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practicebusiness + inspiring business solutions for practice managers

august 2012

Ready,

set,

go!

CQC registration one month in

Technology for life

The importance of rolling out telehealth in primary care

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

CONTACT US intelligent media solutions suite 223, business design centre 52 upper street, london, N1 0QH | tel: 020 7288 6833 | fax: 020 7288 6834 | email: info@intelligentmedia.co.uk | web: www.practicebusiness.co.uk | web: www.intelligentmedia.co.uk | twitter: twitter.com/practice_biz

A refreshing approach to primary care

Part of my job, unsurprisingly, is to travel around the country visiting GP practices. In my travels I usually find one of three types: the homely family-run surgery; the community hub; and the futuristic health centre that could be mistaken for something out of Star Trek. You get different types of managers too – from partners who go under the title of ‘business manager’ to those who quietly keep the practice running but perhaps may not get the acknowledgement they always deserve. What I’ve come to discover is you can’t always judge a practice by its cover and that those surgeries taking an out-there approach to primary care aren’t always the obvious ones. I was lucky enough to visit two very forward-thinking practice managers this month – one being Michael Orozco, well-known in the sector for being a champion for the practice management profession, particularly in his role as PM lead with the NHS Alliance. The second was Methven Forbes of Robin Lane Medical Centre in Pudsey, who takes his inspiration from across the pond, attending conferences in America to help better run his practice. Both practice managers take a refreshingly positive approach to managing general practice, and neither are afraid to be a little nonconventional. In his interview (p22) Orozco speaks of the importance of fostering a culture of customer service in general practice, which stems from his own background on the board of high-end department store Selfridges. He believes the NHS and its subsidiaries have a way to go when it comes to pleasing the customer – ahem, patient. Meanwhile, Forbes (p26) talks me through a new wellbeing centre his practice is launching, as well as a number of innovations occurring around the practice’s services, including an app. Although everything he’s doing at Robin Lane is absolutely right, he was a little reticent to indulge in the detail, afraid other practices would read his story and feel pressured to do the same in a financial climate that may not allow it. But surely that’s the point of these case studies? If they inspire a little aspirational thinking, it can be no bad thing. So if you feel you can’t afford a wellbeing centre, think of Practice Business as Vogue for practice managers. If you can’t have it, at least you can aspire towards it.

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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.

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PRACTICEBUSINESS


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

PRIMARY PROVIDER 10 12 17

provider news All the news a practice manager needs under commissioning

telehealth Technology for life The importance of technology-enabled healthcare

CQC Ready, set, go! We look at CQC registration one month in

PEOPLE IN PRACTICE 22 26

interview Man on a mission Nottingham’s Michael Orozco is a champion for the PM cause

case study ‘Round Robin A look at forward-thinking Robin Lane Medical Centre

MANAGEMENT 32 legal 3PD vision Considering a third-party development? Read this first 34 clinical MFM This month: Cirrhosis

Work/life 36 38

comment Train and deliver A PM trainer on the importance of going on courses

diary Ann Boyle on how best to take an appointment


your monthly lowdown on practice management

sector

06

news

The pros and cons of patient access

A guide to personal health records (PHRs) released by the Patient Information Forum (PiF) has highlighted the challenges practices face reaching the Government’s target of giving every patient access to their GP records by 2015, when all GP surgeries will be expected to make electronic communication available to patients, including online booking of appointments, ordering of repeat prescriptions and access to their own medical records when requested. A PHR is a patient-controlled copy of all the health information stored about them by health and social care organisations, to which they can add their own data. Paper examples, such as women’s maternity notes and children’s red books, already exist but the NHS Information Strategy has accelerated the drive towards online access. PiF believes that PHRs are the greatest innovation in the field of health information for generations – a view they say is supported by patients who already have access to theirs. Yvonne Bennett, a patient at Haughton Thornley Medical Centres, said: “There are countless advantages to this new way of interacting with the health service, including becoming a better informed, active patient, and feeling more in control of your health and care.” However, GPs and managers must ensure confidential patient data is kept secure, warns medical defence organisation MDDUS. They warn of potential pitfalls that come with the increased use of electronic communication between doctor and patient. “Electronic systems can be subject to misuse so any access of this kind would need to be rigorously security protected to help prevent any breach of confidentiality,” said MDDUS medical adviser Dr Barry Parker. “There would have to be sufficient IT support and guidance available for practice staff to ensure the safety of systems in operation.”

