practicebusiness + inspiring business solutions for practice managers
Run up to a flying start
What practices can do to kick-start the commissioning agenda
In the driving seat
One Derbyshire practiceâ€™s reaction to piloting CQC and 111
A new standard helps practices provide better support for LGB patients
Practice Business is an approved partner with...
Editor’s letter EXECUTIVE EDITOR www.roylilley.co.uk EDITOR email@example.com ASSISTANT EDITOR firstname.lastname@example.org REPORTER email@example.com CLINICAL EDITOR dr paul lamden ACCOUNT MANAGER firstname.lastname@example.org ACCOUNT EXECUTIVE email@example.com PUBLISHER firstname.lastname@example.org DESIGNER email@example.com DESIGN AND PRODUCTION firstname.lastname@example.org CIRCULATION MANAGER email@example.com
CONTACT US intelligent media solutions suite 223, business design centre 52 upper street, london, N1 0QH | tel: 020 7288 6833 | fax: 020 7288 6834 | email: firstname.lastname@example.org | web: www.practicebusiness.co.uk | web: www.intelligentmedia.co.uk | twitter: twitter.com/practice_biz
What’s so bad about the health bill?
As the Health Bill continues to be a contentious issue in Westminster and beyond, I’m left scratching my head. Friends on Facebook are circulating ‘Save the NHS’ campaigns and clinical bodies are claiming that everyone and their mother is opposed to the bill and its changes, but my own experience on the ground – at practices and visiting CCGs – has been very different. The people I’ve spoken to acknowledge that clinical commissioning will be a challenge, but it’s a challenge they seem to be up for. On a visit to a CCG this week, currently based at the headquarters of its PCT, I was surprised to see that even the PCT staff members were feeling positive about the changes. How could that be if it means a countdown to their slow demise? But what I soon realised was, apart from those who chose voluntary redundancy, many of this PCT’s staff members were being transferred over to work for the CCG as a commissioning support unit. They didn’t even have to get used to another desk. These staff members were excited to be led by GPs towards better commissioning. Of course, this will not always be the case, but it was a slap-my-forehead moment where I realised how much of the CCG’s admin support will look like the PCTs, right down to the same names and faces. With these changes in mind, we’re launching a new bi-monthly magazine for commissioners called Commissioning Success. From next month’s Practice Business, we will no longer have a commissioning section, but will focus our editorial, news and features around the delivery and providing side of primary care, as we always have done because we feel it is more important than ever. If you’re a practice manager involved in commissioning, you can sign up for a free subscription for Commissioning Success by emailing email@example.com and quoting “PB edit comment”. Look out for a taster of the magazine in next month’s Practice Business. It will take an even more focused look at commissioning better healthcare in the community. What do you think about all this change? Get in touch on firstname.lastname@example.org.
see inside for our guide to managing commissioning
Contents sector 06 news Top news for practice managers – from apps for patients to CQC 08 executive editor comment The latest from controversial columnist Roy Lilley
COMMISSIONING 10 12
commissioning news The practice manager’s update on clinically-led commissioning
comment Run up to a flying start What practices can do to kick start shadow commissioning from 1 April
PEOPLE 18 case study Speak for yourself Manchester’s Robert Darbishire Practice saves GP hours
with dictation equipment
23 interview In the driving seat Derbyshire’s Blue Dyke Surgery pilots CQC and 111
MANAGEMENT 28 CPD Train to gain Train up your staff to save in salary sums 30 clinical QOF This month: Diabetes complications 32 news feature Take pride The new Pride in Practice standard is set to support lesbian, gay
and bisexual patients
35 legal Private practice The legalities surrounding NHS practices offering
Work/life 36 advice Ten habits of bad management Follow this path to running a high-performance
organisation and stopping bad habits in their tracks
38 diary Blogger and practice manager Ann Boyle talks primary care
one in eight Practices could lose over £100K in GMC reform
GP practices could face funding swings of up to hundreds of thousands of pounds if primary care cost estimates are reformed to rely on Quality Outcome Framework (QOF) data, a leading medical accountant has suggested. A report, published by NHS National Institute for Health Research last year, looked into whether the current system for funding GP practices on the basis of GMS and PMS could be replaced by estimates of primary care cost using QOF data. Laurence Slavin, partner with specialist medical accountants firm Ramsay Brown told GP Online: “There would be significant winners, but there would probably be more significant losers.” According to information from the NHS Information Centre, this would result in roughly one in eight practices experiencing six-figure income falls under a new QOF-based system. The General Practitioners Committee (GPC) has defended the current model of funding based on the Carr-Hill formula and MPIG. GPC negotiator Dr Beth McCarron-Nash said the GPC had already done “a lot of explaining” to the Department of Health over the years to justify the current funding model. “There are those within government who think that MPIG is a bung to practices,” she said. “In reality, there are a good many reasons why practices receive the funding level they do.” NHS Employers and GP leaders are currently debating reforms to the Carr-Hill formula and a minimum practice income guarantee. Reformers argue that funding based on practice data would make the system clearer and fairer than and would lower the incentive to ‘cherry pick’ or dump patients between practices.
your monthly lowdown on general practice
GPs to prescribe apps for patients
The latest innovations in smartphone technology will be used to help the public find NHS services, manage conditions and make better lifestyle choices. A call to find the best new ideas and existing smartphone apps to help people and doctors better manage care received nearly 500 entries and over 12,600 votes and comments (see box out). Popular apps include ‘Patients Know Best’, where patients gets their records from all their clinicians and control who gets access to them. The app means that patients can have online consultations with any member of their clinical team, receive automated explanations of their results, and work with clinicians for a personalised care plan. According to the Department of Health it has already proved successful with hospitals
march 2012 | practicebusiness.co.uk
including Great Ormond Street, UCL and Torbay as well as with GPs and community nurses from across the country. Another app for diabetes reminds patients to check blood sugar levels and take medication. It allows them to monitor, record and track blood sugar information, which can then be sent electronically to their surgery or clinic. The app also uses emerging FoodWiz software to help diabetic patients or those at risk control their diet by allowing them to zap barcodes while shopping and get information on the amount of calories, carbs and fats. At an event showcasing the ideas for health apps, Health Secretary Andrew Lansley said: “We are looking at how the NHS can use these apps for the benefit of patients, including how GPs could offer them for free.”
Appiness and health The most popular areas for primary care apps: • managing long-term conditions like diabetes • helping people deal with post-traumatic stress • monitoring things like blood pressure • helping people find NHS services on a map • practical information about keeping fit and eating healthily.
SECTOR | news
clinical news Communication is a top risk for surgeries
Cancer in children
Communication, confidentiality, health and safety, prescribing and record-keeping were the top risks identified by practices last year. For the first time last year, communication overtook confidentiality in surgeries by a small margin, with 99.4% of GP practices identifying it as a risk, according to Clinical Risk SelfAssessment (CRSA) data collected by the Medical Protection Society (MPS) from more than 150 general practices in the UK. Dr Richard Stacey, medicolegal adviser at MPS and a former GP, commented: “Healthcare is never without risk and our analysis has shown that this doesn’t just relate to clinical issues but concerns with administration, training, policies and procedures and communication, both internally and externally.” He warned that electronic communication brings up issues of consent and confidentiality: “Just because a patient has provided their email address or mobile number doesn’t mean they have provided consent for their personal information to be communicated in this way. It is Top concerns in also important that emails and texts form part of the patient’s records and systems are monitored for general practice responses from patients.” • Confidentiality – 98.7% of practices identified confidentiality as a risk Issues with communication are not limited • Health and safety – 97.4% of to those between the doctor and patient but also practices internally, between members of staff. Dr Stacey • Prescribing – 87.8% of practices recommends having regular meetings with staff • Record keeping – 87.2% of practices. members to inform them of key issues, as well as using internal messaging systems.
“One of the main advantages of receiving care from your local GP is that there is no doubt as to who is responsible for treatment and follow up care of patients. A local GP is also more likely to be able to build up a relationship with their patient and understand the social context and environment of the patient and their family” MDDUS medical adviser Dr Barry Parker on why removing practice boundaries could impact on doctors and their ability to provide continuity of care
Percentage of healthcare organisations that list disaster recovery among their top three IT investment priorities for the next year (Source: BridgeHead Software)
Late diagnosis by GPs of cancer in children and young people is resulting in needless deaths, children’s cancer charity CLIC Sargent has warned. The organisation also highlighted the need to provide better support for GPs to help them diagnose cancer early and improve general awareness of the symptoms and signs of cancer in children and young people. Globally every year 175,000 children are diagnosed with cancer, with an estimated 50% dying from the disease, mainly because of poor diagnosis and a lack of effective treatments. Because it is relatively rare, family doctors may only see one or two cases on average in their career, making spotting the symptoms and ruling out a cancer diagnosis more difficult. Young people who have had cancer say they often feel frustrated that when they first report their symptoms to their GPs, they are not taken seriously.
