Commissioning Success Nov/Dec

Supporting excellence in healthcare

november/december 2012

Get your facts right Big data and why the Yanks are leagues ahead

Volunteering information Why working with the voluntary sector is vital

Unpopular decisions The political challenges of closing hospitals

Editor’s letter

CONTENTS COMMISSIONING UPDATE

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EDITOR

CONTACT US

News and updates The latest news for clinical commissioning

06

Get your facts right Roger Hymas on big data and why the Yanks are leagues ahead COMMISSIONING IN ACTION

s commissioning groups vie to become statutory bodies, it’s more important than ever to know where to look for help. In this issue, we look at the various organisations that are there to be by your side, and which should not be overlooked on the road to commissioning.

First off, there is social care (see p26). The whole point of the Health and Social Care Act is to bring together the two halves for the greater good of the community.

As a commissioner, you may well have some involvement with the Health and Wellbeing boards, and this is a great way to ensure service integration between health and social care. For integration in action, have a read of the article on reducing emergency admissions on page 36, which features a case study with Jane Wells, the service director at Oxleas Foundation Trust on how she has worked to integrate with Greenwich Social Services.

Secondly, when it comes to reaching out for help, there is the third sector, or charities. Jane Maher, chief medical officer at Macmillan Cancer Support’s article on the Bournemouth After Cancer Survivorship Project (p24) demonstrates how CCGs can improve the health of those with a cancer diagnosis in their communities. Also, page 44 presents an article on how CCGs can work closer with the voluntary sector.

Lastly, and this is perhaps most important right now, there are the PCTs, which are a wealth of knowledge and information. While CCGs should be cautious not to directly emulate what has come before, primary care trusts are a resource that will not be around forever – in fact, only for a few more months – so now is the time to have a good think about any questions you may want to ask before they disappear completely. Our article on page 48 will help you with your list.

In short, it’s important that CCGs not feel that they only have the support of commissioning support services or units, but should now be making those contacts that make them feel comfortable taking services forward in the long-run. It’s going to be a bumpy road, don’t feel you have to walk it alone.

EDITOR julia.dennison@intelligentmedia.co.uk

SALES EXECUTIVE nazia.chishty@intelligentmedia.co.uk

ASSISTANT EDITOR carrie.service@intelligentmedia.co.uk

DESIGNER sarah.chivers@intelligentmedia.co.uk

REPORTER george.carey@intelligentmedia.co.uk

DESIGNER/PRODUCTION peter.hope-parry@intelligentmedia.co.uk

PUBLISHER vicki.baloch@intelligentmedia.co.uk

CIRCULATIONS natalia.johnston@intelligentmedia.co.uk

SENIOR SALES EXECUTIVE george.petrou@intelligentmedia.co.uk

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12

Transitional thinking Shane Gordon of North East Essex CCG discusses the larger issues

20

New horizons Jan Ledward, commissioning development transition director for NHS North West COMMUNITY CARE

24

Teaching cancer Jane Maher of Macmillan Cancer Support on how CCGs can help sufferers

26

Socially responsible How CCGs can reach out to social care by way of the Health and Wellbeing Boards

32

The TSA effect Lawyer Michael Boyd considers the trust special administration process

34

Unpopular decisions Murray Keith of CLCH NHS Trust looks at the political challenges of closing hospitals INFORMATION AND TECHNOLOGY

36

Emergency info What you can do with good shared information around emergency admissions

40

Making a PACT Ensure your CCG has the right tools to make better medicine decisions

42

Information talks A trainer in information governance talks about why it’s important MANAGING COMMISSIONING

44

Volunteering information Why working with the voluntary sector is vital for a successful commissioning group

48

Working with PCTs When to take their advice, when not to, and what you need to know before they go

50

Top tips Constructive feedback and how it can help

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

MONTH 2012 | 3

Update News

NEWS CCGs ‘must be given a chance to succeed’ Gary Belfield, associate partner at KPMG Management Consulting, has warned that CCGs need time and space to develop before they become excellent commissioners of healthcare.

In a talk at the annual Practice Managers Conference in Suffolk earlier this year, he said: “It’s something of an understatement to say that the advent of CCGs has polarised opinions, but whether viewed with anticipation or trepidation, they must be given every chance to succeed. Assuming control of a healthcare budget of £64bn is a huge

responsibility and it comes with more than the usual challenges of change – but these can all be met with a consistent and transparent approach to healthcare decisions.

“I worry that the pressure on the CCG clinical board members is significant and the succession planning to ‘spread the load’ is not yet in place. The more advanced CCGs have shown that they can link practices together to share the commissioning decision making. This will, in my view, bring long-term success for the CCG. He said practice managers had a critical role to play: “They can prevent an unwarranted variation in practice by partnering with neighbouring CCGs, sharing critical information and engaging in peer review programmes. It’s all about setting clear expectations and having demonstrable measures to ensure equality in the way CCGs are held to account.”

Hospital lets patients control their own medical records using a website University Hospital Southampton has launched a website that allows its patients to connect sections of their hospital records to their online personal health record, the British Journal of Healthcare Computing reports.

The access is designed to encourage patients to take control of their healthcare, reduce the rate of readmissions, improve communications between care teams and patients and automate patient pre-registration.

The site moves information held on the

04 | nov/dec 2012

hospital’s administration systems, such as upcoming appointments or lab results, into the patient’s web record. The patient will then be able to view all information online.

Patients can record daily wellbeing information and upload data from home-based medical devices, such as blood pressure, blood sugar and weight measurements. The site also allows them to take part in surveys, follow care plans, communicate with doctors or fill in assessment forms, before visiting hospital.

NHS Commissioning Board ‘must diversify’ The NHS Commissioning Board has admitted to problems recruiting a diverse workforce, and said it will try to ensure the trend stops, according to the HSJ. At a public board meeting in Newcastle Jo-Anne Wass, human resources director, reported that the latest information on the proportion of appointees from different backgrounds “does not make for easy reading”. The data, showed that the board’s early recruits were more often white, male, and aged in their 40s than those who applied for jobs. It did, however, show that the process appeared to favour disabled applicants.

“This is a really significant issue,” Wass said, adding that the board had already taken action by training recruiting managers and contacting minority ethnic candidates in leadership programmes. She did concede that “clearly more needs to be done”. Wass said she hoped making the data public would “shine a light on the issue” and lead to new recruitment practices.

Non-executive director Ed Smith said he would like to see targets for a staffing mix that “reflects the communities we work in”.

Wass plans to discuss the issue with national director of improvement Jim Easton, who is also the board’s executive lead on inequalities, “as a matter of urgency”.

In need of a confidence boost

36%

of GPs believe the arrival of CCGs will have an adverse effect on the NHS (Source: Lloyds TSB Commercial Healthcare Confidence Index)

Update news

local news

clinical corner

NHS staff celebrate Innovation awards

Awards for outstanding innovations in healthcare were presented to NHS staff at an event organised by Health Enterprise East, the NHS Innovation Hub for the Eastern Region.

The 2012 competition was open to NHS staff working in the Eastern Region to put forward ideas to benefit patients.

This year covered categories around disease prevention and diagnosis; disease management: surgical, therapeutic, and long-term; and IT. Winners included Dr Gerry Rayman, from The Ipswich Hospital NHS Trust, who devised a tool to help prevent hospital-acquired foot ulceration in people with diabetes. A team at South Essex Partnership University NHS Foundation Trust won a prize for its ‘Hydration Swapper’, an innovation to help patients and carers consider fluid-rich meal alternatives.

Endocrinologist Dr Paromita King won for an integrated model for pre-conception care for diabetes. Louise Allen from Addenbrooke’s Hospital won for ‘KidzEyez’, a visual field analyser for children. All were presented with trophies and, where possible, supported by Health Enterprise East to progress their idea.

Liverpool trust publishes research on over-65s

South Tyneside invests in charities for counselling

Liverpool Community Health NHS Trust has published findings from its new research into the effectiveness of low-cost, communitybased exercise programmes to help reduce the likelihood of falls in over-65s.

Undertaken with Liverpool John Moores University, the findings are the result of a yearlong research study on the trust’s multi-awardwinning Liveability service, which specialises in promoting health and independence among older people.

People aged 65 and older have the highest risk of falling, with 30% of people older than 65, and 50% of those older than 80, falling at least once per year.

At present the incidence rate of hip fracture in the over 65s is significantly worse in Liverpool at 476 cases per year compared to the national average of 458 (Health Profile, 2011).

Diane Singleton, liveability service lead, said: “These alarming statistics indicate a great need for effective approaches that help older people to improve their health, fitness, quality of life, and at the same time reduce the risk of falls.”

Newly commissioned counselling services are up and running in GP practices across South Tyneside demonstrating a continued commitment to reach all those who need them by NHS South Tyneside CCG. The additional capacity is being delivered by charities and voluntary organisations with experienced counsellors and have shown a good track record of success in offering counselling services in the region.

Dr James Gordon, lead for mental health and learning disability at NHS South Tyneside, said the new service not only offered a greater number of counsellors and appointments but also brought the service closer to local residents. “We are really keen to encourage mental health charities and voluntary providers to operate throughout South Tyneside,” he said.

Dr Simon Smith, Jo Rosier, Anne Scott and Dr Gerry Rayman with Maggie Philbin, TV presenter and broadcaster, at the Health Enterprise East 2012 Innovation Awards

Patient education slashes physio waiting times A pilot scheme from Wolverhampton City PCT has halved waiting times for physiotherapy appointments and improved patient satisfaction. The initiative, in partnership with charity Arthritis Research UK, created a series of new information and exercise pamphlets for musculoskeletal conditions, which were made available to all 53 GP practices in Wolverhampton to help GPs and patients self-manage musculoskeletal conditions.

The pilot resulted in a reduction of referrals to local physiotherapy services by one third from October 2011 to January 2012, and a fall in attendances to physiotherapy by one third since the pilot started.

The on-going pilot encouraged patients presenting symptoms of back, foot, knee, neck and shoulder pain, as well as carpal tunnel syndrome and tennis elbow, to follow simple exercises as part of a personalised recovery plan, as an alternative to referral to physiotherapy.

It followed a one-month audit of patients in the area who didn’t attend their physiotherapy appointment. Patients revealed this was often because their condition had been resolved within four to six weeks.

Project co-ordinator, Dr Kamran Ahmed, said that although there is a lot of information for patients, it wasn’t all collated in one easy to use format. He commented: “It was frustrating from a clinician’s point of view as it’s important to have access to effective and good quality educational information to help patients manage their condition themselves.”

SEND IN YOUR STORIES

We are always looking for local commissioning news. If you have a story to share, email editor@intelligentmedia.co.uk.

nov/dec 2012 | 05

Update Comment

Author bio Roger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is CEO of Healthcare Commissioning Services. You can reach him on rhymas@hccsgroup.co.uk.

06 | nov/dec 2012

Update Comment

Where on someth ce Roger Hy ing to le m arn from as was booe Here he df A discuss es big d merica, now, fi or even sugge st ata and n how the ally, commissi ing the NHS h ad on Yanks a re leagu ers are listenin g. es ahea d

Get yo

ur fact

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remember the day they stopped booing me at NHS conferences.

It was on 15 July 2009 in York and I was speaking to around 100 associate director-level PCT commissioners about how they might improve their negotiating performance with their local providers. It used to happen a lot. On a good day it was only hissing.

When something like this stops, you begin to wonder why the audience reaction is different. Is it you or is it them – but then the content of my presentation hadn’t really changed much over the previous two or three years. What I talked about was my experiences with health commissioners on both sides of the Atlantic and how much better the US was at using its data to manage the care purchasing process. I always knew that NHS traditionalists in the audiences found some of the words I used hard to swallow. These included ‘private sector’, ‘US’ and ‘health insurance’ or various combinations of them. It got a lot of NHS traditionalists, shall we say, exercised, which was when the booing would start.

