenges because of the demographic of the local population, the NHS Commissioning Board will establish strategic clinical networks in the hopes of reducing regional variation of the treatment of specific conditions. The use of networks in general, whether formal or informal, are encouraged by the NHS Commissioning Board because they have already proven to be a success in many areas, and are an effective way of tackling the management of conditions on a local level head-on. Networks in practice Dorset Cancer Network is an example of a clinical network which combines the knowledge and expertise of a range of organisations to improve cancer care. The organisations that form the network include: Dorset, Bournemouth and Poole Primary Care Trusts; voluntary sector organisations including Macmillan Cancer Trust and Lewis-Manning Hospice; the local acute hospital trusts and

the Dorset Cancer Network Patient Partnership Panel, made up of cancer sufferers and carers. The programme developed by the network covers every step of the pathway, from prevention to diagnosis and treatment, to living with cancer and end of life care. On a practice level, some of the recent projects include creating lung and bowel cancer awareness videos to be displayed on the ‘Life Channel’ in GP surgeries and supporting local cytology with meeting the 14-day national turnaround target for cervical screening results. Strategic thinking Strategic networks will be set up in a more formal way than the current clinical networks – the Government has taken the good practice demonstrated by the success of these groups and decided to apply it to the areas it is believed will benefit most. Rebecca Larder, director, East Midlands Cardiovascular Network explains: “The NHS Commissioning Board has confirmed that it will host a category of clinical network, entitled strategic clinical networks – SCNs – in the new system. These will operate throughout the country, from April 2013, for four groupings: cancer; cardiovascular; maternity and children; mental health, dementia and neurological conditions.” But what will these do that is different to what the current clinical networks are already doing? “SCNs will bring together professionals and organisations to improve the quality of care for agreed pathways. It is expected some of the improvement initiatives will focus on prevention and primary care, and there will be opportunity for GP practices to get actively involved in their work. Once these networks are established there will be local discussions and events to support involvement.”

»

practicebusiness.co.uk | september 2012


38

management | commissioning

Health and wellbeing boards Health and wellbeing boards, as you no doubt already know, will integrate health and social care by acting as a forum where key leaders from the health and social care systems can work together and share knowledge. These boards, like strategic clinical networks, will have influence over commissioning decisions across health, public health and social care. They will have democratically elected representatives and also patient representatives who will be directly involved in commissioning decisions alongside commissioners. The boards will also be a forum for discussion, and must involve local people to ensure input from the public. The boards will consist of: one local elected representative; a representative of a local Healthwatch organisation; a representative of each local clinical commissioning group; the local authority director for adult social services; the local authority director for children’s services and the director of public health for the local authority. This may actually have raised more questions for you than it answers – for example, what is Healthwatch? Is this the same as the Health and Wellbeing Board? Well yes; and no. Healthwatch is centred around input from the local community and is split into two parts: Healthwatch Local and Healthwatch England. Healthwatch Local has been created to develop (or replace) the influencing LINks (local involvement networks), which were usually made up of individuals and community groups such as faith groups and residents’ associations. Representatives from Healthwatch are required to sit on health and wellbeing boards, in order to get the local community input that there is such a high emphasis on. Join the club NHS Medway decided to launch its own ‘commissioning group patient council’, which will work in a similar way to Healthwatch and clinical networks, by advising the CCG, but will combine a more diverse range of individuals, including at least three practice managers – one from each of the localities in the CCG. “We want to become a truly listening, communicating and engaging organisation,” says the NHS Medway website, “supporting people to understand more about their health and by actively incorporating feedback into commissioning decisions.” This is building on the already established Medway Health Network, but adapting it to target commissioning related issues specifically. Other representatives on the patient council will include: nine PPG members (three from each locality) three Health Network members; one Healthwatch representative; a GP lead or appropriate commissioning lead; a Medway Commissioning Group management representative; a ‘communications/engagement representative’; members from the voluntary sector and other provider representatives, and a lay person as chair.

The use of networks in general, whether formal or informal, are encouraged by the NHS Commissioning Board because they have already proven to be a success

september 2012 | practicebusiness.co.uk

By working with other practices in your locality to form a group like the Medway’s commissioning patient council, or a clinical network for a condition that particularly affects your patient population, you can ensure your voice and the voices of your co-workers and patients don’t go unheard in the commissioning process.