Practices balk at bigger boundaries Nearly three-quarters of PCTs have failed to agree outer boundaries with their GP practices by the Department of Health’s deadline of 1 July. Pulse has revealed that practices have avoided extending their catchment area through a loophole that lets them refuse in an ‘exceptional circumstance’. Seventy-three per cent of practices in 25 PCTs had still not agreed an outer boundary, while 81 practices have refused to agree to a new boundary altogether, despite pressure from the top to reconsider. Dr Tim Horsburgh, medical secretary of Dudley LMC, said practices were rightly concerned about the increased workload of an extended boundary. “Suddenly they’ll have thousands of new patients with no provision or planning on how they’re going to provide the extra service,” he told Pulse. “If you’re fully staffed and can’t fit another doctor into your building, then how is that going to work?”

august 2012 | practicebusiness.co.uk

value of teamwork put into question A study has revealed that greater involvement of non-GP staff members in the work of the practice has little effect on the management of long-term illnesses. The study, published in the Australian Journal of Primary Health, evaluated the impact of a structured intervention involving non-GP staff in practices on the quality of care for patients with diabetes or cardiovascular disease. A trial took place in 60 GP practices in Australia with intervention being implemented in 30. The quality of care was then evaluated using a patient questionnaire. ‘We found that although the team roles of staff improved in the intervention practices and there were significant differences between practices, there was no significant difference between those in the intervention and control groups,’ reads the report.


07

SECTOR | news

clinical news CQC WATCH

PMs should approach CQC registration with caution

A report has recommended that practice partners, not managers, be officially responsible for CQC registration, according to GP Online. Answering a question from a delegate at the Commissioning Show last week, Dr Cynthia Bower of the CQC stated that while it is acceptable for practice managers to be the ‘registered manager’ in relation to CQC, it is down to the individual practices to decide which staff member should be allocated the role. She explained that if the responsible party has any criminal convictions or breaks the law in any way, the CQC have to be notified, as they are legally responsible for all care provided by the practice. In other news, under a new pilot scheme, CQC inspectors are set to routinely access GP records without patient consent, resulting in opposition from the GPC. The CQC argued that it was within its rights and in the public interest to do so. A CQC spokesperson told Pulse: “If a GP or member of staff knows a patient would not wish their records to be shared during an inspection our inspectors will honour that wish. All information gathered during the pilot will remain confidential.”

QOF

GPs reduce their spend on NHS community prescriptions The NHS community prescribing spend has been reduced despite an increase in the number of items prescribed. The cost of prescriptions fell by £30m in the first quarter in which GPs were being assessed on plans to improve prescribing efficiency locally, GP Online reports. During that time, the number of items prescribed rose by 11.7 million. It suggests GPs cut the average item cost by 6.2%. QOF points were awarded in the new quality and productivity (QP) domain for targeting three areas to improve quality and lower costs of practice prescribing. A DH spokesman said: “Cost effective prescribing ensures that patients get the right treatment, while at the same time freeing up resources that can be put back into patient care.”

New diabetes indicator

The DH has revealed plans for a ‘composite indicator’ that incorporates HbA1c tests, cholesterol readings and blood pressure and foot checks in all patients with diabetes, and will all be categorised under a single QOF indicator worth approximately £5,000 to practices. However, there has been controversy surrounding the report that prompted the changes – the National Diabetes Audit for 2010/11 – with the GPC questioning the quality of the data used to compile it. GPs have criticised the new QOF indicator plans and believe it will create more work for doctors who are already under a great deal of pressure in light of the NHS reforms. Dr Paul Conley, a GP from Basingstoke, told Pulse: “GPs ensure high-level care for patients with diabetes already, and we’ve had so many changes to the QOF. This extreme micromanaging of complex clinical processes can have the opposite effect, and GPs feel demoralised.” If the changes are implemented they could be included in the 2015 QOF.

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

diary 19 September

They said…

“”

“Unfortunately, domestic violence is very common and GP surgeries are often where women are treated for the resulting physical and mental illness. Sometimes this happens without staff knowing that domestic violence is the cause. This study shows that training staff at general practices seems to be a cost-effective way to help tackle the problem.” Angela Devine, health economist at Queen Mary, on new research from

NHS INFORMATICS: DELIVERING A SUCCESSFUL INFORMATION REVOLUTION The Barbican, London 4-6 October