The opinions I held had been fashioned by over 15 years of experience negotiating with tough hospital managers in the US and in the private sector in the UK. These were people who were highly schooled in the business of achieving commercial advantage for their organisation and didn’t miss many tricks. They used data wherever they needed to win an argument. And there was lots of it, immaculately crafted to support every single point.

s right

Professionalisation of commissioning What I began to notice about PCTs in 2009 was that commissioning was professionalising, thanks mainly to the adoption of the learning that came from the often-maligned World Class Commissioning programme. Many PCTs had begun to accept that they should take a firmer line with the management of hospital trusts, particularly the large acute foundation trusts. And I was never booed again.

Now, more than three years on, I suddenly feel vindicated by no less than The Lancet in a paper it published in October under the title ‘Healthcare Reforms in the USA and England: Areas for Useful Learning’. Part of what the authors have to say is that healthcare systems, wherever they are, ‘need to take information from electronic records, and share, link and analyse it to support improved clinical and patient decisionmaking’. Where the US has always been stronger, ‘is in the development of complex algorithms to prospectively model expenditures’ and that ‘the NHS could learn from the transparent and analytic rigour [applied] in the US’. During the booing years, I never once advocated that the US healthcare system should be brought here, God forbid, but I certainly knew we had a lot to learn from the US approach to analytics and the way the knowledge could be applied to improve commissioning systems.

That there is now an NHS market is no longer disputed, even by the diehards.

We’ve all moved on. But as a market, it

remains an asymmetric one. In the US, providers and commissioners are pretty evenly matched when it comes to the collection and use of data. They go head to head all the time. Sometimes one side has a temporary advantage, sometimes the other. For a long time, managed care (commissioning) organisations were on top, but public opinion has helped hospitals regain the advantage in recent years.

Provider vs. commissioner The provider interest has dominated the NHS throughout the 20-year history of the ‘internal market’. Hospitals have always been in a stronger position at the negotiating table vis-a-vis their commissioning peers, not only because their management teams have professionalised faster, but because they have been able to create and sustain a single-minded point of view about what they want to achieve in their localities.

As a consequence, they have created a business approach that takes in lots of performance data. They know it’s the responsibility of the hospital board to do its best for its patients and staff; but this is, of course, not the same as for patients and the local population, which is the responsibility of the commissioner. And in negotiations with PCTs they have not hesitated to use their information advantage with sometimes devastating effect. I’ve witnessed a number of occasions where a push by an acute trust for more funding has left other parts of local provision – mental health, for example – significantly depleted.

nov/dec 2012 | 07

Update Comment

A September 2012 Nuffield Trust paper, ‘Patient-level costing: Can it yield efficiency savings?’, illustrates hospital trusts’ growing analytics capability and I commend it to all commissioners. It focuses on what are called PLICS – Patient-level information and costing systems. These describe how provider organisations can build a clearer understanding of the patient experience as a continuum of care. They compare patient experiences for the same condition and when the data is assembled at this industrial scale over an extended period of time, managers can begin to recognise the variations in costs relative to hospital income for groups of patients, particularly within the same healthcare resource group, or HRG. You are even able to see performance differences between consultant teams. Scarily, the report found that only one in six chargeable cases incurred costs within 10% of the tariff price, which also means, of course, that a lot of PCTs have been overcharged. Hospitals have nearly always invoiced by the procedure and rarely by the episode of care. This is not payment by results, of course, but fee-forservice, a pricing methodology long abandoned by progressive healthcare systems around the world. The NHS needs to be moving to a reward system which pays for good outcomes, and penalises sub-optimal delivery.

Now if this information is valuable to hospitals, just imagine what commissioners could do with it, particularly when combined with the primary care data, which will become increasingly accessible to CCGs. The real disappointment for our healthcare system is that, at present, hardly any commissioner is anywhere near having the level of business intelligence necessary to help it deliver its mandate to promote healthcare effectiveness while controlling costs. Until we get there, we have no option but to trust hospitals to do some of the commissioners’ work for them by using their data to drive greater efficiency and productivity into internal operations. Their self-interest, we hope, will match the needs of the population.

Big data What I know from every industry or company in which I have worked is that where there is a knowledge asymmetry, one side really finds itself disadvantaged

08 | nov/dec 2012

“During the booing years, I never once advocated that the US healthcare system should be brought here, God forbid, but I certainly knew we had a lot to learn from the US approach to analytics” competitively. We live in a world where knowledge is expanding at an awesome rate. The data ‘exhaust’ from the technology employed in every aspect of life is growing almost exponentially, take Google for example. This is all part of what’s now recognised as the ‘big data movement’. The NHS provider side is also becoming a real big data player as the information systems in which it has invested hundreds of millions come through and start to deliver. Now, I don’t want to advocate the kind of arms race we see in US healthcare, but I’m not sure that the interests of the NHS will be best served by providers continuing to have a disproportionate influence of their local markets, particularly when we are going into an extended period of financial constraint.

What I’d like to suggest is that while CCGs catch up by creating their own information systems, they should be able to access the learning in the hospital knowledge pool to help them improve their decision-making. Certainly, this should happen in the true spirit of what the NHS stands for. But attitudes are changing as the market separation hardens. Knowledge is being used to create power and exert competitive advantage. This means that if I were the lead CCG commissioner for a trust where I know PLICS is being used, I’d ask politely if I can see it. Hopefully, they would accede, but if the answer is no, then I’d write into the annual contract a requirement for the CCG to have access to all the data on an ‘open books’ basis. But, it shouldn’t need to come to this, should it?

So you see why I have always been so

assertive about strengthening the role of commissioning in playing its role in shaping future healthcare. Markets only work where they are close to a state of equilibrium and this has never happened here. Executed properly, certainly with the rigour we see in the US, effective commissioning offers the promise of regulating and controlling costs and ensuring that the consumer interest is better protected.

I know from my dealings with upwards of 30 PCTs over six years that there are real opportunities for significant savings across the NHS. But they won’t come if hospitals are allowed to unduly influence the design of local health economies. Their selfinterest will always be paramount. I don’t know of a single large hospital in England that hasn’t seen year-on-year growth in its income over the past 10 years. And, of course, during all this time, NHS policy has been to move care out of hospitals, which should have led to a lowering of their funding allocation. Somehow the flywheel of PBR – plus the growth of unscheduled care – has just kept on delivering increased income for hospitals.

I’ve never had the time to do the work, but does anyone know of a place where the acute trust’s share of the commissioner’s budget has actually gone down? Which takes me to the inevitable conclusion that the trend in hospital activity has got to be reversed. To achieve this objective, commissioners need to create market equilibrium. Investing in big data is paramount. Get it and use it and all the booing would have been worthwhile.

in action Interview

Shane Gordon is GP and clinical chief officer of North East Essex Clinical Commissioning Group. Carrie Service caught up with him to discuss the issues currently surrounding the commissioning agenda

12 | nov/dec 2012

in action Interview

Clinical thinking

S

hane Gordon is the clinical chief officer for North East Essex CCG, commissioning on behalf of 324,000 patients.

Previous to his current role he was CEO of Colchester PBC group and oversaw its merger with the neighbouring group in 2010 to form the new CCG. He has been heavily involved in developing new services in primary care and has advised PCTs and GP clusters during the transition. We get his advice.

You’re a well-known advocate of GP commissioning and a firm believer that it’s the way forward for improving services in the NHS. Why is that?

Well, yes, I’d say ‘clinical commissioning’ rather than ‘GP commissioning’ – I think it has to be clinical commissioning in its broadest sense. But I think it’s absolutely essential that it does involve GPs, because so much of the care of patients and the journey that patients have through the health service starts at general practice.

If we don’t get the ordinary general practitioner in their surgery making decisions which are supportive of the commissioning agenda and the effective use of resources, then all of our other efforts are going to struggle. If you think about the number of decisions that are made about the use of the resources in the health service, most of them occur in general practice. For example, in a year, GPs will have some 350 million patient contacts – that’s five or six times the total population

of the country. Whereas the total number of hospital contacts is only about 60 million.

So it’s five times as many opportunities to improve the care of patients. And it might be that the cost of each individual decision is lower, but if you look at chances to make things better and chances to improve the efficiency of the service, obviously there are a lot more of those chances happening in general practice and primary care than there are in hospitals.

Do you think we have lost sight of the main vision behind clinical commissioning and the reforms – for example localism?

I guess one of the challenges was some disagreement over what the vision actually was between the various interested parties and I don’t think I have a monopoly on the correct vision. I think we are working in a very complex service in an incredibly complex political environment, particularly the financial restraints that we’re operating under. And as a consequence of that, lots of constraints have been placed on clinical commissioning groups in terms of their ability to operate independently. I think there was never any realistic notion of absolute local freedom. There is a national health service and there is a national health agenda that we have to support. But I think there is a great deal of local freedom providing we’re meeting the requirements of the national service as a sort of minimum standard. So I think that sense of localism does remain. The other kind of constraining factor is: “What is local?” So if local to you

is your region of the country, you might find most of your GPs don’t agree that is local and most of your population might not agree that’s local either. But the health and wellbeing board is probably another level of local and another way in which CCGs have got to conform to the needs of other orders of organisation within the system. But again, it should be perfectly possible to be part of a shared health and wellbeing strategy within your local area and still have a degree of local differentiation, I suppose.

Do you think the appointment of Jeremy Hunt has had any effect on people’s confidence in the reforms?

I think there is a degree of interest to see what particular slant on this the secretary of state takes. One of the intentions of the bill itself was to make the service less vulnerable to the different views of different secretaries of state. So one of the challenges for the health service has been that there has always been a very significant influence by the health secretary on detailed health policy, with a very local impact, and that has been, sometimes, a distraction, at best, to dealing with local health agendas which are really very different in different parts of the country. One of the interesting things for me is waiting to see how well that arrangement protects us from the desire of secretaries of state to make their mark on this earth. And it’s perfectly appropriate, I think, for secretaries of state to demand improvement in the quality of the service because that’s absolutely their role. I think

nov/dec 2012 | 13

in action Interview

if they get into dictating commissioning – specific types of commissioning which have to occur at a local level – I find it very difficult to follow logic with that, because of the great and vast differences between different geographical localities in terms of their health needs. So I’m just waiting to see whether that particular intention of the bill is successful.

Hunt said in his speech at September’s Conservative party conference that the technology revolution had ‘barely touched’ the NHS. As someone with a masters in information technology, what are your views on this and how do you think it could be tackled?

I think it depends which bit of technology he’s talking about – there are lots and lots of different types of new technology. If he’s referring to new media, for example, then yes, probably the NHS, if you look at it as a whole, has been relatively slow to take up the use of Twitter and Facebook and other new media options in communication. I think it does say something interesting about the difference between a public service, which is effectively a monopoly and therefore doesn’t feel it has to respond quickly to these new public trends because it’s not trying to attract people to its particular service – compared to independent sector providers who are much more responsive to new media because they’re trying to attract people. That doesn’t necessarily mean new media is the thing that differentiates good from bad provision, but I think it’s an indication that some of the things that drive innovation are actually about customer satisfaction and it may be that that’s actually the bit that the NHS has been slow to respond to. It’s not new media, but customer satisfaction in general. But there are other aspects, like cutting-edge technology for medical therapies and I think that again the NHS sometimes struggles with making the decision to implement new technologies and new approaches. Again, perhaps because there is no alternative offer where these technologies are available, which makes them think: “Well, maybe we ought to be offering that to our patients as well.” There is something about the NHS being a closed system, which has its benefits, but has its potential weaknesses as well.

14 | nov/dec 2012

“It’s an indication that some of the things that drive innovation are actually about customer satisfaction and it may be that that’s actually the bit that the NHS has been slow to respond to” You were hoping to integrate more new media into the North Essex CCG website, have you achieved that?

It’s a work in progress – our website at the moment needs to undergo further revision now that we’re moving from being a CCG in shadow form towards being a statutory body responsible for [the] local NHS. So at the moment we’re undertaking a review of the content of the website and its

appropriateness. It’s still our intention to include more discussion forums and blogtype entries. I’ve got a Twitter feed on the front page. So yes, it is our intention to pursue those and continue pursuing those.