LGB care The chair of the Royal College of General Practitioners, Dr Clare Gerada MBE, has backed Pride in Practice – a new patient standard for excellence in lesbian, gay and bisexual (LGB) healthcare from NHS North West and the Lesbian and Gay Foundation. Speaking at the Pride in Practice launch, Dr Gerada said she “was disappointed to read that one in 10 LGB&T individuals have avoided using public services for fear of homophobia”. She welcomed the Pride in Practice benchmarking toolkit as a way to challenge the health inequalities faced by lesbian, gay and bisexual patients. For more information, or to register, visit www.lgf.org.uk/prideinpractice. See page 34 of this issue for more details.
Get the latest news in your inbox Want to be bang-upto-date on your health sector news? Sign up to the PB Weekly e-newsletter and receive the latest practice manager news and views straight to your inbox. To sign up, email subscriptions@ intelligentmedia.co.uk with the subject line “PB Weekly” or visit www.practicebusiness.co.uk.
practicebusiness.co.uk | march 2012
SECTOR | news
Roy Lilley Roy Lilley is executive editor of Practice Business. He is an independent health and policy analyst, writer and broadcaster and commentator on health and social issues.
march 2012 | practicebusiness.co.uk
Tangled up in red tape
With all this talk of less bureaucracy, Roy Lilley is only seeing more red – red tape that is I think it is amazing that managers have taken such a hit with the NHS reforms and have done nothing about it. Imagine the government saying it wanted to cull 45% of nurses or chop 45% of doctors in the NHS. There would have been pandemonium: strikes; street protests; the roof would have come in; the media would have been all over it. As it happens; management numbers have been nearly halved and all we have in the media is: ‘bureaucracy has been cut’ or ‘money saved and reinvested in the frontline’. I wonder where the money has been invested? It seems to me most of it will have gone on redundancy payments. PCT offices are like distant American towns in the cowboy movies; brushwood blowing down the main street – well, in this case corridors. I get regular emails from PCT people telling me it is getting increasingly difficult to provide for the demands of embryonic CCGs, the requests from community services setting up as social enterprises of flogged off to the private sector and the day job. The irritating thing is that I don’t think bureaucracy has been cut. Strategic health authorities and PCTs are on the way out and they are about to be replaced with the DH, NHS Commissioning Board, the commissioning support units, CCGs, clinical senates and Health Watch. It looks to me that far from cutting bureaucracy it has simply been spread among five or six organisations instead of two. Into the bargain the organisations that have replaced SHAs and PCTs have created a whole lot of new interfaces, as they try to work together and far from being the ‘new kids on the block’ the whole block is new. The truth is, you don’t cut bureaucracy simply by sacking people. You reduce bureaucracy by finding out what it is everyone is doing, decide which bits you don’t want to do anymore and then sack people. The NHS is still commissioning and will still need people to do that. It is still doing strategic planning and will want people to do that, too. The legal requirements of the organisations will have to be undertaken and met. Staff will have to occupy buildings, which will have to be insured and maintained. I can think of no function the NHS has decided it will no longer do. I haven’t heard or read anything that says the NHS is going to stop doing this or that. I have read a lot that says this or that will be done by other people and that is a whole different ball game. Already I hear tales of PCT people, made redundant, served their time, been on holiday and spent a few quid on a new kitchen and are planning to come back and do their old job at a new desk. Barmy, isn’t it?
It looks to me that far from cutting bureaucracy it has simply been spread among five or six organisations instead of two
Locum insurance One problem, two solutions It is imperative for a practice to keep providing services and running effectively in the event of one of the GPs, practice manager or practice nurses being unable to work as a result of illness or injury. Richard McEwen explains how insurance helps
Richard McEwen is director of general business at Doctor Insurance Services*, based at 131-133 New London Road, Chelmsford, CM2 0QZ *a trading name of R.J. Hurst & Partners Ltd, authorised and regulated by the Financial Services Authority
Most practice managers will recognise the benefits of locum insurance in maintaining a service through unpredicted circumstances, providing peace of mind, but most importantly financial benefits to fund a locum practitioner in the event of incapacity to one of the key staff. There can be a great variance in the price and terms of the covers available from locum insurance providers. Practice managers need to be certain that they are insured by a product that meets the needs of the practice and can be relied upon to pay any claims that may arise. The premium charged for cover is important and will be one of the first points of consideration when practice managers trawl through quotes and policies. But, locum insurance is no different to any other product; you will normally get what you pay for – where a premium looks expensive compared to other offers, there ought to be a good reason and it may worth be paying extra if it provides better cover. Doctor Insurance Services offers two policies – Locum Platinum Plus and Locum Platinum. The former offers long-term insurability, through to age 70 if required, without the need for the insured to declare any changes in health nor any individual’s claims experience impacting on the provision of future cover. As a result, the insured could make multiple claims on their policy through the course of their working life – even if the claims related to the same condition. This provides long term insurability. The Platinum policy is a traditional annual insurance contract providing cover on a year-by-year
basis. The upside is that the premiums are cheaper. The downside is that the insurance is effectively underwritten at each renewal – so if there are changes in health or if claims have been made under the policy, terms are likely to be imposed. This could take the form of a premium loading, an exclusion relating to the change in health or, the worst case scenario, of future cover being declined. This would then be compounded by the fact that, given the changes in health, the staff member would have difficulties in obtaining full cover with any other insurer. This is not to decry the cheaper Platinum model; it does of course work. Premium is a key factor and like any business, practices have budgets to meet and costs to consider. As long as the insured is aware of the terms of cover provided and accepts the long term risk, there is no issue. But, it can prove a risky strategy – you don’t particularly want to find yourself without cover in future years when a claim is more likely. It may be that an annual contract is more appropriate for some members of the team, whereas the long-game approach of Platinum Plus might suit others. There are other factors you should consider in choosing a locum insurance provider. For example, the track record of the insurer/provider to determine their history within the market and their reliability on meeting claims. Also consider the structure of the product – specialists within the GP market will tailor their products to meet the particular requirements of GPs, usually by offering flexible deferred periods to tie in with practice agreements, or providing the ability to split cover so that the practice can mirror any locum reimbursement that may be applicable. Cover can be provided under each contract for GPs, practice managers and practice nurses – with the product selection of Platinum or Platinum Plus to suit the individual rather than the practice. Group discounts are available on Platinum Plus and the first month of cover is free to new applications.
For further information or to discuss your requirements, please feel free to visit the website at www.doctor-locum-insurance.co.uk, call 01245 283483 or email Richard McEwen directly at email@example.com
practicebusiness.co.uk | march 2012
Empowering practice managers in CCGs
Health Bill hits turbulence in House of Lords The Government has suffered a defeat in the House of Lords over the Health and Social Care Bill to do with the issue of mental health, calling for greater prominence of the subject to be in the legislation. Lord Patel, a cross-bench peer, proposed an amendment demanding that the health secretary ensures that mental healthcare is treated as importantly as physical health by the NHS. Despite arguments against amendment the motion was passed by the Lords by 244 votes to 240, other amendments were also debated yesterday in the Lords, though none of them were voted upon by Peers. The Government has thus far offered more than 100 concessions in an effort to get the bill passed, but opponents say the legislation should be dropped entirely. Opposition has been voiced by leading medical groups such as the Royal College of Nursing and the British Medical Association. Cameron defended the bill by reminding that Labour had supported NHS reform and that “they are not in favour of the money. They are not in favour of the reform. They are just a bunch of opportunists”.
Photo: University Hospitals Birmingham on Flickr
commissioning in context
Health expert dismisses “myth” of failing productivity A leading health policy advisor has dismissed the myth that the NHS has become less productive as funding has increased. He says official figures do not accurately represent the improvements made. Professor Nick Black from the department of public Health and policy at the London School of Hygiene and Tropical Medicine in London wrote in a report in the Lancet that the quality of NHS healthcare in England “probably improved” from 2000 onwards. He says a flawed consensus has been used by the Government to defend its NHS reforms. “A review of a much wider range of data than was previously available suggests substantial improvements in the quality of healthcare,” he said. This view contrasts with what Black calls the “myth” of
march 2012 | practicebusiness.co.uk
declining productivity while Labour was in power. According to figures’ analysis from the Office of National Statistics, hospital productivity fell by 1.4% and overall productivity fell by 0.4% each year. However, Black stated that these statistics did not accurately reflect the advancements made in community-based services, and so may have underestimated the work carried out by the NHS. “A review of a much wider range of data than was previously available suggests substantial improvements in the quality of healthcare” stated Black, citing greater compliance to clinical guidelines, better mortality rates and public satisfaction. He believes the myth took hold when the Labour party was still in power and has been poorly defended by the party since the last election. “Despite warnings, estimates suggesting a decline in productivity were seized on by opponents of government policy, fuelled by journalists seeking bad news,” said Black. “Attempts by commentators in the medical press to point out the dangers of misinterpretation had little effect.”