THE RCGP ANNUAL PRIMARY CARE CONFERENCE Glasgow

BMJ Open that calls for training on domestic violence among practice staff

practicebusiness.co.uk | august 2012


08

SECTOR | comment

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

august 2012 | practicebusiness.co.uk

Don’t mention the ‘O’ word

With the – whisper it – Olympics upon us, Roy Lilley has a ponder on branding and whether we give the blue-and-white letters of the NHS enough credit Are you all set for the Olympics? In fact, I’m not sure I can use the word ‘Olympics’. For the duration of the games a new law passed to give the International Olympic Committee a free run. Protection is provided by the London Olympic Games and Paralympic Games Act 2006. This prevents the creation of an unauthorised association between people, goods or services and London 2012. You can’t be an Olympic anything unless you are an ‘Olympic’ something. Apparently a chip shop called the Olympic Fish and Chip Bar has had to change its name. Even the words ‘gold’ and ‘silver’ and bronze’ come within the preview of this draconian law. Thinking about knitting a few ‘Olympic jumpers’ to raise cash for a new scanner at the hospital? Forget it. The five-ring symbol is protected by Olympic Symbol etc. (Protection) Act 1995. If you were thinking about asking LOGOC for a bit of advice or a dispensation; forget it. There’s a website with details on it and the rest is up to you. Infringe their copyright and they’ll send the boys round. Mind you, if it’s G4S, they might not turn up! I guess it is easy to forget that the ‘Olympics’ is a business. Forget the Olympic idea of faster and higher and quicker, or longer and stronger, or whatever it is. It’s about making money, corporate branding and a nice few quid in the bank. Brands are very important, valuable and have to be protected. It makes me wonder what the NHS brand is worth. We seem to give it away quite cheaply, don’t we? Companies that bid to take on NHS services seem to have free access to the familiar blue and white letters; instantly recognised and reassuring. It is a 60-year-old symbol that is known worldwide. Companies that bid for NHS contracts end up using the logo. Should we charge for the use of it? How much would your practice pay to have NHS above the door?

Thinking about knitting a few ‘Olympic jumpers’ to raise cash for a new scanner? Forget it


primary provider

10

Is ‘GP-led’ commissioning over? GPs occupy less than half of CCG board seats Less than half of the seats on the new boards of clinical commissioning groups are occupied by GPs, and as little as a fifth in some parts of the country, according to a Pulse investigation. The publication analysed more than 1,300 board positions, using data released under the Freedom of Information Act, from 100 CCGs. The analysis indicates a very real risk of practices being forced out of the commissioning process as CCGs struggle to minimise costs, avoid conflicts of interest and engage GPs. Financial issues have forced CCGs in some areas to actively reduce the number of GPs on their boards. Facts laid bare

Empowering practices in a commissioning landscape

GPs held 645 out of 1,325 board positions (49%). Managers and finance officers accounted for 267 positions, alongside 140 lay members, 65 nurses, 50 public health representatives, 46 from local authorities, 42 practice managers and 70 others. On 44% of CCG boards fewer than half of members were GPs. CCGs with the lowest proportion of GPs included Nottingham West, which had two GPs (20%); Bury, with three

Drop in NHS managers

There has been a considerable drop in the amount of managers employed by the NHS. The overall number of staff employed in the NHS fell by 1.5%, according to the annual NHS chief executive’s report. The reduction in number was particularly strong in non-clinical areas with the number of managers and senior managers falling by 5.7% over that period. It is likely that these trends will continue through 2012/13. In his introduction to the report, Sir David Nicholson acknowledges the “hard work and diligence” of NHS colleagues. He also praises the “heroic efforts made by the 1.2 million staff who work for our patients in the NHS”. He told delegates at the NHS Confederation conference to “have confidence” in their ability to lead change.

august 2012 | practicebusiness.co.uk

GPs (21%); and Newcastle, also with three GPs (21%).The research also showed that across the country, just a third of CCGs’ accountable officers were GPs and only a third of CCG board members were women. Reality hits

Reasons given for cutting the number of GP board members included reducing conflicts of interest and saving money. Smaller CCGs have complained that the £25 management allowance does not go The percentage far enough to allow for of CCG boards as much involvement from GPs as they occupied by GPs would like.

49%

clinicalnews Flu season at all-time low

Overall GP consultation rates for influenza-like illness in England and Wales indicate that the 2011/2012 flu season was the lowest on record, according to the Health Protection Agency (HPA). GP consultation did not cross the baseline threshold of 30 cases per 100,000, compared to the peak of 130 cases per 100,000 in the 2010/11 season. This represents the lowest winter peak rate for flu consultation recorded. In addition, the flu season started late in 2011/12 with cases not peaking until mid-February – only the fourth time this has happened as late as this since 1989. The number of outbreaks of respiratory infection due to flu, however, was higher than the previous season and predominately reported from care homes for the elderly.


Innovative

Powered by the IntelliCold™ controller, developed by Labcold for safe pharmaceutical cold chain storage, these new fridges feature integral 24/7 temperature logging and alarm battery back up.

Telehealth saves less than thought

Intelligent

Telehealth can reduce deaths and emergency hospital care, but estimated savings are modest and may not be sufficient to offset the cost of the technology, according to a recent study published by the BMJ that suggests that more careful exploration is needed before full-scale roll-out can be implemented. An international team, led by researchers at the Nuffield Trust, assessed the impact of telehealth on hospital use for 3,230 patients with long-term conditions over one year. During the study period, significantly fewer (43%) patients were admitted to hospital compared with 48% of control patients. Significantly fewer (4.6%) of intervention patients died compared with 8.3% of controls. This equates to about 60 lives over a year. There were also statistically significant differences in the mean number of emergency hospital admissions and hospital stays per head. However, the authors say these findings should be interpreted with caution as the differences remained significant after adjusting for several factors that could have influenced the results. But they point out that these effects appear to be linked with short-term increases in hospital use among control patients, the reasons for which are not clear. They also say that the estimated cost savings are modest. The authors concluded that telehealth reduced mortality and helped patients avoid the need for emergency hospital care. But they stress that these benefits need to be balanced against the cost of the technology itself and the level of savings that can be achieved.