Do you think your background in IT has given you the edge in that respect?

I don’t know that it’s an IT thing; I mean, the tools are incredibly easy to use. It’s more of: “Do you think it’s an appropriate thing to use to communicate with people?”

– it’s more of a communications issue, I think, than an IT issue. It’s about adapting to a new way of working.

You recently had your mock authorisation site visit, how did that go?

I think it went very well; it was a very helpful visit, a very helpful afternoon to try out our approaches to presenting and responding to the sort of questions that we might get asked. Many of our team had not been in that sort of situation before and weren’t veterans of World-Class they

in action Interview

Commissioning, for example, so it was particularly useful for them to get the feel of the thing. But it was also very useful to get feedback on where we could improve.

We’ve done a lot of work since then over the last few days to improve our pitch for the real one.

Any pearls of wisdom to pass on?

Yes, I think having a set of examples of where you are at your best – having a small number of those at your fingertips to demonstrate how you do business; how you identify your priorities; how you develop them and respond to contributions from your practices and your patients and turn that into commissioning differently than you would have done previously – and how that delivers better for you [is important].

You have been involved in advising PCTs and GP clusters during the transition process – how do you think they have coped and what do you think have been the main sticking points, if any?

I think it’s been a tough transition on both sides, because there is a risk of people feeling undervalued. And I think it’s really important that we continue to value the contribution that everybody makes to the commissioning effort. On the clinical side, in many areas there’s a lot of development need to understand the responsibilities of commissioning in the broadest sense, the statutory responsibilities, and to understand the approaches and techniques needed to make that work. And on the management side of the equation, I think

16 | nov/dec 2012

there is a process of adapting to the different ways of thinking that clinicians bring – accommodating the rhythm of clinical life into that work as well. The last bit is developing a large enough self-sustaining cadre of senior clinical leaders.

Do you think it’s important not to lose any knowledge from PCTs during the transition?

Absolutely. We mustn’t throw the baby out with the bath water – we’ve got to preserve what is good and build on it. So locally we are very proud of the work the PCT has done and the things they have achieved and we are very privileged to be still working with many of the people who achieved those things.

A great many GPs involved in commissioning are also stakeholders in private provider companies, which has raised questions about a possible conflict of interests. How do you think the Government can prevent this from becoming an issue?

Well, I was a stakeholder in a couple of very small private providers until recently, but I’ve divested myself of those interests because of taking on this particular role. I felt that certainly as the head of the local organisation it was important that I was seen not to have any potential conflicts of interest. I think though, everybody’s got an interest, haven’t they? If you start making decisions which favour those interests then you potentially have some conflict. So those people who say “only use the NHS” have a conflict of interest because they are the incumbent provider and what they are

doing effectively is protecting themselves against competition. And they are people who are outside of commissioning. So the idea that only GPs in commissioning have a potential conflict of interest, I think, is false. For me, the critical bit is that we ensure that our interests are transparent and that we are scrupulous about mitigating potential conflicts. So, for example, we know that we may have to do some commissioning of general practices in order to achieve our aims as a clinical commissioning group. But we will be setting up an independent procurement panel who will advise us on what the right route for commissioning those services is.

Whether that’s a tendered piece of work, an openly contested piece of work, a local enhanced service, a contract variation, an any-willing-provider service – so that we get independent advice that protects us from potential conflicts of interest.

What are your hopes for the April 2013 changeover and onwards?

I think our challenge in the next year is to really start to push on the innovation agenda and to start to deliver some significant changes to the way services are delivered. Because we can’t afford to continue doing things the way we’re doing them – if we want to preserve the quality in services, improve the quality of services, then we have to find some different ways of doing it. So a successful year in 2013 would be making progress in commissioning some significant areas of service differently.

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How the Olympic Games could impact your practice

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Keeping schtum

Quick ways to improve patien t confidentiality

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Fighting Fire with Fire

One practice recovers after an arson attack

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in action Interview

Carrie Service speaks to accountable officer Jan Ledward from NHS Chorley and South Ribble CCG and NHS Greater Preston CCG about collaboration, working in the same building as the PCT and her hopes for the future

Life in transition

20 | nov/dec 2012

in action Interview

J

an Ledward is accountable officer for the Greater Preston and Chorley and South Ribble CCGs. She is professionally qualified in procurement, and has been working in the NHS for 27 years – for the most part in commissioning. The first part of her career was working in procurement in disablement services, transferring wheelchair services into the NHS. Her career in commissioning began in what was once Salford Health Authority as deputy director of commissioning, leading to subsequent roles in locality commissioning in East Lancashire and as director of commissioning at Blackburn with Darwen, a unitary authority, for a number of years.

She then went to work for the SHA, leading a quality improvement programme called ‘Advancing Quality’, and then came back into being a board director responsible for procurement and contracting at central Lancashire. She was also seconded into the commissioning board for a while, developing the authorisation process and returned recently into her current role.

The Preston CCG and Chorley and South Ribble CCGs collaborate a great deal as you use many of the same providers. What are the potential challenges that can arise from collaboration?

Well, the system isn’t mature, and we’re working with our membership made up of a number of practices, who very much see the local population and community and it may be an issue of how we manage risk. If it’s an individual patient that could potentially cost the CCG a huge amount of money and potentially bankrupt the CCG, it makes sense for us to actually collaborate to manage those risks. But when explaining the risk to an individual practice, they may argue they are unlikely to ever see one of these patients – and hopefully they are unlikely to. But it’s the understanding that we have a large number of patients who live in the population so we want to provide as equitable service as we possibly can and in order to that we do need to manage the risk

of any one CCG in the system having that one patient that does actually cost a huge amount.

There are also services where we will have maybe consultant time or consultant expertise which is limited and difficult to recruit to. So again, it’s in our interest to collaborate, so that we don’t lose that expertise to the local system and we move more services away from the big tertiary centres like Manchester and Liverpool into Lancashire, because it cuts down the number of patients that have to travel and we can build capability capacity locally.

Does this mean compromising localism?

For me, both Chorley and Preston [CCGs], grew up very much from the practices’ wish to retain control and influence and a sense of the local population – and they’ve come up with a compromise arrangement around their management. The whole of both CCGs’ management resource is shared. There are some posts that very much work with practices in the locality level, but the majority of the expensive management resource is shared between the two; [this] means that we can invest more in clinical leadership, which is what the reforms were about. So I think they’ve made a very sensible decision to do that; they’ve got a history of working together and they recognise the strength that they’ve got in working together when negotiating with local acute services and mental health services. So it’s a good compromise.

In terms of the whole transition process, how have relations between the PCT and the shadow CCGs worked?

The transition is complex and challenging and I think it has helped, certainly in central Lancashire, to be based in the same building as the PCT. It’s positive in the fact that you’ve got that direct relationship with the PCT and the handover process but it’s challenging for staff because we’re recruiting to our structure and commissioning support are in the process of recruiting to their structure and we’re trying to manage the business

nov/dec 2012 | 21

in action Interview

on a day-to-day basis as well. It’s making sure that we’re not destabilising any one of those as we move forward. I can’t say that it’s always helpful [being in the same building], or people are thankful for it, but we do try where possible to understand the challenges on staff. I had to carry out two roles once I was appointed as accountable officer because I still had a responsibility for the job that I was doing. It’s a case of being focused, but we recognise that there’s no sense in us destabilising or being too stroppy to take on full responsibility of the role until we’re ready. It is about working sensibly with the system. We’ve had a huge amount of support and there’s a huge amount of goodwill from staff who, in fairness, really don’t know where they are going in the future and I think that’s testament to their integrity.

You’re asking them to make big decisions about their careers for the future – where they feel that their skills and capabilities best fit.

It’s difficult for them to know – the CCGs aren’t established, they’re not an entity yet for [staff] to really understand and know whether that’s the place they want to be.

How will the introduction of more private companies working with NHS impact on you?

For me working in a PCT previously, we’ve always worked with the private sector for certain areas – this isn’t new. It’s not something that I think we need to be particularly fearful of. Where we do want to make changes or we’ve got constraints around capacity or expertise, then it’s right that we should look at all sectors in terms of that development. And it’s not just about working with the private sector; we’ve got a huge agenda around integrated care working with our partners in local authorities and it requires us to think differently, it requires us to be prepared to compromise a bit more in terms of how we do things. I don’t think we should be fearful of that change,

22 | nov/dec 2012

or bringing in that learning. It can be seen as a threat, I understand that. But I think it’s how it’s conducted and how open and transparent we are as organisations about the need and the lack of either our capacity or capability or skill. Where the private sector can add value then it’s in the interest of the NHS to make best use of that and we’ll see how that develops over time.

What are your hopes for the future, postauthorisation?

Both CCGs are very ambitious – clinicians have committed their time and their energy to this and it’s not always been a time when all GPs are positive. We do have colleagues who are still quite sceptical about why they have been given this opportunity, but they continue to be optimistic and I think that they still feel that the proof of the pudding is in the eating. We’ve got

“There’s a huge amount of goodwill from staff who, in fairness, really don’t know where they are going in the future and I think that’s testament to their integrity” to build the relationships now with our partners and our stakeholders in this health economy. They are cautiously optimistic that clinical commissioning actually will make a difference. I think we’ve got to start demonstrating now that it is making a difference. It feels like a long time since the white paper came out and it always does feel like a long time with these things. It’s a big organisation to turn around and make the change happen – but we’re now getting close to that being achieved. Our partners, our stakeholders – they’ve been very patient in allowing us the time to develop. I think we now need to start delivering on our plans and the promises that we’ve made.

community care Oncology

Cancer as a teachable moment Cancer is no longer the end of the road that it once was. Jane Maher, chief medical officer at Macmillan Cancer Support, presents Bournemouth After Cancer Survivorship Project as an example of how CCGs can improve the health of patients with a cancer diagnosis

T

hanks to earlier diagnosis, advances in treatment and improvements in the way that care is delivered, cancer is no longer always a death sentence. There are two million people living with or beyond cancer in the UK and this figure is set to rise to four million by 2030.

It is a cause for celebration that more people than ever are surviving after a diagnosis but we know the impact of cancer does not suddenly stop when treatment is complete. Supporting aftercare is an increasingly important part of the cancer care pathway and CCGs have a key role to play in ensuring that survivors improve and maintain their health in the community.

24 | nov/dec 2012

what CCGs can do Published research confirms the benefits of physical activity, with more now known about matching the right activities to the right people and ensuring lifestyle changes are sustained. Doing enough physical activity during and after cancer treatment can significantly reduce the long-term impact of cancer treatments, such as bone thinning, heart disease, depression and fatigue. It may also reduce the risk of recurrence and death from the disease.

Physical activity can be both a cost-effective and clinically effective treatment intervention as it can help lower the chances of getting other longterm conditions, such as heart disease, osteoporosis and type-two diabetes or help to reduce the disability associated with

these conditions.

There are around 200,000 people recovering from cancer treatments every year. Research suggests that such patients appear to be particularly receptive to sustainable lifestyle change (a so-called ‘teachable moment’). At the same time, there over a million people who are more than five years from diagnosis, with a higher incidence of common chronic illnesses than a population without a cancer diagnosis, who could have benefited from support to start exercising during and after cancer treatment.

It is important that evidence-based physical activity services for cancer survivors are commissioned and that advice about appropriate ways to keep active is included throughout the cancer care

community care Oncology

“Commissioning physical activity services will help to reduce unplanned hospital admissions by improving the general health of people living with cancer in your local area”

pathway. Commissioning physical activity services will help to reduce unplanned hospital admissions by improving the general health of people living with cancer in your local area.

Macmillan Cancer Support is keen to work with CCGs to support the creation of a range of appropriate activities for people living with cancer in the community. For more information, including an evidence review, please visit www.macmillan.org.uk/ movemore.

Bournemouth takes the lead An example of how effective this partnership working can be is the innovative Bournemouth After Cancer Survivorship Project (BACSUP).

In 2008, breast and colorectal teams at

the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (RBCH) became increasingly aware of the multiple unmet health needs of their patients.