Visit the Commissioning Success blog at PracticeBusiness.co.uk/CS and stay up-to-date with all the NHS reform news and commentary affecting practice managers.
Labour accuses Government of losing control The Government has been accused of losing control as it allocates a further £617m for redundancy pay-outs for 2011/2012. The new figures were released last month by the Treasury in its supplementary estimate report on public spending, which states that the funds are required for “an increase in the level of provisions for redundancy costs” and is based on “an element of the redundancy and non-redundancy costs set out in the revised impact assessment for Health and Social Care Bill”. “These eye-watering figures provide clear proof that the Toryled government has lost control of its NHS reorganisation,” said Shadow Health Secretary Andy Burnham in the Guardian. “The publication of these figures is yet another humiliation for David Cameron and Andrew Lansley.” Labour claims that the £617m is additional funding needed due to the “chaos” caused by the NHS shake up, which the Department of Health denies. The DH said: “This is not new money. Our planned cost for NHS reform remains exactly the same as we published in the impact assessment in September 2011.”
They said… “CCGs, and CCGs alone, will decide when and how competition, if at all, should be used in the interest of patients. Competition is not necessarily about the use of private sector providers; many forget that competition is possible within the NHS, between one NHS trust and other trusts. It will be for CCGs to make appropriate decisions, based on the quality and state of local provision.” Dr Charles Alessi, a senior member of the NHS Clinical Commissioning Coalition
Practice Business to launch new commissioning magazine This is the last month we will be running this commissioning section in Practice Business. While we will still cover commissioning-related topics, practice managers heavily involved in clinical commissioning will want to refer to our new bi-monthly commissioning magazine launching this month called Commissioning Success. It will be targeted at decision-makers and participants in commissioning, from board members to commissioning support units and supporting groups. Because of our background in practice management, the magazine will focus on the management and strategy behind effective commissioning, as well as keep readers up to date with all they need to know in terms of news and updates. If you’re interested in receiving a free copy, please email your details to subscriptions@ intelligentmedia.co.uk with the subject line “Commissioning Success”.
Data reports in seconds “EMIS Web is brilliant. We can get data reports in seconds”
A dispensing practice near Newcastle upon Tyne is seeing real benefits from switching This month we talk to EMIS Web for both patients and practice to Hilary Aldcroft, staff, just five months after migrating to IT manager at the the award-winning system. Ponteland Medical Hilary Aldcroft, IT manager at the Group, a dispensing practice near Newcastle Ponteland Medical Group, which serves upon Tyne, about how 11,500 patients at two sites, says EMIS Web switching to EMIS Web has made life easier all round: “Staff find it is helping them deliver so user friendly, and the search and reports improved services to function is fantastic.” patients. Because she can now build tailor-made data searches and save them for future use, Aldcroft is able to pull off data reports in seconds. “We are a research practice and EMIS Web is helping to facilitate that,” she says. “I am able to give the GPs the information they need very quickly.” The practice is also seeing benefits from the EMIS Web dispensing module. It allows dispensers to switch between brand and generic versions of drugs – and vice versa, supporting the practice in making costsavings on medication. They can also edit the quantity of the drug without having to change the dosage, enabling them to dispense part of a prescription from available stocks and supply the remainder later. The new module offers further flexibility, enabling a prescription request at a branch surgery to be dispensed at the main practice site – or vice versa. The practice has begun to offer patients online appointment booking and repeat prescription requesting via Patient Access (formerly EMIS Access). “We have only had it for a few weeks, but nearly 400 patients have signed up already,” says Aldcroft. “We are positive it will make a difference to administration in the practice.” The final verdict on EMIS Web? “Easy to navigate, and a faster, clearer system www.emis-online.com than previously,” she adds. “It is brilliant.” Hilary Aldcroft
COMMISSIONING | final countdown
Getting to a flying start Roger Hymas Roger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is the founder of the Commissioning Community website (www. commissioningcommunity. co.uk) and a columnist on commissioning for Practice Business. You can reach him to clarify any issue at firstname.lastname@example.org
From next month, clinically-led commissioning is to officially launch in its shadow form. Roger Hymas looks at how practices can hit the ground running April 1st – D-day for GP-led commissioning – is now just a couple of weeks away. This is the moment when GPs (and that means practice managers and staff as well) assume responsibility for commissioning – albeit for the first year in shadow form. The NHS now has a 12-month transition period from PCTs being in charge to CCGs taking over. What we’re likely to see is a taper from PCT and SHA staff being mostly in control to a genuine clinician-led commissioning system which should come about by the end of March next year. So what should practices do to get this transition off to the best possible start? Here are my 10 simple suggestions for how practices can make a difference.
march 2012 | practicebusiness.co.uk
COMMISSIONING | final countdown
1. Talk to your CCG. Hopefully, advice about what all this means is trickling down from your CCG. Don’t hesitate to tell them about gaps in your understanding and what you think you still need to know to be a good commissioner. Commissioning is a pretty complex subject and there are bound to be parts of the new approach that you still don’t understand. Tell the CCG how you think these needs should be bridged. At the end of the day, it’s your practice’s knowledge and ability which will contribute to a successful result with the CCG authorisation process. The quicker all of you get up-to-speed, the easier this will be.
2. Make sure you give your colleagues in CCG leadership all the help you can. Most of them will continue with their day jobs, working, like you, in practices. Those with the more senior positions are going to be really stretched, particularly while they’re on this very steep learning curve. You wouldn’t believe the range of responsibilities they are going to be asked to cover (I’d guess at about 300). Go to as many CCG meetings as you are asked to. Try to see that the load is spread. See that delegation opportunities are pursued wherever you can.
3. During the transition, be very firm and clear about the support you want from current PCT staff. They will need to understand that accountability and control is shifting. Some will find it hard to let go. Public service is deep in their psyche: many have a strong sense of social responsibility which should be respected. This means that this could be a tense year as accountability shifts. PCTs are still legally responsible for budgets, but CCGs have to deliver them. Many PCT staff will change jobs during the year as PCTs (and SHAs) wind down. Many will turn up in new posts in the NHS Commissioning Board. Don’t forget that PCT staff know an awful lot about commissioning. Make sure that you absorb as much of this knowledge before they go. Encourage lots of briefings. Don’t waste this valuable corporate memory.
4. For those of you with new CCG jobs, try to behave as a leader. You’ve been given the responsibility, so now is the time to show it. For a while this will mean that you might have to go the extra mile in assuming extra duties. We do believe that the work load should get easier in the longterm. But it will be a real strain in the short-term. Try and find a balance.
Remember the biggest savings that you can make will be in controlling hospital referrals. Always ask yourselves a couple of questions about the patient who’s just come into your surgery. Are you sure that hospital is the best destination or could it be that this patient might find a better outcome from community care? march 2012 | practicebusiness.co.uk
COMMISSIONING | final countdown
GeT ReaDY foR RePoRTs. You should expect to see a variety of new management reports coming down from the CCG. Others will disappear, so do not see it as a new level of bureaucracy. You should find that all you are being asked to do is about helping improve commissioning effectiveness. Tell the CCG which reports are helpful and suggest improvements. Be as constructive as you can.
6. Go THRouGH THese RePoRTs ReGulaRlY. Get accustomed to them. Share the information across the practice. Look for how outcomes can be improved and search for savings opportunities. Review what’s happening with your patients, look at their care plans and how quality can be improved and costs lowered. In particular, identify at-risk patients and how you need to manage them. Look at reports on unscheduled hospital visits in particular. These are the patients who are particularly likely to need extra help with the organisation of their care programmes. Get to grips with your referral and prescribing data. See how well you are doing against the other practices in your local peer group. Remember the biggest savings that you can make will be in controlling hospital referrals. Always ask yourselves a couple of questions about the patient who’s just come into your surgery. Are you sure that hospital is the best destination or could it be that this patient might find a better outcome from community care?
in TiMe, as CoMMissioninG BesT PRaCTiCe GeTs TRaCTion, You sHoulD sTaRT To see a loT MoRe DeTaileD DaTa aBouT inDiviDual PaTienTs. If you don’t feel you have enough information or something is wrong, let the CCG know as soon as you can. The best commissioners are those who get and apply the broadest range of practice data. Also, make sure that the information you are producing is of the highest quality.