The IntelliCold™ controller constantly monitors the fridge temperature, diagnoses faults and immediately alarms. All temperature data is recorded, stored and can be downloaded to a PC. Constant checks of climatic conditions inside the chamber means that IntelliCold™ powered pharmacy fridges use less electricity.

Intuitive The IntelliCold™ controller is designed for busy professionals with four clearly labelled soft touch buttons which display important data like minimum and maximum temperatures with one simple press.

Practice Business has launched a new commissioning magazine

While we will still cover commissioning-related topics from a primary care provider point of view, practice managers heavily involved in clinical commissioning will want to refer to our new bimonthly commissioning magazine that launched last 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”.

PHARMACY & VACCINE REFRIGERATION

NEW

featuring IntelliCold™ technology

www.labcold.com PracticeBusinessHP10.10.2011.indd 1

03/11/2011 10:48:39


12

provision | technology

Telehealth in practice Telehealth has been deemed the solution to giving patients the power to self-manage chronic diseases as they continue to be a major drain on NHS resources. Carrie Service takes a look at how practices can benefit from handing over the reins to patients Early indications from government research show that if used correctly telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, and a 45% reduction in mortality rates. These figures were devised from the Whole System Demonstrator Programme (WSDP), a government study that ran from May 2008 to September 2010. The programme monitored 6,191 patients and 238 GP practices for a minimum of a year across Cornwall, Kent and Newham assessing how effective the use of telehealth was in treating chronic diseases – specifically diabetes, heart failure and COPD. There has been a huge push recently to get primary care to implement these types of technology in hope of achieving the Government’s vision of an integrated NHS. But what does this mean for practices? august 2012 | practicebusiness.co.uk

The answer to your prayers? On a practice level, telehealth has great potential to free up time for both support staff and clinicians by allowing patients to take control of their own health and carry out routine tests and checks from the comfort of their own home – no doubt a welcome relief for HCAs and nurses who are inundated with blood tests and for receptionists who are responsible for triaging calls.And it isn’t just limited to use in the home either, but can also be an extension of the services offered within the surgery itself. MikeTurner, practice manager at The Baffins Surgery in Portsmouth believes that introducing a health ‘pod’ – a touchscreen device that patients can use – to the surgery waiting area has reduced the need to book appointments by allowing patients to perform a range of tests themselves, including: weight and BMI; oxygen saturation; pulse and blood pressure. It is also possible

»


14

PROVISION | technology

Patients need to feel empowered by the process, not overwhelmed, so it’s important to provide support to complete clinical questionnaires for asthma, epilepsy and contraceptive checks and the information is then instantly added to medical notes, reducing administration time for staff. This means that patients can carry out tests at a time that is convenient for them rather than having to take time out of work in the middle of the day and subsequently check-ups are more regular. It has proved useful at The Baffins Surgery for re-registering patients, such as those who have moved back to the area after finishing university: all formalities can be carried out via the technology, so no clinical time is used – unless an intervention is needed. Rachel Stark at East Quay Medical Centre in Somerset was at first concerned about the initial outlay of installing telehealth in her practice, but found that after seeing it in action, the potential for data collection greatly outweighed this. She also recognised the potential for the practice to actually make money, as it provided “an excellent way of collating data required by many QOF targets and enhanced services”.

One size doesn’t fit all But telehealth isn’t a quick fix, and should be approached strategically if it is to really have a positive impact on outcomes, says Mike Evans, commercial director of Telehealth Solutions: “Telehealth will only deliver real quality to both patients and clinicians if it is deployed properly to the right patients, with the right clinical protocols and has the right supporting technologies august 2012 | practicebusiness.co.uk

and services.” Knowing your local population and its specific needs is key. When trying to implement a telehealth strategy, usability for patients should be high on the agenda, after all, it is they who will be managing it for the most part. “The technology has to be friendly and value [has to be] gained through its use,” says Evans. Allowing patients to be in touch with their GP and feel ‘in the loop’ with their progress is a good way of achieving this. Evans gives the following examples: “The ability of patients to receive feedback on their health when they have just completed a protocol; or engage with their clinician either through secure video conferencing or a messaging service; the ability to view educational videos; schedule hospital or GP appointments or have motivational/coaching interviews with a specialist triage nurse. All of these activities help the patient engage more strongly, adhere to their care plan, [and] learn how to manage their condition more effectively.” In other words, patients need to feel empowered by the process, not overwhelmed, so it’s important that staff are well-prepped to provide support and answer questions where necessary. Patients are more likely to be proactive if they are provided with enough information to not feel intimidated by new-fangled technology. Allowing them to have control of their own health can have a real positive impact on well-being too by reducing anxiety around attending clinical appointments, in turn reducing DNAs and freeing up time for those patients who are in real need of appointments.