These included fatigue; weight gain or loss; low self-esteem; changes in significant relationships; and undesirable side-effects of diagnosis and/or treatments.

To combat this, RBCH teamed up with a local leisure and cultural trust, BH Live, and launched the physical activity programme BACSUP in 2009. The project was integrated into the existing cancer care pathways for breast, colorectal and melanoma patients. Support was delivered by a team that represented patients, secondary and primary care, community service providers, Macmillan and the Dorset Cancer Network.

The 12-week programme was based at the BH Live Littledown Centre. The first objective was to improve the all-round health, wellbeing, fitness and quality of life for 200 post-cancer treatment patients.

The second objective was to develop a multidisciplinary cancer rehabilitation programme that promoted physical, psychological, social, emotional and spiritual health and wellbeing, together with self help strategies for living with and beyond cancer.

Activities incorporated into the programme included: n one-to-one motivational goal setting and activity guidance sessions n appropriate centre and community-based physical activity opportunities n and access to a range of complimentary services provided by BH Live partners, including: u life coaching u hair and beauty evenings u benefits advice u and healthy homes.

Fifty partners and carers were also able to benefit from the free programme, which successfully demonstrated significant improvements in health, fitness and quality of life amongst the participants.

Results showed that 93% had improved their cardiovascular fitness and 60% had healthier blood pressure. Participants also reported improved self image (100%) and less fatigue (94%).

One participant said: “It’s for the old and the young. I’m old and some of them are really young, but they made us feel really welcome. I’m not a sporty person, but gosh have I enjoyed it.

“I felt my body coming back to me, my joints were less painful, and my confidence came back. It was without doubt the best thing I was ever advised to do.”

BACSUP was successfully submitted as a phase-one test community for the National Cancer Survivorship Initiative. BH Live has received support from Macmillan and RBCH for the next year to develop the programme and a transferrable delivery model with a further 250 participants. This will continue to improve good health and reduce clinical dependency of people living with cancer in the Bournemouth area.

nov/dec 2012 | 25

COMMUNITY CARE HEALTH AND WELLBEING

With the introduction of Health and Wellbeing Boards, it is hoped that health and social care can be better integrated to improve services. CARRIE SERVICE finds out how

26 | NOV/DEC 2012

THE SOCIAL NETWORK

COMMUNITY CARE HEALTH AND WELLBEING

S

ocial care has for a long time been seen as the NHS’s ‘ugly sister’, never receiving the attention and consideration it needs and deserves. But, with a growing ageing population (it is projected by 2035 that, at 3.5 million, the number of people aged 85 and over will be almost 2.5 times greater than in 2010) and shrinking public budgets, something has to be done in order to address the current state of social care.

OVER THE EDGE Health and Wellbeing Boards are to be the driving force behind health and social care integration and it is hoped they will be the piece of the puzzle that has been missing all along. Their main challenge will be to help counteract the pressure placed on public budgets by the rapid decline in health of some vulnerable individuals. The boards, made up of commissioners and members of the local authority (as well as Healthwatch) will review services so that they can better manage the needs of users, allowing people, in particular, the elderly, to hold onto their independence, delaying their need for expensive nursing and acute care. In order to do this, LAs and health partners need to be able to commission the most appropriate and relevant services they can.

Craig Dearden-Phillips, public sector business expert and founder of Stepping Out, an organisation aimed at encouraging social enterprise in the public sector, gives the analogy of a conveyor belt, rapidly moving towards a sharp drop-off or decline in health.

“In most areas of the country now, once you fall off the end of the conveyor belt, for example a very elderly person suffering a fall, you completely stop – you don’t get back to normality and independence very easily, because there aren’t the services to support this,” he says. None of the community services or services available in primary care are currently designed to slow down this conveyor belt effect, allowing people to simply fall off into an endless hole of uncontrolled expenditure. “The Health and Wellbeing Boards ought to be a mechanism to work with GPs to slow down that conveyor belt and also be a kind of ‘grab-arm’ so that people can be pulled back again into more light-touch independent care,” explains Dearden-Phillips.

A BUDDING RELATIONSHIP? As Health and Wellbeing Boards approach implementation, it is inevitable that some issues will arise from this now formalised partnership. Indeed, in anticipation of this, the NHS Confederation released two documents earlier this year to help facilitate the two sectors working with one another: ‘Working with local government: a guide for GP commissioners’ and ‘Working with GP commissioners: a guide for local councillors and officers’. ‘There are many ways that councillors can expect to benefit from these new relationships, but they will need to aware of areas of difference, show understanding, and be open and honest with their new partners,’ advises the latter.

‘Understanding and awareness are the most important first steps for GP commissioners wanting to foster strong, productive relationships with local government,’ says the former.

Although local authorities and PCTs have always worked together, this new official arm of commissioning in the form of the Health and Wellbeing Boards and their executive body, the integrated commissioning boards, has brought social care to the fore, recognising its potential impact on the independence of service users. Ernie White, cabinet lead member for health at Leicestershire County Council and chair of its Health and Wellbeing Board, says that first hurdle for the two sectors working together is to establish a common aim. “We need to ensure we have clear, jointly agreed outcomes and a definition of what we are aiming for in terms of integration between health and social care,” he says. He adds that it is important to establish this from the offset to ensure clarity and a sense of purpose and direction. When I asked if there were likely to be any challenges borne out of the reforms, White raised the issue of the financial environment in which councils are expected to implement these new initiatives. With the new national eligibility criteria for social care to be introduced, councils might be forced to readjust their minimum requirements after having only recently made changes because of financial restraints. “Like many other local authorities,” he explains, “in response to increased financial pressures, we have

NOV/DEC 2012 | 27

COMMUNITY CARE HEALTH AND WELLBEING

recently raised the bar on eligibility from moderate to substantial and critical and would hope that the plans for the national eligibility criteria recognise the increased pressures that local authorities are under and take this into account on setting the minimum level.”

MANAGING DEMENTIA Dementia is one of the conditions that could benefit greatly from better integration and it cannot come a moment too soon as stories enter the press about people in care homes suffering mistreatment. At the National Children and Adult Services conference held in London at the end of October, Health Secretary Jeremy Hunt, promised to give greater priority to the treatment and management of dementia.

Stating that England would be “one of the best countries in Europe to be old”, Hunt announced £50m of government funding to be allocated to creating specially designed care homes and wards for people with the condition. He said: “Dementia is one of the biggest threats we face in the 21st century...

If the best dementia care in England is exemplary...the worst is nothing short of scandalous. We’ve all seen the reports – of people with dementia being criminally abused by their care-workers or drugged up with chemical-cosh just so a care assistant can get a good night’s sleep. These may be extreme, isolated events but they highlight a culture where dementia is stigmatised and where those with dementia are not valued. It is not acceptable. It must and will change.” Hunt has urged care groups and providers to join 42 social care bodies, constituting 1,800 care services, which will pledge to provide nothing but first-rate care for people with dementia.

CARING FOR THE CARER Dame Philippa Russell, chair of the Standing Commission on Carers – a carer herself for both an elderly parent and an adult son with learning difficulties – has campaigned for better consideration and support for carers. In a webchat with a

28 | NOV/DEC 2012

group of carers in February this year, she spoke about the impact of Health and Wellbeing Boards and how organisations can get involved in seeing that their needs are considered in any changes to service design. ‘You get best results when you work together,’ she wrote, ‘so I hope one

“We need to ensure we have clear, jointly agreed outcomes and a definition of what we are aiming for in terms of integration between health and social care” or two local groups, carers centres, Age UK, MENCAP or whoever has the initial interest and resources, get everyone together and ask your PCTs and local authority how they are going to assess local need.’ Addressing carers, she stressed the importance that their voices are heard by the local authority: ‘Is the local issue overnight short breaks or sitting services – or both? Are there good local providers you want to keep and use or are there gaps? What works well and where are the problems? You could ask for the plans to take special account of carers’ health needs and be capable of putting more help in for carer emergencies.’

Lancashire Care at Lancashire NHS Trust, like some other areas, has taken a proactive approach to seeing that the carer voice is heard. It now has a user and carer involvement steering group, part of its service user and carer experience and involvement team, aimed at gathering feedback on the services in the area. Acting as an expert resource, the department promotes user and carer involvement in order to improve services. They also lead in implementing feedback initiatives like ‘Patient Stories’, ‘Patient Opinion’ and national surveys. Service users and carers can register with the team and some are invited to sit on interview panels, so that their point of view is taken into account when taking on new hospital staff. The team has worked with its network of

contacts to launch Voicenews, a bimonthly newsletter aimed at promoting carer and user participation in the provision of services in the area.

Although health partners and local authority figures will provide a wealth of information, strategic knowledge and experience towards the provision of social care services, the patient and carer’s viewpoint will be one of the most valuable sources of information available.

Let’s hope that some good can come out of the recent shocking headlines about inadequate and abusive carers as we realise that at some stage in the nottoo-distant future, we too will be in the position of relying on the care of another.

The next few years will determine just what that future will look like.

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Commissioning Success promises to be the only management title speciďŹ cally targeted at CCG board members, participants in commissioning, and all related health networks and shadow boards

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sponsored feature malnutrition

Malnutrition Matters:

Commissioners’ roles in meeting Quality standards in nutritional Care ailsa Brotherton (BAPEN Secretary) Janine roberts (Programme Director, Malnutrition Task Force) anne holdoway (Chair Parenteral and Enteral Nutrition Group of the British Dietetic Association) dr Mike Stroud (Consultant Gastroenterologist, Senior Lecturer and Co-chair of the Malnutrition Task Force)

I

n his article, ‘Is your secondary care provider shopping with your Commissioning credit card? The current funding model for malnutrition’, the expert in medicines management, Shailen Rao, described the outcome of his discussions with commissioners on the current model for oral nutritional supplements (ONS) and tube feeding. These had led to the unanimous conclusion that ‘the most prudent approach would be to engage local commissioners, expert clinicians (especially dietitians) and the provider companies of nutrition products to work out the best model going forward.’ and that ‘A commissioning-led solution could actually provide an opportunity to embed service specifications for malnutrition management within contracts of existing providers including GPs, community service providers and acute trusts’.

In this follow up article, Ailsa Brotherton (BAPEN Secretary), Janine Roberts (Programme Director, Malnutrition Task Force) Anne Holdoway (Chair Parenteral and Enteral Nutrition Group of the British Dietetic Association) and Dr Mike Stroud (Consultant Gastroenterologist, Senior Lecturer and Co-chair of the Malnutrition Task Force) outline how local commissioners can grasp this opportunity to improve patient care and patient experience whilst significantly reducing costs.

BaCKground: underStanding the proBLeM in your LoCaL area Malnutrition costs lives and money. Commissioners have a duty to ensure they commission harm free care and will be focusing their attention on improvements in the delivery of such care in 2013-14.

30 | nov/dec 2012

Nutrition and hydration support are fundamental elements of harm free care. In addition to the impact on patient experience and outcome, malnutrition costs the UK health economy an estimated £13 billion annually and affects an estimated 3 million individuals1. Implementing NICE Guidance on Nutrition Support for Adults (CG32) is estimated to be one of the highest areas of savings to the NHS2 and we have the tools needed to screen and treat malnutrition in all care settings. Even a saving of 1% of the estimated spend could save £130million.

Treatment with oral nutritional supplements (ONS) is associated with a reduction of overall hospital readmissions by 30%3 and the use of ONS in the UK has been found to: save £849 per patient based on length of stay4; .reduce complications such as pressure ulcers by 19%5, and decrease antibiotic use by 56%6. Specifically community patients given ONS do better with evidence that they have improved functional outcomes7, increased quality of life8 and improved nutritional intake without suppressing normal food intake9. In addition, the provision of community meal services has been demonstrated to yield a Social Return on Investment of a minimum of £5.44 for every £1 invested10.

However, despite this compelling evidence for effectiveness, many commissioners are not yet commissioning good nutritional care for their local populations. This article has therefore been written to guide you through the steps you need to take to make the change.