40

management | QOF

Paul Lambden Dr Paul Lambden is a practising GP and a qualified dentist. He has been a GP for 35 years, over 20 of which have been in practice. He has previously worked as an NHS trust chief executive, principal of a medical defence organisation, LMC secretary and Parliamentary special adviser. He is a writer and broadcaster

Epilepsy

Epilepsy is a common chronic neurological condition that was first identified by Hippocrates and claimed the likes of Charles Dickens and Napoleon as its sufferers. Paul Lambden explains what QOF points are available for registering and managing patients with the disorder Epilepsy is a common, chronic neurological disorder. Sufferers experience recurrent seizures (fits) associated with bursts of abnormal electrical brain activity. The condition, which was first identified by Hippocrates, affects all ages, races and social classes. A total of 14 points is available for fully meeting its Quality and Outcomes Framework parameters. Epilepsy commonly develops in childhood or over the age of 60 but may present at any age. The seizures cannot be cured but are frequently controlled by anti-convulsant medication although about a quarter of sufferers continue to have seizures despite treatment. The incidence of epilepsy is about one per cent and in the UK there are estimated to be about 450,000 sufferers. There is one QOF point available for producing a register. Common causes include head injury, infections such as meningitis, a stroke, tumour or scarring in the brain. In many cases it is idiopathic (meaning no cause is apparent). There are over 40 types of seizures and they may vary from simple ‘absences’ to generalised convulsions. In the simple form, the individual may simply go ‘blank’ for a short period and feel confused or disorientated. In the generalised form, the patient may become rigid, fall to the ground and have a convulsion, during which they experience violent shaking. It is during such episodes that patients may injure themselves by suffering head injury or biting their tongue. Some patients get a warning that they are about to have a fit while others have no warning and are unaware that anything has happened. In such cases the diagnosis is often made by eye-witness accounts of the events. Epileptic seizures may occur as a response to a particular trigger, such as reading, rapid breathing, stress, sleep deprivation, fever or being exposed to flashing lights. Sometimes the fits occur when the patients are actually asleep. In many patients no cause is found for the epilepsy but in others birth trauma, head injury and congenital abnormality or, later in life, stroke or tumour may be the initiating cause. In some people the epileptic fits stop spontaneously and the remission may be temporary or permanent. The management of an epileptic fit by an onlooker is simply to move harmful objects out of the way of the individual so that he or she does not injure themselves on them. Under no circumstances should any attempt be made to put anything between the teeth. Patients with epileptic symptoms can be investigated to see if a cause can be identified. Brain electrical activity can be recorded using an electro-encephalogram (EEG) and this can help to establish which part of the brain is affected. Magnetic resonance imaging (MRI) scans are also useful to establish whether there is a physical cause which might be amenable to treatment. Patients with epilepsy can be treated with anti-convulsant drugs. Therapy has been available for about 100 years. Early drugs used were phenobarbitone and later phenytoin (Epanutin). In recent years the number of available drugs has increased considerably and there

The management of an epileptic fit by an onlooker is simply to move harmful objects out of the way of the individual. Under no circumstances should any attempt be made to put anything between the teeth september 2012 | practicebusiness.co.uk


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are now more than 20 available medicines. The drugs cause side effects in most patients including drowsiness, mood changes and unsteadiness as well as more generalised constitutional effects. About half of all patients obtain control using a single drug with about 15% being controlled with two drugs and an additional three per cent with three drugs. In some patients, surgery is an option where the irritable focus of the seizures in the brain can be destroyed or ablated and such treatment may abolish the fits. In cases of tumour or bleeding, surgery may help in resolving the symptoms. Sometimes surgery is partially successful. For some patients the incidence of symptoms can be minimised by avoiding the triggers that induce the fits. Up to four QOF points can be achieved for recording fit frequency in up to 90% of epilepsy sufferers and up to another six points for recording freedom from seizures for the preceding 12 months in up to 70% of patients. Up to another three points can be obtained for counselling up to 90% of appropriate women about contraception and pregnancy. Seizures can have profound effects on the life of someone with epilepsy. Their nature and unpredictability cause injury, embarrassment and limit activities. Epileptics are prohibited from driving unless they can show to the DVLA with medical corroboration that their fits have been abolished for a period with treatment. Doctors have a duty to report a patient with epilepsy to the DVLA if the patient has not done so him or herself. Epileptics are prohibited from flying aircraft. Epilepsy has affected many famous people, including Sir Isaac Newton, Napoleon, Charles Dickens, Richard Burton and Agatha Christie. These days, with specialist support, life can be returned to normal for the large majority of sufferers and treatment continues to improve.