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provision | CQC update

CQC: are

you ready? With registration now open, it’s time for practices to at least start thinking about CQC. Carrie Service gets some advice about registration and asks readers how their preparations are coming along It may not have been at the top of your list of priorities, and there has no doubt been plenty of other pressing matters for you address recently, but now that registration is open, there’s no more putting it off, practices need to begin addressing the issue of CQC.

In plain English please One of the main challenges identified by PMs who responded to a reader survey on CQC was not the fear of not complying to CQC standards, but worrying that they might not fully understand the terminology used and which services the CQC applies to, an issue also raised by Richard Banyard, director of CQCassist: “There is a lot of guidance out there about what you’ve got to do, but there’s very little as to how you actually do it – particularly self-assessment or how you select the registered manager, and there are issues as to which services should actually be put forward for registration.” Of the 15 ‘regulated activities’, Banyard believes around five may, or may not, apply to GP services. There is a lot riding on which services practices select, because if they get it wrong, they will be breaking the law. “A good example of this is minor surgery,” says Banyard. “If you forget to apply for minor surgery, but then

you do it, legally [come April] you are committing an offence.” So how many you of have started the process of registration? Pulse reported last month that 2,000 practices had already applied. Scott Hollis, CQC manager at Williams Medical Supplies, has seen a definite increase in activity with regards to CQC of late, and a definite sign that practice managers need reassurance that they are on the right track: “Since CQC has been on the radar of practice managers, we have had hundreds of enquiries. We have also received many phone calls asking how they register and instructions on how to log their details on the website.”

Are you taking this seriously? Feedback from our readers has suggested that some of you are a little unsure of where to start when it comes to CQC, and feel that it has been put on the back-burner somewhat. In many ways this is completely understandable because if you are a well-managed practice with good systems and procedures in place, you probably have nothing to worry about. But never-the-less, the CQC registration form is a legal document, and this is something that practice managers should make sure partners are proactive about, so that they don’t feel put-upon.

»

practicebusiness.co.uk | august 2012


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COMMISSIONING | CQC update

“A lot of GPs are entirely leaving it to their practice manager,” says Banyard. However he admits that this is for reasons he understands. GPs are in a completely new position and, unlike dentists, have not been subject to this sort of scrutiny before. “GP boards, as practice entities probably aren’t grasping the fact that they are about to fill in a legal document that needs to be fully understood by them,” reflects Banyard. “The challenge [for practice managers] is probably getting boards to understand the process and also to allocate amongst themselves some of the key responsibilities.” Although it is unlikely that the practice manager will nominate themselves as the registered manager for CQC, the majority of the responsibility for ensuring compliance does appear to be lying with you. So where do you go for support?

But there is a certain amount of anxiety evident in practices about the integrity of this advice, with one PM who responded to our survey saying: “I’ve no idea whose advice to trust. I don’t know who I can trust to give fair, impartial, practical advice”, and one practice even claimed they were given incorrect information from a consultant. Banyard advises PMs not to overlook the CQC itself as a source of support if they are feeling unsure: “In the case of any doubt at all, get it in writing from the CQC, because at the end of the day it’s them that determine whether or not you comply.” Finally, are there any common pitfalls that practices should watch out for? “Common areas that could be overlooked include surveying and testing for Legionella and asbestos,” explains Hollis, “particularly for buildings that were built pre-2000.” He warns that this should be completed by a specialist, rather than surgery staff. He also advises PMs to not get complacent because their practice might seem too new/big/small etc. to not breeze through CQC: “Our experience suggests that the challenge is consistent irrespective of the size of practice. All surgeries face the same day to day headaches around issues such as staffing, hygiene standards and other health and safety factors.” Banyard believes that what practices are going through now is just the tip of the iceberg – the biggest test won’t be getting through registration and compliance; it will be maintaining the CQC standard after they’ve made it through: “That’s when the fun starts in terms of compliance,” he explains. “That’s when the CQC will be clearly looking to ratchet up any standards in areas where they perceive there to be a risk,” he warns. So, watch this space.