8. suPPoRT THe sMalleR PRaCTiCes. The single handers in particular will have a disproportionate load as GP-led commissioning takes off. Make sure that all practices are equally equipped to deliver the best quality commissioning. You should recognise that you are all in this together.
9. unDeRsTanD THaT as THe PCT’s influenCe DeClines, PRaCTiCes Have a BiG sTRaTeGiC ConTRiBuTion To Make To THe effeCTive RunninG anD DeveloPMenT of loCal CoMMissioninG. Tell the CCG how you want to see care pathways develop, how budgets need to be framed and how the health status of your local population can be improved. Eventually, you will want to participate in a range of activities across the entire annual cycle – Commissioning Intentions, provider contracts, patient and public engagement programmes. This is what the best commissioners do.
10. finallY, GeT involveD in CCG ManaGeMenT in as PosiTive a waY as PossiBle. Understand that this is your CCG and look for ways to make a real difference. This should be seen as a collective – even a cooperative – undertaking. It’s not the PCT sending out orders any more. It’s all the practices taking charge. Recognise it as a consensus building process: the more involved you are, the better the CCG will become. Embrace the challenge. Let’s face it, in just two weeks’ time, you’ll all be commissioners. march 2012 | practicebusiness.co.uk
In just two weeks’ time, you’ll all be commissioners
G N UP T H O
YO U R G U I D E TO
commissioning HAS LANDED A new bi-mo
nthly magaz ine from the team to help Practice Bus you succeed iness in commissio ning Launching in March, Comm issioning Suc to be the only cess promise management s ti tl e specifically CCG board m ta rgeted at embers, parti cipants in co and all relate m missioning, d health netw orks and sha dow boards
So whether you’re on a the board of a clinical commissioning group, participating in commissioning, a provider or interested from the side-lines, stay one step ahead of the Government’s plans to give clinicians power over £60bn of the NHS’ budget. This magazine is aimed at GPs, practice managers, secondary healthcare clinicians and nurses – anyone who has an active role in commissioning. It will provide them with the must-have tips and tools to make a success of clinically-led commissioning.
Be one of the first to sign up and receive a six-month subscription for free (worth £69.99) commissioningsuccess.com email@example.com BROUGHT TO YOU BY THE TEAM BEHIND
one-to-ones with the people making a difference
Switching to digital dictation has paid dividends to staff productivity and efficiency at the Robert Darbishire Practice in Rusholme, Manchester, saving GPs and secretaries hours of time. Julie Penfold interviews practice manager Scott Brunt to find out more
march 2012 | practicebusiness.co.uk
people | case study
How was dictation and transcription handled at the practice, prior to the change? Previously we had always used traditional analogue machines and recorded dictations onto tapes using handheld dictaphones. There were a number of problems and frustrations we encountered when working this way. Dictaphones and tapes would go missing or take considerable time to find. As a result of this, GPs would regularly wait until they had several letters to do before passing on the batches to our secretaries. This meant secretaries could often wait up to a week before tapes were handed over for transcription. Urgent referrals meant interrupting the day and finding a specific dictation could take a long time, particularly if a GP wanted to upgrade the urgency of a referral. Finding dictations could be very time-consuming if labels were missing or tapes were incorrectly addressed. Tapes could get out of date order and secretarial work was also hard to plan as it was difficult to tell how many letters were on each tape. A pile of tapes could mean a lot of work or only a little. Letters at the end of a tape could also be missed, or a tape could go missing. Unclear sound was also a problem, as dictations were often unclear and crackly. Analogue machines and tapes were also costly to repair or replace. All in all, the old system was not very efficient. What prompted the practice to first consider the switch to digital equipment? The main catalyst for the change occurred when two or three of our analogue machines broke around the same time. We knew others were also starting to get old and would need replacing in the near future. We had previously considered switching to a digital system but had decided to put this on hold due to changes by our local PCT to the practiceâ€™s IT network and server infrastructure. The sudden breakages of the tape-based machines gave us the impetus to replace the whole system while we had the opportunity. Though it did cost more than replacing a few analogue machines, we saw the switch as an investment. When considering the right digital dictation solution for the practice, what pointers did you take into account? The new system had to be one that was easy to use and because we are a large practice, it had to be able to manage multiple GPs dictating as well as multiple secretaries transcribing. We wanted to steer away from handheld machines as with our previous experience, we knew they would just go walkabout
and would prove quite costly to repair and replace. We also wanted a system that attached to the computers and was simple to administer. Were there any teething problems when bedding in the new digital dictation system? The practice switched to digital dictation in July 2010. The switch was really straightforward, with only the one minor issue, which was a result of user error. A new member of the secretarial staff had started at the practice shortly after the digital system was introduced. One of the GPs had recorded more than one dictation to a file, which they are not supposed to do. However, on this occasion the GP was following an old habit of batching letters, which was common practice when using tapes. The new secretary did not notice there were a further two letters to type after the first one. The error quickly came to light when one of the patients called the practice to chase their referral soon after their appointment. As everything is archived with the digital system, we were able to retrieve the file very quickly and see what had gone wrong. To prevent this happening again, we asked staff not to assume each file only contains one dictation and to ensure they play each file right to the end in future. How have both clinical and non-clinical staff responded to the digital dictation changeover? All the staff have responded extremely positively without exception. The GPs enjoy the confidence of knowing dictation equipment is always available so they no longer have to batch their letters. When the GPs dictate a letter they tag it with the patient number and priority. As soon as each dictation is completed, it is available for dictation, giving GPs confidence their letters will be done promptly. Dictations are displayed to secretaries in order of priority and date and they can see how long each file is, so they have more control over their work and are able to plan accordingly. Additionally, they can also retrieve a deleted dictation in the event of any queries. Though dictation and transcribing is still a time-consuming process, the new system works
Although it was expensive to install, the digital dictation system will definitely pay itself back in terms of efficiency and ease of use for all staff practicebusiness.co.uk | march 2012
people | case study
Clockwise from left: The practice, based in Rusholme Health Centre; Dr Mohiuddin Miah dictating a letter; secretary Heather Peel transcribing
really well for the practice and helps to maintain increased efficiency. Could you tell me more about the audit the practice carried out to review the time it was taking to produce letters? We were eager to review whether the switch had been a worthwhile investment. Prior to the switch we had always kept computerised records of how long it took us to complete transcriptions. We used to document what was the outstanding backlog that day, from one dayâ€™s backlog to sometimes three days or one weekâ€™s worth. We decided to compare a two-week period before the change and a two-week period following the switch. We tried to use representative periods, not choosing weeks where there were many staff holidays or absences. We wanted to compare two similar weeks. The comparison included looking at all the referral letters during those periods and reviewing when the GP originally saw the patient and when the letter was completed. From our records, which detailed the backlog, we could also estimate when the letter was dictated. We looked at 80 letters from each two-week before and after period and compared the averages from the two. There was a really noticeable difference on comparison. What findings did the review reveal? We found that the much-improved convenience of march 2012 | practicebusiness.co.uk
Practice Robert Darbishire Practice
the system meant that GPs were submitting their dictations much more quickly. The average before was 2.1 days to dictate a letter following a patient appointment, in the second period this fell to 1.1 days. The maximum time it took a GP to dictate a letter before the new system was installed was 13 working days from seeing a patient. Afterwards, the maximum time fell to six days. We also found that the enhanced efficiency of the new system meant our secretaries could be more productive. Their average turnaround time fell from 2.3 days to 1.7 days. Overall, the time taken from appointment to letter fell by just over a third. Something that is not covered by the figures is exactly how much simpler it is to use and administer the system. Though that does not jump out particularly through these figures, if you asked the secretaries what stands out for them, the hassle-free nature of the system is what they would especially note and the difference it has made to how they work. Do you feel the move has been a worthy financial investment for the practice? Yes, definitely. It is a system we will have for a very long time. Although it was expensive to install, the digital dictation system will definitely pay itself back in terms of efficiency and ease of use for all staff. All the hassle has gone out of dictation and transcription and the system has proved to be one of the best investments we have made.