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

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ager


42

management | Legal

Bigger fish to fry As we saw earlier in this issue, smaller practices are under increasing pressure to merge with larger practices. But what legalities does this entail? Oliver Pool talks mergers, federations and other structures Mergers of GP practices are on the increase. For a small practice under pressure from commissioners and regulators, joining forces with a neighbour looks increasingly attractive. At the other end of the scale, larger practices forming ‘super partnerships’ of 20,000 patients and upwards gives potential for economies of scale, and greater influence in the local healthcare economy. Some take the view that mergers are the only way forward, on the basis that the current smallbusiness model of general practice isn’t sustainable much longer. But there are other options. Many practices are already part of informal federations sharing knowledge, resources and work. There are many different types of federation out there. Informal federation may become more definite structures as time moves on, although critics suggest federations are only a temporary solution – at best that can help the current model of general practice to survive a bit longer. Before a merger can be achieved, a lot of groundwork needs to be carried out. Each practice will want to carry out due diligence on the other and accountants should be involved. It is key to investigate how well the two practices might fit together, culturally and practically. In particular, if the two use the same IT system then a large amount of work will, effectively, already have been done. A common obstacle to a merger is where there is a difference in partnership profits. In some cases the merger is driven by the fact a partner is approaching retirement. If that partner runs the less profitable practice, he or she may be content to move to a salaried role until retirement instead of having a profit share in the new business. The PCT (or its successor) should be involved at an early stage, because it effectively has a veto. september 2012 | practicebusiness.co.uk

GMS contracts are non-assignable, meaning that strictly the PCT ought not simply to move it from one provider to another. If for any reason the PCT did not wish a merger to proceed, it could argue that the dissolution of one partnership means the

Practice ‘super partnerships’ allow for economies of scale and greater influence in local healthcare contract should be put out to tender, which would be likely to scupper the entire deal. Whilst unlikely in practice, this illustrates the importance of keeping the PCT informed. There will almost certainly be a TUPE transfer of staff, on which legal advice will be required. That aside, in legal terms a merger can be documented reasonably simply: a partnership deed can be drawn up for the newly-merged partnership, which will include “cross indemnities” – i.e. provisions under which the partners of practice ‘A’ indemnify the partners of practice ‘B’ against any liabilities in practice A up until the merger, and vice versa. In reality it is likely to be one or both practice managers making the merger deal happen. Our advice for those in that position is that it is very important to ensure that you do not oversell the benefits of the merger to the partners – far better to under-promise and over-deliver.

For further advice on practice mergers, cooperative working and other reorganisations, contact Oliver Pool on

opool@vwv.co.uk or 0117 314 5429


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TAKE A CHILL PILL september 2012 | practicebusiness.co.uk


45

work/life | stress

Stress at work can cause major problems for you and your colleagues, resulting in an unhappy environment for all concerned. George Carey finds out how to keep it at bay The problems around work-based stress are well documented and while the stigma formerly attached to raising such issues has thankfully disappeared, it’s still an issue for millions of people in the UK. Despite not working directly with patients for the majority of the day, practice managers are exposed, if indirectly, to the heightened levels of stress associated with a healthcare environment. When this is added to the general stress of a management role, it can be a toxic combination. To acknowledge and attempt to alleviate the stress that managers can experience and pass on to their staff, The Chartered Institute of Personnel and Development launched a free stress management tool this July, developed with the Health and Safety Executive. Ben Willmott, CIPD head of public policy, comments: “Stress is a major cause of sickness absence and lost productivity and is linked to a higher risk of accidents at work. Prolonged exposure to stress is also linked to conditions such as depression, anxiety and an increased risk of heart disease. Managers can either cause or exacerbate stress or help prevent and manage it.” So how can you go about creating a stress-free environment? The HSE defines stress as “the adverse reaction people have to excessive pressures or other demands placed on them”. Stress symptoms include a pounding heart or palpitations, a dry mouth, headaches, odd aches and pains and loss of appetite and the way you deal with stress can encourage unhealthy behaviour, such as smoking and drinking too much. Life coach Suzy Greaves, says one of the key skills to managing workplace stress is knowing how to say no. “I’m constantly challenging clients who say they have no choice but to overwork,” she says. “I coach people to become empowered and believe they have a choice.” She explains that saying ‘yes’ can win you brownie points in the short-term, but if you take on too much and fail to deliver, it can be a disastrous long-term strategy. “Have confidence in your ‘no’ when you think it’s the right decision, even though it may not be the most popular one,” she says. “In the long-term, your ability to say no will be one of your most valuable attributes.” Greaves says you can prevent exhaustion by knowing how much work you can take on. By taking on too much, you could end up doing nothing well. Calculate how long you’ll need to deal with your current workload so that you