Our experience suggests that the challenge is consistent irrespective of the size of practice. All surgeries face the same day to day headaches

No-nonsense advice Although it is down to the individual practice whether or not it seeks advice from an outside party, and LMCs are suggesting that it is unnecessary, Banyard advises PMs to consider all options because they might be wasting precious time carrying out unnecessary tasks under the premise that this will make them compliant: “The reality is that practices are busy places and I have found that practice managers do spend an awful lot of time, which you could call wasted, updating policy and procedures – which I’m not saying is right or wrong, it’s probably an excellent thing to do – but it’s not going to get you through the CQC.” There is a glut of consultancies all claiming to be the solution to your CQC woes.

august 2012 | practicebusiness.co.uk


19

dbg | advertorial

complete compliance support With a heritage stretching back over 20 years, dbg is the UK’s largest outsourced healthcare provider, providing bespoke support services to over 7,500 healthcare practices The strength of dbg’s long-standing success lies in the personalised service it provides its members, always putting members’ interests first while offering practical, cost-effective solutions covering all areas of the practice, including equipment testing and calibration, staff training and business support. With the role of the Care Quality Commission (CQC) now extended to include GP practices across England, compliance is a key area many practices will find they need support in. To address this growing demand, dbg offers a range of comprehensive, tailored packages designed to help practices meet their new compliance obligations. These packages have been specially designed using the experience dbg has already gained helping its dental practice members through the same process of CQC registration and inspection. This puts dbg in the ideal position to provide GP practices with all the help and support they need to meet every one of the CQC’s Essential Standards. Donna Hickey is head of compliance at dbg, and is confident that dbg offers practices the complete solution to all their compliance needs. “At dbg we aim to become GPs’ and practice managers’ first port of call should they need help in any area of their practice,” says Hickey. “Our services are there as a ‘menu’ so practices can pick and choose what they need help with, but we can also offer more comprehensive packages depending on what the practice requires. “If you’re a practice manager and not sure where to start with CQC compliance, the first thing we recommend is for you to take our ‘Essential Standards

Practice Assessment’. For this we will send in one of our competent practice assessors to spend the day in your practice working with your team. We will interview staff and provide lots of practical help and advice while onsite to give you as many easy solutions to problems that we can. We will then provide you with a full report and action plan that you can use to see where your practice is in terms of the CQC’s Essential Standards. “The ‘Essential Standards Practice Assessment’ is a great first step for practices as it’s a complete overhaul of the whole practice. We can share common resolutions to problems that are practical tips that we’ve picked up from all the other practices we’ve worked with. “If you know your practice has some issues and you need help, the next package we can offer you is our completely bespoke dbg360,” continues Hickey. “This package can be completely customised to suit your needs as it includes 10 flexible hours per year on site that you can apply to any training or engineering inspection work. If you need training, then you can put all your hours into training, or similarly you can put all the hours into engineering services, or you can mix and match as you require. Not only is this service extremely cost-effective, but it also lets you tailor your support depending on what you need most. “Of course one service I shouldn’t forget to mention is our innovative Virtual Compliance Office – dbgVCO. This is a completely bespoke online compliance tool that is free for all dbg members. Using our many years of experience in compliance the powerful software lets users carry out online self-assessments and tests to check on their current compliance status. It also provides regular updates and health and safety alerts to ensure all users keep on track and don’t fall behind, dbgVCO is the essential CQC audit tool.” With such a wealth of experience and a range of packages designed to offer practices real, practical support at great value, it is no wonder dbg is at the forefront of CQC compliance support.

has over 20 years’ experience working alongside healthcare practices

Bespoke support service

Experts in CQC compliance

7,500+ member practices

Special member discount on all services

Earn while you learn CPD on all calls

Contact us 01606 861 950 sales@thedbg.co.uk www.thedbg.co.uk

practicebusiness.co.uk | august 2012


ADVERTORIAL

Medicines Optimisation with FDB

The Challenge First Databank’s (FDB™) 2011 extensive independent research drilled 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.

sales@fdbhealth.com


ADVERTORIAL

The Solution 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: • 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, the information required to build condition specific formularies, and repeat prescribing analytics.

These tools will not only free up Medicines Management team time for direct clinical care and local initiatives but also provide essential information for effective CCG budget management. 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


people

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one-to-ones with the people making a difference

Under new management As co-lead of the NHS Alliance’s PM network, Michael Orozco is a champion of the profession. But he hasn’t always been in health. Julia Dennison finds out how a retail background gives him insight into general practice For all its influence in the world of general practice strategy and redesign, The Peacock Practice occupies a humble building on the outskirts of Nottingham. It’s not surprising, therefore, that the three partners and their team have outgrown the Victorian houseturned-GP-premises and are planning a move to a new building better suited for their growing services. The move will be welcome, but there is an undeniably comforting, settled-in feeling to the place that reflects the family business – the two GP partners are married and business partner Michael Orozco, who I am here to see, is their brother/brother-in-law. There are family photographs and heirlooms decorating the consulting room we meet in, which could easily be mistaken for someone’s lounge – albeit one with a plinth instead of a sofa. All this will surely be missed

august 2012 | practicebusiness.co.uk

as they move into the new practice in November, but they are determined to maintain a familiar feel in the new place. They are, after all, in safe hands – as their business partner is one with much experience around the area of strategic planning, and business relocation. Michael Orozco is known in practice management circles as a leader and advocate of the profession. It is therefore almost hard to believe he’s only been in the sector for six years. Originally from London, he has a background in high-end retail, security and events management that spans two decades – the majority of which was spent overseeing the security operations at Selfridges on Oxford Street. He started working with The Peacock Practice around eight years ago on a temporary basis – to get a feel for another sector – and two years later, temporary turned into permanent as