Step 1: prepare to MaKe Change Understand why it is important that you commission good nutritional care for your local population as a priority in 2013. Implementing nutrition and hydration support will demonstrate improvements in quality of care, patient experience and patient safety: If the NICE Nutrition Support guidance on screening, assessment, treatment and prevention of malnutrition was fully implemented, it would result in better nourished patients and reduced complications including secondary chest infections, pressure ulcers, falls, wound abscesses and cardiac failure. Conservative estimates of reduced admissions and reduced length of stay for admitted patients and reduced demand for GP and outpatient appointments underlie the significant cost savings that NICE have identified.

Form your Local Team. This should consist of an executive lead, a CCG team member, a Dietetic Manager, a Gastroenterologist, a GP, a nursing lead and a local patient and/or carer representative Take your First Actions. It is important to: • Agree your scope of work • Agree roles and responsibilities • Gain local stakeholder engagement • Go and see and experience what actually happens in your hospital(s) • Communicate what you are aiming to do • Set up regular project meetings

Convince people that change is necessary by sharing examples of the benefits to patients, staff and the organisation this will need good clinical and executive leadership at a local level and support from key stakeholders success is dependent upon getting the right team members engaged Further resources: NICE Cost saving guidance http://guidance.nice.org.uk/CG32 BAPEN Commissioning Toolkit http://www.bapen.org.uk/professionals/ publications-and-resources/commissioning-toolkit

sponsored feature malnutrition

Step 2: Know where you are Create and agree your vision with the team of what best practice looks like. Undertake a gap analysis to determine where you are compared to your vision and develop an implementation plan to achieve it. Use the tools in the BAPEN commissioning toolkit to help you in the process of understanding your needs and the delivery of your improvements

Collect the data in Step 3: Use these tools in the BAPEN Toolkit to help you to collect the right data Tool 3

Development of nutritional screening, assessment and care pathways

Tool 4

Education and training: knowledge skills and competencies of staff

Tool 5

Develop service specifications and management structures for nutritional care

Tool 6

Developing quality frameworks for nutritional care

Step 4: Measure, Monitor and Sustain Collect the data: Use the tools in the BAPEN Toolkit to help you to collect the right information Tool 1

Assessment of population at risk of malnutrition in all settings

Tool 2

Assessment of current screening in place and provision of nutritional care

Tool 8

Work with local providers to understand and agree your current position as a baseline for improvement

Agree as a team, the current state in relation to: • How you raise awareness in order to prevent malnutrition?

• How you are identifying those with malnutrition or those at risk through screening e.g. through the use of the ’Malnutrition Universal Screening Tool’ (‘MUST’) • How you are managing malnutrition – what options are available, what pathways are used, what support is offered to help people eat and drink?

• What your patients and relatives tell you now about how you are doing?

• Identifying the issues and challenges to implementing good nutrition and hydration support • Developing the new vision • Agreeing the actions and changes that need to happen to raise awareness and provide good nutrition and hydration support • Agreeing ‘Quick Wins’ • Prioritising other actions for change

Create short term wins Implement some quick wins Our top tips include: 1. Implement the Malnutrition Community Pathway: an evidence based pathway created to ensure the right patients in the community receive the right type of nutritional care to improve quality and reduce costs. www.malnutritionpathway.co.uk 2.

Work with your local acute providers to implement the new BAPEN quality guide available at www.bapen,org.uk 3. Set up a nutrition steering committee that spans health and social care to create and implement an integrated nutrition pathway of care

Step 3: Making Changes to Improve Use your implementation plan as a guide and start making/testing changes in relation to raising awareness with patients, families and their carers; raising awareness – staff education; screening: identifying those at risk (individual and/or prevalence); managing malnutrition by ensuring patients are on the right nutritional care pathway and have the right support to eat and drink regularly; monitoring on a regular basis by understanding and agreeing the information required regularly for the individual, the organisation and the community in order to work together and achieve integration.

Tool 7

Using quality indicators, monitoring and review

Measure: It is important to: measure the improvements against your baseline; ask the patients and those who care for them if you are making a difference; realise your benefits and quantify them (and tell people about them), monitor the outcomes, and sustain the improvements.

Monitor and Build on the Change: Commission for sustainable change in practice by ensuring nutrition and hydration become embedded in the services you commission. View the short-term wins as the beginning of your journey to improve nutritional care and celebrate each success but, after each success, set a new improvement goal to ensure that excellent nutritional care is delivered to every patient in every setting on every day.

Sustain: Anchor the Changes in your commissioning contracts: Seek evidence from your providers that they are monitoring malnutrition on a regular basis at Trust and individual level. Ensure plans are in place to reduce the incidence of malnutrition. Build nutrition and hydration into every care pathway (e.g. dementia, stroke, cancer).

Finally celebrate your successes and share them with BAPEN and the Malnutrition Task Force.

Top Tips • Keep communicating to all stakeholders as changes happen • Gather momentum and start to tackle the harder more difficult changes • Tick off the changes in your implementation plan • Meet regularly with the project team to ensure all the changes have owners and timescales.

Exemplar case studies: Be one of the first Clinical Commissioning Groups to fully implement the BAPEN Commissioning toolkit and work with us to share your story

References: 1. Elia M, Stratton RJ Redditch: BAPEN. 2009 2. NICE Cost Saving Guidance. April 2012 http://www.nice.org.uk/usingguidance/ 3. Cawood AL et al. Ageing Research Reviews. 11(2); 278-296. 2012 4. Elia M. Stratton RJ Redditch: BAPEN. 2005.

5. Stratton RJ et al. Ageing Research Reviews. 4(3):422-450. 2005 6. Cawood AL et al. Proceedings of the Nutrition Society. 68 OCE7, E544. 2010 7. Stratton et al. Clinical Nutrition Supplements 2, 5-23. 2007 8. Parsons et al. Clinical Nutrition Supplements 6(1): 31. 2011 9. Stratton et al. Disease-related malnutrition: an evidence-based approach to treatment.

Oxford: CABI publishing. 2003 10. Hertfordshire community Meals Social Return on Investment Analysis. 2012

nov/dec 2012 | 31

community care Legal

The TSA effect The first application of the trust special administration process is underway in an attempt to preserve the continuity of the NHS services for patients of the South London Healthcare Trust. Lawyer Michael Boyd considers the process, its likely outcomes and the implications for commissioners

32 | nov/dec 2012

community care Legal

How did things get so bad?

The South London Healthcare Trust (SLHT)’s problems can be traced back to the merger that created it in 2009, involving three south London NHS trusts. The newly constituted SLHT assumed responsibility for a significant debt, which had been accumulated as a result of costs overruns on the construction of two new hospitals. The failure to deal with on-going issues saw the debt rise to £150m, accumulating at a rate of £1.3m per week, until the secretary of state declared the trust unsustainable and instigated the trust special administration (TSA) process on 16 July 2012.

Immediate impact on commissioners and patients It is important to note that TSA does not equate to insolvency. SLHT will continue to provide the same services and standards of care to its patients, at least until the secretary of state decides whether to implement the recommendations made to it by the trust special administrator. In addition, it is important to bear in mind that, in assuming the functions of the SLHT, the trust special administrator is obliged to maintain patient services.

In order to address the serious financial issues at the heart of SLHT’s decline, it is likely that SLHT will have sought to renegotiate the terms of its commissioning contracts. Again, depending on the outcome of the process, it is likely that further negotiations will be required.

What about statutory consultation duties?

Questions have been raised whether the TSA requirements allow the administrator to avoid the statutory ‘engagement and involvement’ obligations which arise when there are changes to health services.

The TSA consultation process is quite inflexible in terms of scope, information and time, relative to the more flexible nature of the statutory engagement principle which allows consultation to be guided by the subject matter and gravity of the plan, proposal or decision. As a result, depending upon the trust special administrator’s recommendations and breadth of consultation, although the TSA process may satisfy the statutory consultation requirement and prevent the need for a separate consultation, it would be dangerous to assume that it would do so in every case, no matter what the Department of Health’s guidance for trust special administrators says.

In addition to the prescribed consultees, it is likely that, in order to fix the problems affecting SLHT, the trust special administrator will need to gain the buy-in of third parties who will not be bound by its report. The DH’s guidance makes it clear that the TSA process does not provide for service configuration by the back door.

Likely outcomes of the TSA process and the position of creditors There are two probable outcomes: SLHT’s continuation as a going concern or the acquisition of its services by a third-party, leaving the trust as a ‘shell’ for dissolution.

As an NHS trust, any liabilities remaining to SLHT’s creditors must be handled by the secretary of state, either by assignment of the liabilities to the secretary of state itself or to another NHS body.

Private financial initiative (PFI) partners, however, have little to be concerned about, as their position will have been secured by arrangements put in place when the deals were first signed. However, they may find that the SLHT seeks to manage these contracts more aggressively and to use prior performance shortfalls as leverage to extract concessions.

The TSA process, the necessity for consultation and the final report Following the installation of the trust special administrator, the secretary of state acknowledged that in this case, the statutory 45-day period for the production of a draft report is insufficient, and has extended this period to 75 days due to the complexity of the issues.

Once published, it is imperative that the trust special administrator invites responses within five days. Consultees – which include commissioners – then have 30 days in which to respond and will be invited to at least one meeting with the administrator. It is unclear whether patients must be consulted but it is likely their views will also be sought.

Following consultation, the administrator must provide the final report and copies of all responses received to the secretary of state within 15 working days of the consultation period’s end. The secretary of state must then decide what action must be taken.

“Differing from the private sector, the transparency within the NHS means that its trusts are unlikely to become unsustainable providers overnight”

The position of commissioners Differing from the private sector, the transparency within the NHS means that its trusts are unlikely to become unsustainable providers overnight. The warning signs will have been in the public domain for a considerable period of time, so commissioners will have had a lengthy lead-in time to prepare for a TSA and consider the options available to them.

It is worth noting that although commissioners do have rights under their contracts, those that are NHS contracts are only enforceable with the consent of the secretary of state. As a result, they will not always be shielded from the consequences of the TSA process – which could include contract termination.

In the context of a local economy-wide solution, with various organisations suffering costs in reaching a solution, commissioners may be expected by the secretary of state to assume a share of the wider costs of sorting out what is clearly a very messy situation.

Michael Boyd is partner and head of the healthcare group at business law firm DWF

nov/dec 2012 | 33

community care hospitals

Unpopular opinions Despite being politcally taboo, studies show that closing hospitals and moving care into the community is better for patients and budgets. Murray Keith of Central London Community Healthcare NHS Trust looks at the challenges

34 | nov/dec 2012

community care hospitals

M

ore hospitals.

More schools.

If there’s a sure way of appealing to the electorate it’s to put our hard-earned taxes towards the institutions that really deserve the state’s support. It’s popular and it’s also common sense. As far as hospitals go, it’s also plain wrong.

As their name suggests, the acute hospitals are often outstanding at dealing with emergency situations. These are always going to arise. At the same time, though, the health issues we are seeing from Central London Community Healthcare (CLCH) – which are mirrored all over the country – are changing. The UK has an ageing population, it’s a population that is living longer and – crucially – it’s a population that is surviving with more and more long-term conditions (LTCs). Advances in medical science and the standards of nursing care mean that many conditions that would have been fatal even 30 years ago can be held in check. The life expectancy of those with diseases including diabetes, COPD, heart problems and certain cancers has very considerably improved.

The figures are startling. There are currently around 15 million people living with an LTC in the UK and 60% of people over 65 suffer from one or more. Long– term health problems already account for 80% of GP consultations. The King’s Fund estimates the cost of caring for long-term illness at £69bn per year, much of which goes on hospital-based care. It is this ever larger group – and ever larger cost – that is of particular importance as the NHS seeks to improve patient outcomes and control costs under the new Health and Social Care Act. This is where the Department of Health’s out-of-hospital agenda comes in.