Patients 19,800 Clinical staff 14 doctors, two nurse practitioners, four practice nurses and three healthcare assistants Administrative staff 25 PCT Manchester CCG Central Manchester Practice manager Scott Brunt Time in role 11 years Background Scott started his career at two single-handed practices before joining the Robert Darbishire Practice in 1998 as IT manager, later progressing to practice manager. Scott has recently had a change of job title again and is now the practiceâ€™s MD, following the retirement of the practice director after 29 years.
people | interview
First in line Verity Shelton, practice manager of the Blue Dykes Surgery in Chesterfield, must be doing something right because she has been asked to pilot general practice initiatives before they are rolled out to the rest of the country. Julia Dennison visits her to find out her experience of trialing CQC registration and the 111 number
Verity Shelton is a busy – albeit experienced – practice manager. She has worked in primary healthcare for going on 27 years – 22 of which as a practice manager and knows what she’s doing, maintaining a level head while juggling her work at the busy Blue Dykes Surgery in Chesterfield with life as a parent of four, all while finding time to bake, offering me a slice of her delicious bread and butter pudding cake she made that morning when I sit down to talk with her. “This is a really good practice,” Shelton says of Blue Dykes. “They’re very familyorientated; they’re very staff-orientated as well, so the patients get a very good service. It does work well.” She has much experience to base this on, having worked at seven GP practices in her time. In her experience, the role of practice manager has become more challenging with time, with larger workloads to contend with. Much like GPs, who as generalists seek support from their specialist colleagues, so too, she believes, should practice managers reach out to each other around topics like building maintenance,
practicebusiness.co.uk | march 2012
people | interview
HR, pay roll and accounts. Finding support has become easier with the rise of commissioning, as Shelton is very heavily involved with the practice manager group that supports her local clinical commissioning group. “Each practice manager has different skill sets that you can gain help and support from,” she says.
CQC pilot There must be something about Derbyshire, and Blue Dykes in particular, as it is often chosen to be a ‘guinea pig’ for new NHS initiatives. The Chesterfield surgery was one of 22 practices in Derbyshire involved in a pilot of CQC registration, which included assessing the practice against the standards and welcoming the CQC for an inspection once registered. The registration process has met with controversy in the press over the workload it could imply for practices, and while it was hard work, Shelton and her GP colleagues finished it and survived to tell the tale. “It was quite involved and didn’t flow particularly well because it was the draft application process,” she remembers. The CQC has since promised to simplify it further. The CQC’s preliminary inspection of Blue Dykes took around two hours and was the first the inspector had performed, so it aired on the side of caution. “She was saying things that perhaps I thought were unnecessary on occasion, but it’s all a learning exercise,” says Shelton. This included pernickety points, like recommending Shelton put a cover over the radiator in the corridor to protect patients from burning themselves if they fell against it and couldn’t move (though Shelton points out her staff would be quick to pick them up if that happened). Shelton’s involvement with practice managers in the CCG has allowed her to help others prepare for registration. “There were three of us practices [in the CCG] that had got on the pilot, so we worked together as a group of three practice managers to deliver quite a comprehensive workshop to doctors, nurses, and admin teams from the whole of the 14 practices,” she explains. So what is Shelton’s advice for other practices embarking on the CQC registration process – the deadline for which is a year away? “Get started now if you haven’t already looked at it. It’s not going to go away – they might change or tweak it a bit – but you need to just get on with it.” She recommends looking at the CQC and BMA websites for ideas on how to improve your practice’s policies and procedures. She also underlines the importance of getting your whole team onboard – from the partners through to the cleaners – because it will have an impact on everyone. It’s also important to distribute tasks. “It makes people feel like they want to be more involved; they want to move forward with things and they understand it more if they have some ownership of it,” she explains. “The march 2012 | practicebusiness.co.uk
admin team is quite happy to take on little aspects of the CQC that are appropriate for their role.” Shelton now has a handyman come in three times a week to ensure everything is running normally at the practice, for example, gritting the walkway in times of snow (like the week of my visit). “We really do invest to make sure we’re as good as we can be at the moment,” she says, warning surgeries not to make any big investments in premises, such as replacing the flooring or furniture, without knowing what has to be done for the CQC: “Just be mindful, particularly if you’re going to start investing money in your building, you need to make sure you’re investing it correctly.” Indeed, becoming CQC compliant has cost Blue Dykes surgery money and it will need to spend more. For example, Shelton is looking into installing electronic doors in a bid to be in line with the Disability and Discrimination Act, as well as changing the floor and chairs in the waiting room to materials that are more easily cleaned. At least she can take comfort in the fact her premises was built for purpose. “There are going to be some practices that can’t change at all because they’re in old houses and they’re going to really struggle,” she predicts. “But I think the CQC will work with them and understand the difficulties.” She adds: “As long as you realise where the issues are and you’ve got a timeline of how you’re going to work towards them, I feel CQC will be accepting, providing the issue is not of a dangerous nature.” Shelton recommends dividing registered manager duties among a number of different responsible people.
Practice Blue Dyke Surgery, Chesterfield PCT Derbyshire County CCG Hardwick Health Patients 9,250 Partners Five Clinicians Five partners; three salaried GPs; six nurses; two registrars and two part-time medical students Admin staff 16 Time in role 11 years Background Verity Shelton has worked in general practice since leaving school at 16, starting out on a Youth Training Scheme. Blue Dykes is her seventh GP practice and third as a practice manager. She qualified with AMSPAR.
people | interview
Blue Dykes is looking to have between two and five registered managers (you can have as many as you need). A word of advice she has for practice managers is to be think carefully before agreeing to become the CQC registered manager, as it can have great legal implications. If you don’t comply when you say you do, “you could end up being prosecuted,” she reminds.
Patient outreach Part of Blue Dykes’s strength lies in its stellar patient participation group, which Shelton helped to set up in 2008. While it runs very well now, this hasn’t always been the case. “It was quite hard to start it up,” she remembers. She approached it carefully: “We sat down as a practice and thought there were a few patients who would be really good in a patient participation group – they’d look at it from a wider perspective, as opposed to just coming in with their own issues. So we invited those patients and also put information up on the noticeboard.” Issues to come out of the first meeting included the usual moans and groans around appointments. One thing the PPG was positive about was the plan at the time to transfer the practice’s phone number to 0845 in a bid to ease call demand. The practice made the move, but decided to move back to a local number a year and a half ago after investing in a new telephone system. The practice is also participating in the pilot scheme for the 111 non-emergency number. Despite controversy surrounding its efficacy in the media, Shelton is positive about the number and the service it gives to patients. “Patients like it,” she says. “It works very well, possibly because it is serviced by our area’s out-of-hour provider – Derbyshire Health United. It just gives a better service altogether.” In terms of promoting it, she has flyers to hand in the waiting room, as well as giving it as an option on the answer phone message. “I think they need to think long and hard and realise that using their outof-hours provider would probably be a good route to go down,” she adds.
of GP practices in the area. To accommodate the extra patients, the practice has taken on more salaried GPs and also plans to extend the premises into what is now the car park. Shelton is also planning to alter the reception desk to improve patient confidentiality. Having started out on the Youth Training Scheme when she first started working, Shelton believes it’s important to do the same for other future practice managers. “Because I came from the background as an apprentice, I think it’s really important to give people opportunities,” she explains. “So we look to offer apprenticeships to young people.” As part of this, she encourages all admin team members at the surgery to gain level two and three NVQ qualifications in customer service. Indeed, there is a strong community feel at Blue Dykes, where staff and patients pitch in to raise money for local and national charities. For example, the surgery collected £500 last year for Movember and held a Christmas toy appeal in partnership with a local church for disadvantaged families in the area. It is little wonder that this surgery is singled out as exemplary across so many initiatives. It will undoubtedly be leading the way for years to come.
Future plans Blue Dykes has recently broadened its boundaries to take on 250 more patients in response to a shortage
As long as you realise where the issues are and you’ve got a timeline of how you’re going to work towards them, I think that’s what CQC is really concerned about march 2012 | practicebusiness.co.uk
Medical terminology training Substantial time commitments are often associated with continued professional development (CPD) and training GP practice staff. This need not always be the case with a new online training course from Mediterm Training, the largest provider of training in medical terminology in the UK. To take the pressure off, Mediterm Training is offering the Level 2 AMSPAR course to medical secretaries, summarisers and reception staff, to study in their own time, with the option of sitting the final exam at the practice under invigilation. This Level 2 qualification is structured around a 12-week online course, covering six modules. Each module covers terminology relating to a particular body system, together with roots, prefixes and suffixes (the nuts and bolts of medical terminology), prescription abbreviations and medical specialities/departments. Full mentoring support is available from the experts at Mediterm Training, along with feedback and on-going assessment through marked revision tests after each module and completion/ feedback of past papers. On completion, trainees have the option of upgrading to the Level 3 Certificate. Courses start in March, August and October of 2012. Courses cost ÂŁ245 plus ÂŁ55 exam and registration fees.