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people | interview he took up partnership in the surgery alongside his brother and sister-in-law, leaving London behind for greener pastures (quite literally).

Fact box Practice: The Peacock Practice Partners: Three Staff: 15 – including a salaried GP, a diabetes nurse, COPD nurse and a healthcare assistant. Patients: 4,500 CCG: Nottingham and North East CCG

Making the move One of the main reasons the practice approached Orozco was to help with an opportunity to purchase an ex-PCT health centre for a new premises. They needed someone to coordinate and project manage the purchase and relocation while exploring wider opportunities with providers for additional services in the locality. Six years later and the practice has still not moved in. This has been a source of frustration for Orozco. “When you come from a different background in the private sector you expect things to be done in a certain way and with some expediency, as time is money,” he says. “When I came into the NHS, my first thought was: They’re 20 years behind what we were doing in retail.” He finds this lethargy not solely around major upheavals, like moving premises, but in the way certain areas of the health service interacts with their colleagues, the public and patients. He believes there is a strong element of ‘silo’ thinking and working when they should be striving for greater collaboration and integration across health and social care. Having a retail background, Orozco believes it’s important for patients to be treated like customers. “Now, some people won’t like to hear that,” he’s quick to add, “but, fact is, that is what they are because you are a service provider – you are delivering a service and if you think about it, anyone who delivers a service, that person on the other end is a customer, end of.” Of course, he’s mindful that there is a difference between a surgery or hospital and a department store, as we are, of course, talking about people’s health, but much can be gained from having a more customer service approach. For example, he believes all practices should have a PPG group. Orozco admits that his move into the health sector had initially been a bit of a culture shock and he is getting used to what he finds to be a slower pace. “In terms of the service itself it can be very active, but in terms of the process overall in the NHS and how things are managed, on occasion it can also be very inefficient,” he explains. “GPs are effectively running a small business.” It is the practice manager, he believes, who underpins it all and that is why they are key to the future of general practice. “GPs, by nature, are not business people,” he continues. “That’s not what they’re there for; they trained to provide a high standard of clinical care. If you look at the

eight years that they’re trained, there’s very little, if anything at all, around business, so it’s crucial that the team under them, and specifically the practice manager, be the key link to that business.” Changing profession Since entering the world of general practice, Orozco’s main areas of focus, much of which he brought from his experience in retail, have been strategic planning, service redesign, new business/ procurement, and public involvement. His observation since working with practice managers as the co-lead of the NHS Alliance’s Practice Managers’ Network for the last few years has been that there is a wide variance between practices when it comes to a practice manager’s responsibility and autonomy. He sees members of the profession fitting into two categories: those practice managers who work under their GPs and those who are supported to take the strategic lead. Sometimes what kind of role they take isn’t up to them, but dictated by the culture in the practice. “You will get those practice managers who have the autonomy and really have earned that autonomy and some who don’t,” he comments. “It really does depend on how good the relationship is between the practice manager and the partners. That’s crucial and it does vary.” He has observed this variance time and time again: “When you speak to practice managers, some of them don’t have a lot of autonomy or have the opportunity to be involved in the decision-making process, therefore, effectively, they find themselves as almost glorified administrators when they can do so much more.” So what can practice managers who feel undervalued do? Orozco believes it depends on how long they’ve been in the role. “Once you’ve been in the role a long time, it’s hard to think of doing anything else,” he says. And while it may seem like the easiest thing is to change jobs, this isn’t the easiest economic environment to do so, though, Orozco adds, there are the jobs out there and there’s no harm in having a look to see what else is out there. “That I would encourage anyway,” he says, “because it gives you an insight into what else is out there and how you might be able to transfer your skills as sometimes we can all get cocooned into a certain way of thinking and working because it is the safe option.” Increasing demands With the changing NHS, practice managers are likely to be more in demand. “Certainly now, with our practice income being squeezed year on year,” says Orozco. “But juxtaposed with that, our work is increasing.” The Peacock Practice