This recognises the complementary role that the acute hospitals can play in working with community healthcare providers like CLCH

in looking after those with LTCs. The agenda recognises that flexible and dependable intervention either in the patient’s home or in a nearby clinic can limit and sometimes completely prevent hospital admissions for those whose LTCs become acute. The advantages of maintaining the stability of patients’ conditions go without saying. Less well known, though scarcely surprising, are three other factors. Treating patients in their own homes or in their local community clinic is considerably cheaper than in the acute hospital sector, according to some studies, by a factor of up to five. Secondly, patients generally have a strong preference for treatment in or close to their own homes.

Thirdly, patient outcomes in such settings appear to be broadly comparable to those in the acutes.

So to caricature the implications of the out-of-hospital agenda, it means fewer acute hospitals, more care in the community. Not more hospitals. Fewer hospitals.

Needless to say, this puts the issue firmly on the political agenda. Hospitals are longstanding and very visible parts of the community. The reorganisation or closure of buildings, departments or entire hospitals is hugely controversial. Nobody welcomes protesters’ placards and local MPs voicing their dissent. In the area covered

by CLCH in North West London there’s currently a vigorous campaign to oppose the downgrading of A&E units.

At CLCH we wanted to make sure that we understood the political dimension of this issue as well as the medical one. So we commissioned the political polling company Dods to talk to MPs about the issue. The results were intriguing.

The good news was that 90% of MPs agreed that improved community healthcare was essential for dealing with an ageing population. They understood that the increased prevalence of LTCs meant that the acute hospitals were in danger of

“Treating patients in their own homes or in their local community clinic is considerably cheaper than in the acute hospital sector; patients generally have a strong preference for treatment in or close to their own homes; and patient outcomes in such settings appear to be broadly comparable to those in the acutes”

being overwhelmed. MPs also supported the delivery in the community setting of children and young people’s day-to-day care (99%), care for the elderly (92%), and the treatment of long-term conditions like diabetes and heart disease (76%). This saw almost no difference across political parties.

There was also a degree of consensus that community care allows hospitals to focus on acute care and improves patient experience. Finally, 75% of MPs across parties thought at least sometimes, more priority should be given to community healthcare rather than acute hospitals.

The main reasons for the difficulty behind increasing the priority given to community healthcare differed across parties. For Conservative MPs, public, media and political attachment to acute hospitals was most important, as well as opposition from staff and the wider public reaction to such changes. For Labour MPs, it was a question of cost in a time of austerity, though public support for acute provision and wish to defend it against closures also played a role. Liberal Democrats were more likely to focus on the lack of cohesion in NHS delivery or political will to plan for the long-term.

So there’s the problem. At CLCH we have recently reformulated where we think we need to take the trust.

It’s encapsulated in our vision: ‘to lead out-of-hospital community healthcare’.

We think the reasoning behind this is duly forward-thinking, and that we are preparing for tomorrow’s healthcare world, not yesterday’s. We also believe that partnerships with acute trusts can provide answers to a number of the major issues facing the healthcare landscape of the future. We are not here to do the acutes down.

Clearly, though, there are some challenges in explaining that against the traditional model. Our intention is of course to work alongside local decision makers and explain the transition in as much detail as possible. But the hurdle of the opinions of the public and their elected representatives is one of the biggest of all.

Murray Keith is director of strategy and business development at CLCH NHS Trust

nov/dec 2012 | 35

IT Emergency admissions

A difficult admission

36 | nov/dec 2012

IT Emergency admissions

Emergency admissions are on the rise and GPs and their commissioning groups have been asked to work together to reduce them. Julia Dennison finds out how using data can really help and the whos, whats, whens and whys that contribute to A&E attendance

A

&E is under more pressure than ever. Over 20 million patients visit it each year and this number is growing steadily by three per cent every year, with no sign of declining.

These acute services are also expensive – so not the kind of stat you want to see on the up and up. With the Nicholson Challenge to save £20bn breathing down the neck of CCGs, cutting back on expensive emergency hospital visits could be a winning card. The fastest and easiest way to go about doing this across your locality is by gathering evidence.

Accident and emergency departments, minor injury units and walk-in centres are required to collect a standard set of details on individual attendances. This ‘commissioning dataset’ has been collated by the Information Centre for Health and Social Care and made available on a national basis through the Hospital Episode Statistics (HES) system. However, this doesn’t always help. A recent Foundation Trust Network (FTN) benchmarking report said the diagnostic information collected as part of the national A&E Commissioning Data Set still demonstrates ‘poor coverage, quality and limited relevance’ to clinicians and policy-makers. A significant percentage of attendances are not given an A&E CDS diagnostic code, for example, and even the diagnostic categories that do exist are not detailed enough to inform improvement, the FTN believes. To help with this, the College of Emergency Medicine has begun development of a Unified Diagnostic Dataset, which will hopefully allow for better data to analyse in future.

In the meantime, GPs can do a lot to help CCGs analyse patient data and working with the data they have can answer a lot of commissioners’ questions.

For example, Stillmoor House Medical Practice in Bodmin, Cornwall reviewed its A&E attendances in a bid to help its CCG with commissioning. From the review of 138 patients, 26% related to out-of-hours care and 16.6% were via the minor injuries unit (MIU). Only six patients could have been seen by a GP but chose to go to A&E instead. For two out of these six, it would have been better for them to see the GP. The conclusions were that while attendances were generally felt to be appropriate, MIU staff could be better trained to handle more cases; an acute care-at-home service would help reduce a number of criteria and increased nursing cover and advanced care planning could be done more, particularly in relation to falls/dementia/nursing residential home patients.

While these conclusions may not have been surprising,the practice felt it was important that information was shared throughout the locality to help everyone make progress. “Overall the process went well although there were some inaccuracies with the discharge data which perhaps affected the overall results,” says Michelle Pratley, of the practice’s support team. Overall, she felt the exercise was worthwhile, as it gave a clearer picture of the source of admissions and produced some possible alternative care pathways which could be applied to future commissioning plans.

When analysing data, it’s important to know what you’re looking for. There are a number of different data sets that CCGs can track in order to help reduce emergency attendances that result in admission. Matt Murphy, MD of EMIS IQ, the software firm’s intelligence division, recommends considering things like whether patients who live closest to A&E are the highest users, or maybe it is more likely to be patients with multiple comorbidities with poor

access to care. Also, look at disease groups to identify areas of poor management in the community. Perhaps A&E attendance also shows that patients need better education about the services available to them as an alternative to A&E. Besides benchmarking member practices, Murphy suggests CCGs consider using risk modelling tools to predict which patients are at the highest risk of hospitalisation and focus resource and multidisciplinary team planning around the effective provision of care for these patients. A good IT and data system can help. “CCGs should look for a data system, which allows them to pull on a number of different data sources and run searches and reports across primary and secondary care data as a minimum,” he says. “They should be able to analyse data at different levels – patient identifiable, anonymised, pseudoanonymised in order to support agendas such as public health, i.e. development of the JSNA [Joint Strategic Needs Assessment], epidemiology [health needs], Primary Care Quality Improvement, commissioning cycle etc. This data should be interrogated by experienced analysts with a good working knowledge of clinical codes.”

Who and what?

There are certain demographics that are important to consider. Patients aged 75 years and older account for over 12% of all A&E, attendances and nearly half of these end in admission, according to a recent benchmarking report by the FTN. These are a high-need and high-cost group due to the complexity of their clinical conditions.

Chronic repeat attenders to A&E account for up to eight per cent of all A&E attendances. According to the FTN, trusts are taking action to segment and understand their patient population and put specific plans in place to reduce these repeat attendances. Around the country, a significant focus has been put on implementing support services, like community alcohol teams and Rapid Assessment, Interface and Discharge (RAID) services for those with mental health needs.

When?

Another matrix to watch through data is time. South Warwickshire NHS Foundation Trust had identified two spikes

nov/dec 2012 | 37

IT Emergency admissions

in admissions through GP referrals – at 2pm and 7pm, when GPs had finished their home visits, after seeing patients in their surgeries first. This put a strain on ambulance services as well as the acute trust itself – particularly in the early evening, as the options to stabilise and discharge patients are limited when social care and other community services have shut for the day.

To take the pressure off and even out the number of patients arriving at A&E, the emergency department at South Warwickshire has encouraged GPs working in the same practice to rotate their time spent on home visits so the patients weren’t arriving all at once. This benefited the trust and the patients, who might also benefit from more choice of surgery visiting times.

Why? In addition to knowing who is presenting to the emergency room, it is also helpful to know why – in terms of what medical conditions and the healthcare services they used or considered before they walked in the door to A&E. Of course, not every attendance can, or should, be prevented. There is an absolute and obvious need for emergency services, however, certain conditions may be better suited for a community setting, rather than an acute hospital.

Christine Falzon, pathway lead for respiratory conditions at Central London Community Healthcare NHS Trust, believes COPD is one of these conditions.

The best way to manage COPD patients, Flazon believes, is to have real data on admissions, A&E attendance and GP practice attendance so that patient care can be targeted at those patients who use health services inappropriately. “Where the cause of admissions and A&E attendances is due to poorly managed COPD, specialist community services can improve outcomes, however most services are still poorly equipped to manage patients with anxiety and depression,” she says.

An integrated approach Remember – as a CCG, you’re not a lone island. “Collaboration with other CCGs can prove useful in terms of the sharing of resources, knowledge and costs,” says Murphy. In terms of data management, he

38 | nov/dec 2012

urges CCGs to consider sharing things like data warehousing costs and infrastructure; analysts to interrogate the data on behalf of CCGs; and standardised reports to support the commissioning agenda – i.e. one report generated for all CCGs to show A&E attendances, inpatient spells, outpatient appointments, primary care data such as QOF scores, access rates etc.

In the end, integrating data and services

“Unfortunately, the diagnostic information collected as part of the national A&E Commissioning Data Set still demonstrates poor coverage, quality and limited relevance to clinicians or policy-makers” seems to be the solution. This has worked in Greater London where In a bid to reduce emergency admissions, Jane Wells, service director at Oxleas Foundation Trust, has been working on an integration project between Greenwich Community Health Services, Oxleas NHS Foundation Trust, and Royal Borough of Greenwich, Social Care. The initiative was aimed at providing a collaborative and proactive approach to managing older people with urgent health and social care needs. “We noticed that we’d had lots of good services set up to manage admission avoidance and facilitate discharge, but they had been commissioned

in a real piecemeal fashion,” she comments.

“We knew we’d had improvements over the years in our performance in terms of admission avoidance but we weren’t there yet. So, we looked at the key areas we wanted to really knuckle down in and get better.” This turned out to be mostly around community services, intermediate care and social services – so the trust decided they would integrate them. Wells then went about engaging the staff to design a new model themselves. The end result was a Joint Emergency Team (JET), which includes nurses, therapists and social workers; and a Hospital Integrated Discharge Team, to act as points of contact for patients coming and going from A&E, as well as co-located community assessment teams. The result has been a considerable improvement in A&E admission avoidance and attendances.

Sharing data has proved a slight struggle for Wells and her team. “What we don’t have is joint IT systems,” she says. While this has been a challenge, she didn’t let it be a “showstopper”: “We knew if we tried to fix the IT system, we wouldn’t have achieved any outcomes for the patients.” In the meantime, she says, it’s more important to keep an open communication across health and social care, rather than wait for the perfect IT system – and the same goes for waiting for commissioning to get started. “We could wait until the planets align,” concludes Wells, “or we could just get on with it.”

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PRACTICEBUSINESS

INFORMATION TECHNOLOGY MEDICINES MANAGEMENT

Making a PACT

Using diabetes as a case study, POLLY ELLISON looks at prescriptions and what you can proactively do with the information to ensure your commissioning group has the right tools to make better medicine optimisation decisions

W

ith an annual NHS spend of over £8bn a year on prescribing, clinical commissioning groups are going to have to look carefully at how they can support GPs with their prescribing in order to deliver savings.

Robust information management of prescribing data is essential particularly as recent figures have shown that the number of prescriptions for treating diabetes in England has topped 40 million. This represents a 50% rise in six years and a 6.1% (2.3 million) rise on the number of

40 | NOV/DEC 2012

items prescribed in 2010-11, according to data from the Health and Social Care Information Centre.