For more information, or to book, visit www.meditermtraining.co.uk or contact Gill Critchley on 01625 266610 or Gill@meditermtraining.co.uk.
business intelligence and management sense for practice managers
Skilled assistance Are you getting the most out of your staff? With health resources stretched to the limit, it is vital that practices take full advantage of whatever skills they have at their disposal. Carrie Service looks at the benefits of upskilling HCAs Healthcare assistants are an integral yet frequently undervalued part of the clinical team. Many have the ability to offer skills beyond their job remit that could provide much needed support to nurses and doctors. Giving HCAs the opportunity to gain extra training is a great way of tapping into this resource, allowing you to benefit from cheaper man-hours. Untapped potential Mike Roberts, from training provider M&K Update, believes that practices should be taking real advantage of the diverse range of previously gained skills many healthcare assistants have to offer, however resistance from some doctors, nurses and other health professionals often prevents
march 2012 | practicebusiness.co.uk
this. “HCAs are drawn from a wide employment pool; no two HCAs are alike,” he says. “Many bring a wealth of life and past working experience with them and I fear that this aspect is neglected and they can be viewed as ‘unregistered’ and ‘ungoverned’.” Upskilling healthcare assistants with recognised qualifications could help to counteract these preconceptions and change the way the role of healthcare assistant is viewed. Train to gain When providing additional training for staff, it’s vital that you identify the areas where upskilling will be genuinely beneficial so that it doesn’t result in empty spending. One area in which any member of practice
management | HR
staff can always gain from extra training is anything concerning the legal implications of working with patients, says Pauline Webdale from AMSPAR (The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists). This includes confidentiality, consent, capacity, accountability and boundaries. Ensuring that HCAs are made aware of these legal issues and receive the correct training could save time and money further down the line by preventing any possible legal issues before they occur. Another key skill for HCAs to gain is knowing how to care for the overall wellbeing of patients, particularly when working with the elderly and people with learning difficulties. This helps support a general knowledge of all mental health issues, and is just as important as gaining new practical skills: “Dementia awareness training is useful, as is a greater understanding of palliative care. Sometimes practices focus too much on the practical skills,” reflects Webdale. The better equipped a clinical team is from top to bottom to deal with patients who have specific needs, the more sympathetically and efficiently the patient can be treated.
If we are paying the rate that we are paying nurses, we need to be able to use them at a higher skill level. Practice managers need to realise that healthcare assistants can do the role Under new management The main drive for upskilling HCAs is, of course, freeing up the practice nurse’s time so that it can be reallocated elsewhere. “Nurses need to let go of a lot of the tasks that they do and concentrate on what they really specialise at, which is chronic disease management,” explains Annie Barr, clinical director at training consultancy Annie Barr Associates, and the same should apply further up the hierarchy: “We need the same process for GPs to let go and let nurses have the reign in terms of chronic disease management.” Barr stresses that although this isn’t
the case for all GP practices, and some are making good use of HCAs, there still needs to be a shift in the delegation of duties in order to see the benefits for all members of the team: “There needs to be a devolvement of responsibility for the doctor to ensure that the nurse is competent as well.” Time well spent There are a plethora of courses available for HCAs, but which are the most useful for general practice? It’s important to get the basics covered first with a “properly structured induction” into primary care, says Webdale. Barr agrees: “If you’re starting out, the clinical skills course is definitely the best course to do. It covers everything you need to know for a healthcare assistant role.” This basic foundation of knowledge can then be built on with further qualifications to benefit the running of the practice. Barr recommends the following courses (in this order): Clinical skills, a pneumococcal, influenza and swine flu vaccination course, venepuncture, B12 injections, and wound management. An influenza vaccination course is where a lot of practices start when upskilling HCAs because they can utilise this for their flu jab campaign and gain QOF points. Freeing up the nurse’s time has benefits that reach beyond the realms of the practice, as allowing nurses to spend more time on triage and running minor illness clinics may reduce unnecessary A&E attendance. Some nurses may use the extra time to focus more on long-term conditions, such as chronic obstructive pulmonary disease, sexual health or osteoporosis screening. Other areas they may concentrate on include obesity clinics; antirheumatic drug monitoring; cardio vascular disease prevention and assisting the GP with mole clinics. Practices that are not utilising their HCAs to their full ability are losing out, not only on useful practical care skills, but also financially, says Barr: “If we are paying the rate that we are paying [nurses] we need to be able to use them at a higher skill level. Practice managers need to realise that healthcare assistants can do the role.” One final and important observation to make is that offering healthcare assistants the opportunity to gain new qualifications does wonders for their work ethic by building confidence, increasing efficiency and therefore ultimately improving patient care. “If you invest in the team, quality and efficiency will follow,” as Roberts puts it. So make the most of your healthcare assistants and don’t be afraid to invest a little money and faith in them while you’re at it. practicebusiness.co.uk | march 2012
management | qof
Paul Lambden Dr Paul Lambden is a practicing GP and qualified dentist. He has been a GP for over 30 years, with over 20 in practice. He has previously worked as chief executive for an NHS district, LMC secretary and special adviser to the Parliamentary Health Select Committee
There is a wide variety of potential complications with diabetes, many of which are covered by QOF and points are available for keeping a register and for addressing the issues. Dr Paul Lambden explains what to look out for The basic cause of diabetes is well understood and, simply speaking, results from the production of little or no insulin (Type 1) or insufficient insulin for the bodyâ€™s needs (Type 2). The condition affects about two per cent of the population, although in some groups, such as the elderly, up to 10% may be affected. The disease is chronic and diabetic patients may have to manage it for many years. Not everyone with diabetes develops complications and there is plentiful evidence that with good control of blood sugar, blood pressure, cholesterol level and a healthy lifestyle without smoking, complications will not occur in most people. However, it is important to make this message clear early in the management of the disorder because, once established, complications can rarely fully resolve. There are a large number of potential complications and the Quality and Outcomes Framework addresses many of them. The complications can be broken down by system and broadly fall into several groups. Acute metabolic (chemical) disturbances such as diabetic ketoacidosis and hypoglycaemia (low blood sugar) are serious conditions. Ketoacidosis results from lack of insulin, high blood sugar with resulting dehydration and collapse. It also results in breakdown of fat stores with the consequent release of ketoacids into the blood. The complication can lead to organ damage and death if not treated appropriately. Hypoglycaemia occurs when the blood sugar falls too low, associated with relatively too much insulin. The result may be rapid collapse but the condition is readily responsive to the administration of glucose or glucagon by injection, which raises the blood sugar. Many complications affect the larger blood vessels such as the coronary vessels supplying the heart, the blood vessels to the brain and those supplying the periphery, including the limbs. The result is an increased incidence of heart attacks, strokes and circulatory problems. These complications mainly affect patients with Type 2 diabetes. A key aetiological factor for large vessel disease is atheroma. It is a fatty deposit which can be found in the blood vessels of many people consisting of cholesterol, fat, calcium and other blood components. The formation of atheroma in diabetic patients is aggravated because blood platelets, which are essential for clotting, tend to be stickier and the lining of the blood vessels seems more susceptible. Over time, in poorly controlled diabetics, the vessels become increasingly narrowed and blood flow becomes sluggish. In the heart, this can prevent the muscle responding to exercise by increasing blood flow to provide more oxygen and the result is angina. If the vessel becomes completely blocked the result is a heart attack and the severity depends on the area of muscle supplied by the blocked artery. A stroke occurs in the brain as a result of similar arterial narrowing with blood clot formation or as a result of an embolus, normally blood clot which has broken away from elsewhere in the body. Peripheral vascular disease is the consequence of vessel narrowing in the limbs. Risk can be reduced by controlling the blood sugar, reducing weight and eating sensibly, stopping smoking and taking regular exercise. The statins, which reduce cholesterol, and ACE inhibitors are amongst drugs shown to help keep blood vessels healthy. Haemoglobin carries oxygen in the blood. Glucose binds to some molecules producing glycated haemoglobin (HbA1C). In healthy non-diabetics, the HbA1C is less than six per cent (42 mmol/mol). As a haemoglobin molecule lasts about 120 days, measuring HbA1C gives a measure of blood sugar control over the previous 12 to 15 weeks. The complications involving the smaller blood vessels are disorders such as retinopathy, nephropathy and neuropathy. All these complications
Half of all patients with diabetes have retinal damage after 15 to 20 years march 2012 | practicebusiness.co.uk
affect Type 1 and Type 2 diabetics equally and depend on the level of control. Retinopathy occurs as a result of damage to the blood vessels in the light sensitive retina at the back of the eye. The result is that the weakened vessels break down causing small bleeds into the retina. The result of the damage is irreversible loss of vision, which can lead to blindness and glaucoma. Probably half of all patients with diabetes have retinal damage after 15 to 20 years. Nephropathy is the progressive loss of kidney function, resulting in loss of blood proteins in the urine. It starts with leakage of tiny amounts of protein, microalbuminuria, which gets worse over time leading to fluid retention and swelling as protein levels fall. Ultimately kidney function declines to the extent that its blood filtration role is compromised and chronic renal failure results. Diabetic neuropathy affects the sensory nerves associated with touch, pain, temperature and position and the motor nerves supplying muscles. The mechanism of the nerve damage is not fully understood. The result is feelings of numbness in the feet, impairment of feelings of pain, sometimes shooting pains and loss of coordination which may present as difficulty in walking. Neuropathic pain can be very severe. QOF points are available for keeping a register and for addressing the issues reducing complications. Points are available for weighing and discussing weight loss, for reducing the HbA1C below 59 mmol/mol (7.5%), for regular retinal screening and for testing of pulses in the legs and feet and checking for sensory disturbances to identify peripheral vascular disease and neuropathy. More points are available for obtaining good blood pressure control, checking for albuminuria (signalling early renal complications), cholesterol levels and ensuring they have a flu vaccine each year. Ninety-two of 1,000 points are available for diabetes management.