can see if you have any extra capacity. “If you’re extremely busy and someone asks you to do more, you can say no. Outline your reasons in a specific, measurable way, but always offer a solution.” Although it may sound counterintuitive, one of the biggest problems is identifying with the problems of the people that you deal with, according to stress therapist Helen Wingstedt: “On one level it works because the two people are empathising with one another and it makes the other person feel comfortable, but it can also evoke the same feelings of stress in the person doing the empathisisng.” Wingstedt’s approach is all about separating positive and negative stress. Negative stress is driven by baggage, conflict and upset from the past. Positive stress is more taskorientated, such as: I need to get to work on time; finish this report; or complete the staff rota. It’s about achievable goals. As she explains: “When someone’s got lots of short-term tasks, it keeps stress down because you can achieve them quicker. Every time you achieve one, you dump a load of stress. As soon as you’ve completed something, your mind dumps the stress because you don’t need it anymore, which makes you feel really good and gives you a natural high.” The problems come with longer-term problems such as planning the budget for the next five years, or opening a new practice. The more long-term goals you have, the less you’re achieving, but stress is mounting up all the time. The answer is to break them up into small tasks. Wingstedt explains: “Rather than worrying about opening a new practice in three years, you work backwards and work out what you have to do between then and now. You can break it down into 60 tasks in those three years. It lets you dump loads of stress in the meantime and lets things happen naturally.” She concludes: “It’s about setting up work practices so that you can recognise the problems and deal with them. Once you tell someone, it seems really obvious but it’s just a matter of reminding yourself that you don’t have these issues and taking a step back.” While all of this sounds like common sense, it can be difficult to remember at nine o’clock on a Monday morning with a mountain of work precariously balanced on the edge of your desk. If all else fails, take a holiday, but be warned: it will all be waiting for you when you get back.

It’s all about separating positive and negative stress

practicebusiness.co.uk | september 2012


46

Work/life | diary

Practice diary THIS MONTH: Sharon Turner from East Bank Road Medical Centre in Sheffield about moving premises Sharon Turner Sharon Turner is the practice manager at East Bank Road Medical Centre in Sheffield

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

Until recently, the future for our surgery looked bleak. We were operating from an old, cramped, rundown premises that simply wasn’t fit for purpose. We had made alterations and extended over the years but reached a point where we had completely run out of space and the building could not be developed further to the appropriate standard. We were aware the process of premises development was a complicated one and there were many different options available. We discussed them at length and took the plunge. When we finally made contact with GP Surveyors, who became our specialist advisor throughout the process, some of the weight was lifted and we knew we had the foundations of a good professional team. We had to be patient when locating an appropriate plot of land, gaining backing from the PCT (including negotiating our new notional rent figure) and securing funding from Lloyds TSB. However once we got the final go ahead, a whole project team was drafted in which included architects, developers, solicitors, accountants, the PCT, the local authority and more. Suddenly we weren’t in it alone and could finally see the light at the end of the tunnel. The project ran smoothly and it was great to see our new surgery developed from nothing into a fantastic, state-of-the-art premises which delivers some of the best primary healthcare services in South Yorkshire. The new build saw our practice expand from five to 14 consulting rooms which now also provides a community base for other specialist services including: diabetic eye screening, physiotherapy, mental health services, an onsite pharmacy, chiropody, and a phlebotomy training service. We have also managed to increase our own clinical team, provide student placements for undergraduate doctors and we will be recruiting for yet another GP next month. Our premises is bringing in additional income to boot as it was specifically designed to achieve the maximum notional rent possible and to allow

us to create an income stream from tenants. The success of our project is due to the time, commitment and effort put in by the surgery staff and development team. The lack of high quality GP surgery premises like ours has dominated the UK healthcare headlines over recent months, with many practices worried about how they will be able to meet the growing demands on primary care. The public ratings on the NHS Choices website is only adding to the growing pressure on surgeries as patients are now able to make informed decisions about where they can get the best quality of care and service – something the CQC will also be looking out for in their inspections. My message to other practices who are struggling in inadequate premises is to take the bull by the horns and find out what your options are for improvement. Don’t view the Health and Social Care Act as a deterrent. Get out there and speak to people who can help, do your research and build a great team around you. You’re right; you probably can’t do it on your own. But, you don’t have to.

Top tips Development tips from a practice that has done it l Don’t underestimate the value of creating a fool-proof business plan. You must have all bases covered before you begin to avoid any losses. l Don’t assume the PCT or funders will support your project. You will have to present your business plan and be willing to make adjustments. l Give yourself plenty of time. Development projects can take a long time to come into fruition. However, the longer you delay, the longer you will have to wait for a new premises. l Once you’re given the go ahead, spend time sourcing the best specialist development team. You could be working with some of them for a year or more, so they need to be right. l Have confidence in your project and the benefits that it will bring to your community. If you don’t believe in it then no one else will.


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Fighting Fire with Fire

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

020 7288 6833 subscriptions@intelligentmedia.co.uk @ www.practicebusiness.co.uk/subscribe/

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


Practice Business September 12  

Practice Business