Barbara Young, chief executive of Diabetes UK, has described it as a “wake up call” to all concerned, saying: “We face the real possibility of diabetes bankrupting the NHS within a generation.”

Traditionally, PACT (prescribing analyses and cost) data has been used as it is derived from prescriptions issued by general practitioners. Health authorities, health services researchers and GPs all use PACT to audit and help improve their prescribing.

In addition to PACT data, medicines management has been further assisted

by drug knowledge-bases, now widely used throughout the UK having been integrated in many clinical systems across the whole healthcare community. A good system of this kind will hold clinical and commercial information on thousands of pharmaceutical products and provide up-to-date clinical decision support and referential medicines information for all healthcare professionals.

PACT data and drug knowledge bases have assisted GPs greatly, providing a better understanding of prescribing data and more efficient medicines management.

As CCGs become established in 2013, GP practices will need to be more responsible

INFORMATION TECHNOLOGY MEDICINES MANAGEMENT

for their drug budgets and the pressure will be on to generate the massive savings it is believed can be made from good medicines management.

However careful some GPs and GP practices are in their prescribing, there are certain areas where prescribing is notoriously difficult to control. GP locums and GP registrars can distort practice prescribing however careful the practice’s partners may be. The recent introduction of a web-based support solutions for prescribing healthcare professionals within the primary care sector has been a welcome one for many practices, as it provides prescribing decision support that improves patient care and potentially delivers cost savings. One leading brand alone is now installed in more than 6,500 GP practices, across 138 NHS primary care trusts and NHS health boards throughout the UK.

“As CCGs become established in 2013, GP practices will need to be more responsible for their drug budgets and the pressure will be on to generate the massive savings it is believed can be made from good medicines management” GP training practices and those practices that traditionally use a large number of GP locums have found this kind of support solution invaluable as it not only delivers recommendations for existing patient medications, but it also supports decisionmaking when initiating new treatments during a patient consultation. In addition, it assists GP locums and GP registrars stay in line with practice/CCG formularies. Web script support services often partner with drug knowledge bases, as well as many of the leading primary care software providers.

In addition to the software support, one of the most effective and efficient ways to improve prescribing in practices in recent years has come about as a result of the introduction of prescribing support pharmacists. Via recommendations from pharmacists, many practices have changed their prescribing profiles significantly to optimise their drugs budgets by allowing

PCT/CCGs to define drug switch opportunities. PCT/CCGs have been able to increase the number of hours done by prescribing support pharmacists in certain practices, to ensure that the GP practice consortia have good medicines management in all their GP practices, generating savings for all, not just a few, and thus increasing the savings made by the consortia as a whole.

A combination of software and prescribing support pharmacists continues to assist both GP practices and CCGs as they strive to generate more savings, however, as diabetes increases in the UK over the coming years so the pressure to make savings will increase. In England, 2.5 million people have been diagnosed with diabetes and the number is expected to reach 4.2 million by 2025. The growth in diabetes drug prescription numbers is faster and greater than for prescriptions overall, where items have increased by 33%.

The net cost in diabetes drugs, including treatments for type-one and type-two diabetes, also rose by just under 50% in the six years between 2005-06 and 2011-12.

Any savings made in medicines management may well have to be redirected towards the existing NHS Health Check, which everyone between the ages of 40 and 75 should be getting. To date, this has seemed poorly implemented but improving this service is the only way that the NHS will be able to end the steep rise in the number of people with diabetes, so beginning to bring the spiralling financial cost of the condition under control. As Young says: “We need to grasp the nettle on preventing type-two diabetes, which accounts for around 90% of diabetes cases.

We need a government-funded awareness raising campaign on the risk factors and symptoms of type-two diabetes and we need to get much better at identifying people at high risk so they can be given the support they need to prevent the condition.”

Diabetes awareness campaigns need to go hand in hand with good medicines management. Until this happens, the increase in spending on diabetes-related medicines is inevitable as such medicines are vital to reduce the risk of complications caused by diabetes, such as blindness, amputation, kidney failure and stroke.

NOV/DEC 2012 | 41

IT GOVERNANCE

GABBY PROWSE, a trainer for the Avon Local Medical Council in information governance, talks about why it’s important in the transition to clinical commissioning

INFORMATION TALKS

I

t’s no secret that it’s vitality important to have robust information governance (IG) arrangements in place at all times. This means adequate resources to enable clear and effective management and accountability structures, governance processes, documented policies and procedures and, the bedrock of good information governance, trained staff.

Transitions pose a challenge to continuity and ensuring the governance arrangements are securely in position regardless of who the responsible organisation is becomes essential.

The National Information Governance Board (NIGB) guidance suggests that GPs on the CCGs have a good understanding of confidentiality requirements, but this doesn’t take into account General Practice Information Governance Toolkit requirements

42 | NOV/DEC 2012

number 13 and the CCGs’ number 28, which potentially create gaps in knowledge and experience.

This is why the NIGB also suggests board members should be supported by a qualified information governance expert.

With stretched staffing budgets, the wearing of multiple hats will be inevitable but also means CCGs have to be extra vigilant and not become distracted from information governance by other competing organisational requirements. This is a serious business when you look at the potential penalties and consequences. For example, the Department of Health states: “The area which receives greatest media and public attention is the loss or inappropriate use of confidential patient information and recent legislation allows the Information Commissions’ Office to fine an organisation up to £500,000 for a

IT GOVERNANCE

serious breach of the Data Protection Act 1998. Each CCG will be accountable for ensuring that it has adequate IG measures in place covering all aspects of information handling, e.g. information security and risk management; data protection and confidentiality; information quality; and corporate records.”

Connecting for Health also states that sustaining robust information governance means that, “all staff should receive annual basic IG training appropriate to their role through the online NHS IG Training Tool [IGTT]. Information governance and awareness should be at the core of the organisation’s objectives, embedded amongst other governance initiates. Without this knowledge, the ability of an organisation to meet legal and policy requirements will be severely impaired.”

They also state that “the organisation should establish a clear plan for IG training appropriately tailored to specific staff groups and roles. Any training that is provided should be regularly reviewed and updated in line with legal requirements, corporate and/or Department of Health policy, or any major changes which may impact on the information governance agenda.”

TRAINING IS CRUCIAL Tailored, position-specific training is crucial to the success of the information governance process; without it, costly mistakes and loss in public confidence are inevitable. This may mean a mix of online and face-to-face bespoke training is necessary to fulfil the individual’s exact needs. Following on from the initial training, there will also need to be regular and systematic assessment of training and development needs, i.e. a training needs analysis.

As CCGs complete the Information Governance Toolkit as part of the authorisation application process, this will also be key to ensuring there is an adequate IG framework to support the transition. This period between now and 1 April 2013 will also allow time to build capacity and capability within the CCG and test robustness of systems and processes.

FURTHER GUIDANCE Other than the NHS IG Toolkit and Training Tool, the NIGB issued an information governance transition plan spread sheet in June 2012, designed specifically around PCT transition and the commencement of CCGs. The NIGB says: “The transition takes an organisation through the IG requirements for PCT closure through to CCG authorisation and commencement. By completing the spreadsheet and assigning responsibilities, you can create a plan for the information governance aspects of transition.”

So what should Tailored, position-specific training the CCG Information is crucial to the success of the Governance Team structure look like? information governance process; There is no set without it, costly mistakes and loss in format for the governance public confidence are inevitable ” team structure, so organisations will need to determine the arrangements that suit their requirements, but the NIGB state that “clinical commissioning groups should appoint a Caldicott Guardian and a senior information risk owner (SIRO) at board level to ensure their respective functions continue both during transition and for the future”.

A suggested list of roles needed to fulfil robust governance arrangements is: • CCG accountable officer (chair) – a member of the executive team • SIRO – a member of the executive team • Caldicott Guardian • CCG clinical lead

“

• •

Information asset administrator Operational information governance manager or IG lead • FOI and data protection leads • Information security manager/adviser • Human resource, training and finance involvement.

These posts may be recruited to PCTs until the CCG is authorised to take on statutory duties, as may PCT information governance policies be adopted as an interim measure.

The NIGB Transition Plan, alongside their recommendations for successful transition, also suggests that: 1. “GP practices ensure that their data controller responsibilities continue to be satisfied and that data is not disclosed inappropriately outside the practice to staff working on behalf of clinical commissioning groups.” The Data Protection Act 1998 and the Freedom of Information Act 2000 are the two key pieces of legislation governing the use of information held by CCGs. Clinical commissioning groups and the shadow NHS Commissioning Board will not be able to process personal data unless and until they become legally constituted bodies.

2. “In future, audit is applied to all of the Information Governance Toolkit requirements annually during transition and that they are conducted independently.”

Finally, once the CCG becomes a legal entity it will be required to register as a data controller with the Information Commissioners Office (ICO).

Useful resources • DH: Informatics Planning 2010/2011 • DH: Confidentiality NHS Code of Practice 2003 • DH: Records Management NHS Code of Practice 2006 • DH: Information Security NHS Code of Practice 2007 • ICO: ico.gov.uk • IG Toolkit: https://nww. igt.connectingforhealth. nhs.uk/ • IG Training Tool: https:// www.igte-learning. connectingforhealth. nhs.uk/igte/

NOV/DEC 2012 | 43

MANAGING COMMISSIONING THE THIRD SECTOR

VOLUNTEERING

44 | NOV/DEC 2012

MANAGING COMMISSIONING THE THIRD SECTOR

INFORMATION With CCGs tasked with providing services that are both cost-effective and locally inspired, working with the voluntary sector has become more vital than ever.

CARRIE SERVICE reports

T

he voluntary sector has a great deal to offer to the NHS, particularly at a time when integrated care and health and wellbeing are so high on the agenda. Charity organisations and voluntary groups have a wealth of knowledge on the needs of local people and are well placed for analysing the impact certain services could have on outcomes. So what can commissioners do to ensure they are tapping into this resource and putting it to good use?

BUILDING BRIDGES Dr Anna Dixon, director of policy at The King’s Fund, stresses the importance of engagement between commissioners and voluntary organisations. In an article for the Guardian, she highlighted three areas where she believed commissioners could improve the relationship between the public and voluntary sectors. “Firstly, there is a need for commissioners to engage with voluntary organisations to better understand what they can offer,” she explained. “Secondly, commissioners may need to adapt how they procure services to enable smaller organisations to compete. This means engaging early to give the sector time to develop their offer or partnerships… It also means a different approach to contracting.”

In other words, if commissioners want to make the most of what the third sector has to offer, they need to make things easier for them by minimising bureaucracy and reducing red tape. “Thirdly,” adds Dixon, “funding mechanisms need to be developed that recognise social value, encourage innovation and facilitate access to capital to develop services.” Her final recommendation is that the third sector itself needs to develop a more collaborative approach by forming strategic partnerships with CCGs.

TAKING VOLUNTARY ACTION Bernard Collier, chief executive of Voluntary Action Westminster, an independent charity working with local voluntary and community groups, has sat on the Central London CCG for the past two years, and is also part of its transformation and redesign group, which looks at how individual services could be better implemented. Collier’s role within the CCG entails deciding how the voluntary sector might be involved with this process of redesign. As many aspects of secondary care are now being moved over to the primary sector, Collier believes there are all sorts of areas where the third sector might be able to help. “There will be more people that have long-term conditions that may not be entirely medical that need some support,” he explains, “and I think that the sector definitely has a role to play – if not in providing direct medical services, they may be able to provide the volunteers, the network of friends, that will enable people to be sustained in the community.”

SHAPING THE FUTURE Voluntary organisations are perfectly placed for influencing the redesign of services within the NHS – Collier gives the example of the provision of mental health services. “We can get together providers of mental health services to put in their views about current configurations and how they might think they can be done better,” he suggests. “So the sector can advise on how services are working and how they might be configured differently to better serve the needs of the community. They may also be able to deliver the services themselves.” He acknowledges that there needs to be a “firewall” between organisations that are providers and the influence they have over provision, however he maintains that

NOV/DEC 2012 | 45

MANAGING COMMISSIONING THE THIRD SECTOR

involving a variety of organisations in the thinking of the CCG is vital to improving the way services are commissioned.