MANAGEMENT | LGB care
Pride in Practice is a new patient standard that launched on Valentine’s Day. JULIA DENNISON takes a look at the initiative and what practices can do to reach out to their gay, lesbian and bisexual patients
Taking it in pride
Despite a significant portion of society’s best efforts, homophobia and prejudice towards lesbian, gay and bisexual (LGB) people still rears its ugly head in Britain. Both in high-profile court cases, such as one recently involving B&B owners who refused custom to a gay couple, others, less notorious, occur every day on a minor scale, in the normative speech of individuals who may not intend any harm. In the healthcare sector, GPs and their practices are expected to set an example in the community. This is why it is particularly disappointing when cases of homophobia occur within general practice. For example, when Dr Muhammad Siddiq, the head of the Islamic Medical Association, sent a letter to GPs’ magazine Pulse in 2008 insisting that gay people needed “the stick of law to put them on the right path”, for which the General Medical Council suspended his medical practice for 12 months. However, much like in society at large, discrimination against LGB people can happen on a smaller scale in primary care – from the language used in patient surveys, to the posters displayed in the waiting room. It is with this in mind, and in the hope to prevent future occurrences of homophobic behaviour, that the Lesbian and Gay Foundation (LGF) and NHS North West partnered last month to launch Pride in Practice, a new patient standard for excellence in lesbian, gay and bisexual healthcare.
SETTING A STANDARD
With GPs at the fore of the commissioning structure, their being aware of the needs of LGB patients will give us more opportunity to develop the services right throughout the whole healthcare system. We’re looking at it as the first door to open in the pathway march 2012 | practicebusiness.co.uk
The new Pride in Practice standard acts as a benchmarking tool to encourage practices across the UK to ensure their LGB patients are treated fairly and their services are inclusive of their needs. The standard started with a simple mission: to get posters up in GP surgery waiting rooms that featured positive images of people of diverse sexual orientations and helpful messages for LGB patients. It has since expanded to become a more overarching equality standard towards which practices can strive. The surgeries that sign up to Pride in Practice will be expected to create a welcoming environment for LGB patients. This can be done by using inclusive language and imagery throughout the practice; monitoring sexual orientation within a patient population; consulting with LGB patients; getting involved with health promotion and outreach; and training staff on specific LGB issues. Once a surgery demonstrates that it runs an accessible and supportive service, it will be awarded either a bronze, silver or gold certificate of recognition (see box out for suggestions on ways your practice can become more LGB-friendly). Achieving the standard also helps practices meet their legal duties under the Equality Act. The project hasn’t always seen smooth sailing. GP project manager at the LGF, Dennis Baldwin had some initial difficulty getting the project off the ground, reporting instances of posters in surgeries in “heavily faith-based” areas getting torn down by patients on several occasions. This got into complex legal ground, as he explains: “The issue then was basically where do [practices] draw the line with their patients and services as being understanding of their religious beliefs, but also, where it became a criminal act by defacing [property] of the surgery?”
MANAGEMENT | LGB care
WHY GP PRACTICES? Shahnaz Ali, associate director for equality, inclusion and human rights at NHS North West, who commissioned the project, believes practices are a great place to start when it comes to reaching out to the LGB community. “GPs will remain the first point of contact for the vast majority of people who need healthcare,” she says on why the project is so important. “Lesbian, gay and bisexual people have a right to feel safe and welcome in the NHS and have equality of access to services.” She pointed to some shining examples of good practice already existing in surgeries, on which the project hopes to build. Two of these exemplary practices are Ancoats Urban Village Medical Practice and The Docs in Manchester, both of which piloted the Pride in Practice standard in the run-up to its launch on 14 February. Jacquie Heywood, practice manager at Ancoats, says she is proud to be involved in the scheme. She used the self-assessment form provided by the LGF as an opportunity to reflect on how her practice welcomed people in the LGB community. “You look at your own practice and survey what you do already and which ways you could change it to make it more accessible to lesbian, gay and bisexual people,” she says. “It’s quite amazing – you think you’re very forwardthinking and open to everyone, but I must admit, we found the odd thing we could change.” Many of these changes were seemingly small, such as using the term ‘partner’ instead of ‘husband’ or ‘wife’ on forms, but Heywood believes it is the little things that can make a big difference.
Things a practice can do to be more LGB-friendly n Create a welcoming environment with pamphlets and posters including positive images of people of diverse sexual orientations n Have a gender-neutral intake form, including options such as ‘partner’, ‘same-sex partner’ or ‘civil partnership’, along with standard terms like ‘married’ n Ensure clinicians use gender-neutral questions to ask about relationships and sexual behaviour n Ensure the surgery has a written anti-discrimination policy with specific reference to sexual orientation n See that the practice is able to refer LGB patients to appropriate, LGB-friendly specialist services and resources if necessary. practicebusiness.co.uk | march 2012
MANAGEMENT | LGB care
A HEALTH ISSUE Pride in Practice is not just about stopping discrimination based on sexual orientation, it is also about the health of LGB patients. Another priority for the LGF is expanding its evidence base, in terms of what it knows about the LGB community. “What we need to do is increase that knowledge and understanding,” says Baldwin. This will help them understand and tackle health conditions more prevalent in lesbian, gay and bisexual people. As part of this, the LGF is encouraging surgeries to monitor the sexual orientation of their patients. “Without it being on the census, we don’t have a true understanding or picture of the size of the lesbian, gay and bisexual population,” he adds. Furthermore, there are important issues to address around the mental health and wellbeing of LGB patients. For example LGB adolescents are twice as likely as their heterosexual counterparts to attempt suicide. Baldwin links all this back to the health bill going through Parliament, part of which encourages GP practices to help keep patients out of hospitals and in the community. “What we’re trying to do is help and support doctors in terms of early diagnosis, early signposting and early support of lesbian, gay and bisexual people so any issues they do have…can be supported the best that they can [to] keep them active and productive in society,” Baldwin says. “With GPs at the fore of the commissioning structure, their being aware of the needs of LGB patients will hopefully give us more opportunity to develop the services right throughout the whole healthcare system. We’re looking at it as the first door to open in the healthcare pathway.”