THINK BIG One route Collier suggests CCGs can take in building better relationships with the voluntary sector is by going through umbrella bodies to mediate the message across their component organisations. This would allow commissioners to make contact with providers who may be able to offer their services to the CCG, but also creates an opportunity for wider engagement, which could go even further than the work of patients’ groups, says Collier.

“Although, there has been a lot of work going on making patients’ groups relevant and representative of the wider community,” he reflects, “there is nothing better to get into the wider community than actually getting a whole variety of voluntary or community organisations in, because they are actually out there.” And by making contact with an umbrella body you instantly make contact with the hundreds, or even thousands of organisations they represent.

A TARGETED APPROACH Another method of involving the voluntary sector in a way that could have a significant impact on the provision of services is to target a specific area of commissioning that your patient population is affected by. Collier suggests perhaps developing a reading group dedicated to looking at all of the documents and papers released on a specific health issue, with the view of producing a concise, usable report for the CCG. As CCGs approach accreditation, Collier believes the Government has made Voluntary sector services it clear that it wants can help to equip GPs with just GPs to be on the board and raises the necessary skills and the issue of a loss of expertise to assess local engagement if this need and commission is the case. Creating high quality mental health some kind of sub-board, services and treatments” he believes, is one way maintaining that engagement with the voluntary sector. “Because the truth is, most voluntary and community organisations don’t deliver services, but they do have a view and want to have an influence,” he says.

Amy Whitelock, policy and campaigns manager at mental health charity Mind, makes the important point that GPs cannot be experts in every in-depth aspect of health – they are by nature, general practitioners after all. “We appreciate GPs already have a large workload and surveys have shown some feel they lack confidence and expertise in mental health commissioning,” she says. “We know there are still huge variations in access to and quality of mental health services, with some people waiting over a year for access to psychological therapies and many receiving little choice of treatment. Voluntary sector services can help to equip GPs with the necessary skills and expertise to assess local need and commission high quality mental health services and treatments for everyone that needs them.” Not only that, but voluntary

“

46 | NOV/DEC 2012

organisations can help facilitate access to people with mental health problems and others who are likely to be marginalised or harder to reach, says Whitelock.

KEEP YOUR FRIENDS CLOSE It’s also important to maintain and nurture any current links that the PCT has with the voluntary sector, particularly for conditions that are proving to be a continual challenge for the NHS, for example, diabetes. “There are several national diabetes charities – the JDRF, IDDT, DRWF as well as Diabetes UK. All of them have volunteers and supporters, but Diabetes UK in particular has a huge tribe of helpers,” says Sue Marshall, a type-one diabetes sufferer and author. “The NHS’s diabetes healthcare professionals are well served. There’s a lot to be gained from growing the already strong links between the NHS and diabetes charities.” Huw England, MD of Commissioning4health, says that there is a wealth of opportunity for commissioners to gain support from the voluntary sector, but they need to create links with the existing networks in order to make use of it. “The challenge and the opportunity for the emerging clinical commissioning groups and GP commissioners in particular is how they access the wealth of innovative and high-quality support services available to them, be that through local voluntary groups or through the private sector. Accessing that support is sometimes difficult,” he explains. “Making use of local, regional and national networks in the voluntary sector…that are either already in place or available via web-based platforms, to support GP commissioners, is going to play a part in moving clinical commissioning groups from pre-authorised bodies into statutory bodies in 2013.”

MEDICINES OPTIMISATION WITH FDB

THE CHALLENGE

THE SOLUTION

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

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

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

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

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

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

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

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

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

•

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 www.thelancet.com Published online May 10, 2012 DOI:10.1016/S01406736(12)60240-2 4. ‘Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study’, May 2012 ProfessorTonyAvery1,ProfessorNickBarber2,Dr.MaisoonGhaleb3,ProfessorBryony DeanFranklin2,4,Dr.SarahArmstrong5,Dr.SarahCrowe1,ProfessorSorayaDhillon3, Dr. Anette Freyer6, Dr Rachel Howard7, Dr. Cinzia Pezzolesi3, Mr. Brian Serumaga1, Glen Swanwick8, Olanrewaju Talabi1

MANAGING COMMISSIONING PCTs

The legacy T of primary care trusts There’s a long list of things a CCG should be learning from PCTs before they go. But how much should start from scratch under the new NHS agenda? POLLY ELLISON finds out when to take their advice, when to ignore it and what you need to know from them before they go 48 | NOV/DEC 2012

he legacy left by primary care trusts, once they cease to exist on 31 March 2013, will depend on the relationship key individuals within the PCT have had, over the years, with their GPs. Good relationships have seen positive outcomes which have lent themselves to a smooth transition from PCT to CCG. Where relationships have not been so good a more complex picture emerges.

Some PCTs have been seen to ‘reinvent’ themselves into the new CCGs because they saw the opportunity to take control in unchartered waters, and safeguard their jobs, one of the things that the government is trying to avoid by implementing the current changes. One thing is certain and that is that every single CCG currently evolving, differs from its neighbours and has a different set of priorities depending on its local health needs. How different a CCG will be from the PCT it takes over from will very much depend on how good the PCT was,

MANAGING COMMISSIONING PCTs

When labour abolished GP fundholding in 1997, health authorities were replaced by primary care groups which then formed PCTs. In 2004 practice based commissioning (PBC) was introduced and practices were given indicative budgets along with data on the volume of services their patients were using, thus allowing them once more to become involved with commissioning. PBC struggled in the early years as a lack of incentive meant GP practices were slow to participate. At this point, rather than offering incentive, it seemed that the solution lay in recruiting

of a population’s health needs. A CSS can specialise in one particular activity or product, it could offer a “one stop shop” service, or anything in between. CSSs will not be able to make actual commissioning decisions however, the CSSs will be able to provide support or advice to enable the CCGs and NHS CB to make better informed decisions. The idea is that each CCG will be able to choose from a variety of organisations to create a model of service which best meets their needs, and the needs of its population. For example, a CCG could choose to run all its support functions in-

“The legacy left by the PCTs will very much depend on how successful they were, which in turn links directly to how good their personnel were, and how good their relationship was with their GPs ”

and how much those on the new CCG Board will be able implement in the way of changes.

Undoubtedly, GPs will be pleased to have experienced support in the running of their CCGs as they are, after all, keen to practice medicine, not run bureaucratic organisations. But it is to be hoped that some of the layers of management are now a thing of the past. Long before the PCTs evolved, GPs were commissioning services.

Indeed, many remember the days of GP fundholding very positively. Under GP fundholding, GPs held real budgets with which they purchased primarily non-urgent elective and community care for patients; they had the right to keep any savings and had the freedom to deliver new services.

Some practices went a step further to form consortia, creating larger organisations to pool financial risk and share resources.

Some of those GPs involved in fundholding now find themselves sitting on clinical commissioning groups (CCGs). They bring a wealth of expertise to the CCG table as a result.

numerous layers of managers, within the PCT, to try and do the work on the GP practices behalf. Undoubtedly, by the time the PCTs cease to exist some of these managers will have moved on to pastures new. It is to be hoped that those more expendable will have moved on whilst those skilled in commissioning are retained.

When the White Paper was first announced there was a flurry of activity as some key, valued personnel jumped ship straight away, leaving a fear amongst GPs that they would be left with those less valuable members of staff within their CCG. Another fear is that those members of the PCT who have elected to stay on till the end, may well reappear in another guise in one of the CCG support organisations.

From April 2013, CCGs and the NHS Commissioning Board will be responsible for the whole commissioning process. Like all organisations, they will also require services like HR, IT and administrative support. To allow them to concentrate on improving clinical care pathways and improving efficiency, they will be able to contract with other organisations, in order for these new organisations to carry out some of the commissioning functions for them. These organisations are called commissioning support services (CSSs).

The commissioning support involves a wide variety of activities from payroll services for staff, to complex forecasting

house, if they have the necessary skills and are big enough to make it cost-effective. If it is a small CCG, it could band together with others and buy all its services from a “one stop shop” CSS to benefit from economies of scale. For some a combination of the two will work best.

By the nature of their expertise, the CSSs could potentially attract all those from the PCT who could not find jobs directly in the CCG, particularly when it comes to the commissioning support units (CSUs). All organisations contracted to provide services for CCGs or the NHS CB are given the blanket term “commissioning support service”. Some of these will develop from existing PCTs and will remain part of the NHS for a transition period. These will be called commissioning support units (CSUs) to distinguish them from the wider CSS marketplace. Either via TUPE or recruitment it is possible that many ex-PCT staff will re-locate to these organisations.

The legacy left by the PCTs will very much depend on how successful they were, which in turn links directly to how good their personnel were, and how good their relationship was with their GPs. It is to be hoped that good practice and good personnel are recruited into CCGs, and that re-invention does not take place. Otherwise many will be left wondering what the point of this vast exercise was.

NOV/DEC 2012 | 49

MANAGING COMMISSIONING TOP TIPS

Is your feedback demotivating your CCG team and standing in the way of commissioning? MAIREAD DILLON and JANE PENSON from Toastmasters International give their seven top tips for giving constructive feedback

COMMISSIONING CONSTRUCTIVELY 3

If you want the person to change their behaviour, you should give an example of the behaviour you want to change. For example, if the person often arrives late to meetings, give examples of when the behaviour occurred. Point out the ways that their lateness has affected other members of the team or the business as a whole. At this point, allow the person to tell their side of the story. There may have been genuine reasons behind their behaviour rather than a careless attitude.

Feedback is important to us all. Constructive feedback helps to motivate people, makes them feel valued and encourages them to perform better. Poorly delivered feedback can do the opposite; it demotivates, can foster resentment and at worst turn a productive team member, who just needs a little guidance, into the rotten apple that spoils everyone. So it’s essential to get it right every time. These seven top tips will help you get it right every time…

1

MAKE THE PERSON FEEL LIKE A MILLION DOLLARS

The most important part of giving feedback is to thank the person for their contribution and make them feel great about themselves. Praise them for their efforts and let them know you understand how much work was involved.

2

BE ENTHUSIASTIC

This is your opportunity to empathise and encourage the person to develop and improve their skills. It is not about perfection every time; it is about progress towards a goal. So encourage them to keep trying and never give up.

50 | NOV/DEC 2012

LISTEN WHEN ASKING FOR CHANGE

4

GIVE SPECIFIC EXAMPLES

To demonstrate that you really understand how the person’s contribution added value to the organisation, give specific examples. If you are giving feedback about a written report, for example, say that it provided sales personnel with up-to-date information that helped them towards their goals.

Collect your comments into meaningful sets to make them easier to digest. For example, a writing project could be broken down into: content, impact, structure and accuracy.

5

BIGGER PICTURE

Explain to the person how their work contributes to the running of the organisation. This is very inspirational and will often help them to understand how to do the job better. Put simply, if you know what people do with what you send them, you can send the right stuff.

6

USE A LIGHT TOUCH

7

OFFER A SUGGESTION SANDWICH

Ask yourself if the person’s performance was adequate for the purpose, rather than comparing it with how you would have done it.

For example, if you are reviewing a piece of writing, think about whether it will do the job it was intended to do. You would have written it differently of course, but be careful only to recommend changes if you can explain why. People can be demotivated by ‘red pen’, and they will not be able to learn from comments they do not understand.

A successful model for feedback is to start with positive comments about the person’s strengths and successes.

Follow this with constructive suggestions about how to perform even better, allowing them to comment and ask questions. Finally bring in some additional positive points and encourage them to feel motivated to introduce the changes you have suggested.

Many people find delivering what they might call “negative feedback” difficult, but by following these suggestions giving feedback can be a constructive and pleasant process for both people. The end result of a feedback session should be that both parties feel they have gained from the experience.

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