Taking the work of Pride in Practice’s pilot practices forward is a priority for the LGF this year. “The success of the GPs’ surgeries project highlighted the impact that accessing a welcoming space can have in terms of quality of care for LGB people,” says chief executive Paul Martin OBE. “Pride in Practice aims to continue this work in encouraging GPs’ surgeries to be more aware of and more accountable for achieving excellence in LGB healthcare.” The standard has supporters in high places, as the launch last month in Manchester saw a talk from RCGP chairwoman, Dr Clare Gerada, and was applauded by TV’s Dr Christian Jessen of Embarrassing Bodies fame. “I think Pride in Practice is a great initiative,” Dr Jessen says. “GPs are going to have to be more accommodating to all of their patient needs. It’s important to remember that patients have a choice about which GP practice they use, especially as these days they have to run more like a business, it is in the interests of practices to show that they are welcoming to lesbian, gay and bisexual patients.” To register for the Pride and Practice standard, visit www.lgf.org.uk/ prideinpractice or for more information, contact Dennis Baldwin, GP project manager, on 0845 3 30 30 30 or email firstname.lastname@example.org. The LGF hotline is open and staffed from 10am-10pm for LGB-related queries from practices or the wider public. march 2012 | practicebusiness.co.uk
Photo: Olga Besnard / Shutterstock.com
A PROUD FUTURE
MANAGEMENT | Legal
Think outside the core Constricted budgets and a need for a healthier bottom line (as well as a sense of duty) has driven GP practices to offer additional services outside their contract. OLIVER POOL presents a guide to providing outside the core We are increasingly seeing GP clients becoming involved in delivering new services outside the core GMS or PMS contract. If you are thinking of doing this, it may be worth your while considering setting up a new structure to run the new service, such as a limited company. One reason for this is the goodwill rules. You can’t sell goodwill in your GMS/PMS contract, but you can in most other services. That means that when you retire from practice, you have to transfer the goodwill in the normal practice for free. But that’s not the case with non-core services. If you set up and run a successful service, goodwill will certainly arise. Goodwill is the value of your business over and above the value of its assets – i.e. the value of your patients’ attitude to the service and their likelihood of using it again, and to an extent it reflects the result of the time and effort you have put in to setting it up. When you come to sell to a third party (if you have set up a pharmacy for example) or to pass the service on to your successors, you may feel that it is only right that you should receive something for the goodwill you have helped build up. Setting up a separate entity to run the non-core services can help you distinguish the GMS/PMS
Running services via a separate entity will mean having to make two registrations with the CQC not one
goodwill (which you can’t sell) from the goodwill in your new services (which you can). There may also be tax advantages, which your accountant can help with. Do bear in mind that if the non-core services you are running are regulated by the CQC, then running them through a separate entity will mean having to make two registrations with the CQC rather than one, when the time comes. And it is always important to make sure that retiring GPs are contractually obliged to sell out of the non-core service at the same time they retire from the partnership. Where a separate legal entity occupies premises owned by a GP practice, thought should be given to the legal basis of occupation. While a lease or licence is not always necessary, it is at least worth recording who is responsible for outgoings and property costs so that these are accounted for properly. Where the ownership of the separate entity is not the same as the GP practice, even if there is some overlap between partners and shareholders, then a formal lease may indeed be required. Property arrangements in these circumstances can cause potential difficulties with Notional Rent payments under the Costs Directions 2004. These payments can be subject to an abatement on a pro rata basis if a third party makes contributions to costs in respect of property which benefits from Notional Rent. Notional Rent is also potentially subject to abatement where practice income from private services exceeds 10% of total income.
Legal update sponsored by Veale Wasbrough Vizards Most of the problems identified above can be avoided with the right legal advice. Please contact Oliver Pool if you would like to know more on 0117 314 5429 or at email@example.com.
practicebusiness.co.uk | march 2012
Ten habits of bad
In a bid to help GP practices become ‘high-performance organisations’, ANDRÉ DE WAAL, a professor in strategic management, reveals some of management’s worst practices that all practice managers should avoid If you’re looking to run a ‘high-performance organisation’, or HPO, it is imperative to be able to recognise the signs of bad management. If non-HPO managers are not checked and dealt with, an organisation will never be able to become excellent. Here are 10 habits that HPO managers would never put up with.
1. Bad managers clean
up the mess of their predecessors – even when there is no mess
advice for busy lives
When appointed in a new position, the bad manager claims that the predecessor has made such a big mess of the department that it will take at least a year to get everything in order, and of course the bad manager cannot possibly work yet on achieving the departmental targets this year.
march 2012 | practicebusiness.co.uk
The bad manager only feigns interest in employee feedback, and won’t actually act on what he or she hears. Instead, bad managers stick to their own plans
2. Bad managers are
always busy, busy, busy
They are involved in many projects; in fact, they’re so busy, there isn’t enough time to work on regular tasks. And because these projects are vital for the success of the organisation (or so they say), bad managers can’t possibly be expected to work on their departmental targets. They will get to that when their other projects are finished – which they never are.
3. Bad managers know
how to play the goals game
They know that departmental goals should be loose, with lots of slack, which means the targets will be very easy to achieve. Bad managers will never get optimal results from their departments; but that doesn’t matter to them, bad managers would rather have low performance than run the risk of punishment for falling short of ambitious targets.
WORK/LIFE | top tips
5. Bad managers always
4. Bad managers only
blame somebody else
manage from a distance
Bad managers love to use performance indicators because these make it possible to practice hands-off management. This in turn makes it easy for bad managers to avoid the dayto-day department activities altogether. And of course, if anything goes wrong, they can dodge accountability: they weren’t there, after all!
6. Bad managers make
lengthy, impressive plans
When writing up the latest game plan, bad managers know complex plans always impress top management because it seems like they are on top of their game and have thought of everything. They also know that you can bury all kinds of assumptions and preconditions in these verbose plans, which function as safeguards when top management starts complaining that goals have not been achieved. An additional advantage is that employees will not read nor understand these.
8. Bad managers only have eyes for the shareholder
Bad managers know who butters their bread: the shareholder. Therefore, bad managers work diligently on satisfying these shareholders, even if this works to the detriment of the organisation’s long-term interests.
9. Bad managers are
Bad managers have a host of excuses at their disposal when they don’t achieve targets. They blame the management reports because they don’t accurately reflect performance – their own reports show otherwise. They blame the outside world: the economy was going down; it rained too much; it hasn’t rained enough; whatever – that is the reason everything was going against the department and therefore it was just impossible to achieve the targets. Next year, they say, will be better. They blame the weakest colleague, it was his or her fault so the organisation first needs to hire someone new before they can be expected to achieve targets.
7. Bad managers only
communicate in one way
Bad managers are all capable of holding an open forum for employees to voice concerns, questions, and suggestions. This sounds like the mark of a good manager, right? However, the bad manager only feigns interest in employee feedback, and won’t actually act on what he or she hears. Instead, bad managers stick to their own plans. If people complain, the bad manager will use open forums against the participants.
10. Bad managers have an
exit strategy every three years
When the organisation is on the verge of holding a bad manager accountable for his or her (in) actions, the bad manager moves on to another organization. In fact, the bad manager had plotted his or her exit strategy for a long time, and always has a fall-back organisation where he or she could flee.
They have Machiavelli’s The Prince on their nightstand and turn to it often for advice on effective “divide and conquer” strategies in the organisation: manipulating colleagues, employees, and bosses. As a result, people becomes preoccupied with watching their back.
It goes without saying that these 10 habits don’t exist in HPOs. But as most organisations are not HPO yet, it is good for you to be able to recognize the signs of bad management, this way you can deal with these ‘bad managers’ quickly… which is, after all, also a characteristic of an HPO manager. André de Waal is associate professor of strategic management at the Maastricht School of Management and academic director of the HPO Center (hpocenter.com) practicebusiness.co.uk | march 2012
Work/life | diary
Practice diary Ann Boyle Ann Boyle started working in the NHS just over 15 years ago as a receptionist and soon worked her way up to become manager for a large GP practice in the North. You can follow her blog at BeyondtheReceptionDesk.wordpress.com
If you would like to contribute to the diary page, please get in touch by emailing editor@ practicebusiness.co.uk march 2012 | practicebusiness.co.uk
Practice Business welcomes different columnists to share their experiences and provide their view from the practice manager’s desk. In the second of a three-part series, general practice blogger Ann Boyle discusses why it’s important to be tactful when sending out patient letters I had a frantic phone call one Friday evening from a good friend – she was in a right panic. She had received a letter from her surgery (not the one that I worked at) asking her to make an appointment to see the doctor regarding her recent smear test. She didn’t know what to do; she had in previous years had abnormal smear results and of course was now thinking the worse. I tried my best to console her – but she had made her mind up – she convinced herself that the doctor was calling her in to tell her she had cancer. As you can imagine she had a very stressful and sleepless weekend. Monday morning came and she rang the surgery – at first she was told that there were no appointments that day – but she insisted on seeing the doctor. Her appointment was for 11am – she was at the surgery at 10am – she sat and waited – she was called in to see the doctor for him to tell her that the smear had not been taken correctly and it would need to be repeated. That was it – it needed to be repeated – more than likely the nurse had not taken it correctly. To say she was over the moon was an understatement. But the worry she went through that weekend was awful. So, it got me thinking – how many other people received letters at the weekend that could cause worry and concerns – having to wait until Monday morning before speaking to a healthcare professional? Probably quite a few, I should imagine. So I spoke to the partners at our next staff meeting and we all agreed that such letters that might cause concern to patients or their families would be posted between Monday and Wednesday, hopefully arriving before the weekend so if the patient was concerned at all they could phone or make an appointment to speak to or see a doctor. General recall letters such as for a flu, diabetics, or heart clinic appointment would go as normal. If there was an urgent letter that needed to go out on either the Thursday or Friday and the doctors felt it might cause some concerns one of them would phone and explain the letter was on its way and if the patient had any concerns they would try to answer their questions. A simple change to your system like this could save a lot of worry for patients.