»

practicebusiness.co.uk | august 2012


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people | interview

is lucky to be moving into a premises they will own, so it puts them in a more stable position for the future, but not all practices will have that opportunity and security. However, Orozco insists, the changes to the NHS also bring opportunity for those who want or can take it, for example, the PCTs are in the process of divesting all their estates. He thinks taking the right opportunities might just ensure the sustainability of general practice and help remove its inefficiencies. The first step would be taking a more collaborative approach to primary care provision. He gives an example: “When I first started working in general practice I went out visiting other practices, speaking to other managers and speaking to people at the PCT – what I wanted was an insight into everything, from the top down, so I had an understanding of the thinking processes and attitudes,” he remembers. “I walked into one health centre where there were three GP surgeries with tree receptions. People would argue that that’s the NHS, but I would argue that’s madness. I can understand culturally that’s the way it is, but in the future we can’t afford to do that. In business, you can’t afford to duplicate because it costs money and is inefficient, so in the future there’s going to be some hard decisions because practices will need to think more globally; they will need to think more about collaborative working.” Experts have suggested that federating could secure the future of smaller practices, but Orozco argues that collaboration doesn’t have to be that formal. For example, the five practices in his locality work together on their contingency plans and have the same software system to facilitate that. “It’s getting into this mind-set that we need to do more to support each other right across the board,” he says. This includes sharing services, support and ideas. He recommends collaborating with other practices on CQC registration. By teaming up with other practices in the area, he was able to convince a representative from the CQC itself to present to the local practice managers about what is required for registration. The fact that 91 practice managers attended, leaving their busy practices for the day, proved its worth. “Something I picked up in retailing is that networking is crucial,” he says, which is why he recommends practice managers reach out to their colleagues and local networks and strengthen their links. To bolster the support and networking available for practice managers, Orozco and his colleagues at the NHS Alliance are creating a new website – a kind of a one-stop-shop for procurement. “Practice managers underpin general practice, and there’s more responsibility coming down and they’re going to need that support,” he explains of the motivation. “It’s going to be a challenge in a future for the practice manager’s role. The call now is definitely for them to be more strategic in their thinking.” However, for those who are keen to take on the challenge, he believes it is a great time to be a practice manager. “There will be challenges but it is rewarding,” he says, and at the end of the day the proof of a well-run practice is in its patients. august 2012 | practicebusiness.co.uk

When I came into the NHS, my first thought was: They’re 20 years behind what we were doing in retail


26

people | case study

Doing it for the people Pudsey will soon be known for more than a yellow bear. Under the prowess of METHVEN FORBES, the local Robin Lane Medical Centre opens the Pudsey Wellbeing Centre to boost community spirit. JULIA DENNISON reports

ABOVE: The front of the new Pudsey Wellbeing Centre

Walking into Robin Lane Medical Practice in Pudsey, outside of Leeds, I’m met with a typical waiting room full to bursting with your usual crowd of subdued patients, intermixed with a few crying babies. But take a step behind the scenes of this PMS surgery, catering to 11,500 patients (and counting), and you find anything but average. My first clue of this practice’s cachet is when I’m instructed by the receptionist to go to the board room (a nod to the practice’s business-like approach to primary care), where I bump into another journalist. This one is from the Yorkshire Post and she is putting together a day-in-the-life on the practice’s partners. But it’s no coincidence the local paper has stopped by since Robin Lane is only days away from cutting the ribbon to its new Pudsey Wellbeing Centre opening next door and this is just the kind of heart-warming local-community-in-action story a local paper thrives on. So while this journalist eyes me up suspiciously for stepping on her turf, as a representative of a national magazine championing practice management, I know her presence only goes to prove that this is a practice worth profiling.

august 2012 | practicebusiness.co.uk

Often, when a GP practice is forward-thinking enough to open something like a wellbeing centre, it has other projects up its sleeves – and I was not wrong with this one. Alongside the centre, Robin Lane is launching the Pudsey Wellbeing Card, which will give local residents access to discounts on healthy products and services in the area. Meanwhile, it’s about to roll out a smartphone app for its patients that lets them book appointments, text clinicians, request repeat prescriptions, access their medical records and receive appointment reminders from the digital device in their pocket, which many of them are using for practically everything else in their lives anyway. From a health perspective, the practice team prides itself in developing new models of proactive primary care and even runs its own ophthalmology clinic.

Man behind the methods In order to understand the motivation behind all the changes at Robin Lane, you have to meet business partner Methven Forbes (who also goes by his nickname Samuel). He works alongside a practice manager to oversee the business of running

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people | case study

Fact box Practice: Robin Lane Medical Practice Business manager: Methven Forbes Partners: Five Staff: 35 Patients: 11,500 CCG: Leeds West CCG Contract: PMS

the practice, focusing particularly on the strategy, while the latter sees to its day-to-day administration and management. Forbes has a passion for blue sky thinking (he’s currently undertaking a masters in innovation) and has been ambitious from the outset. He started at the practice in 2004 as the practice manager and was promoted to partner in 2006, when he decided to take it up a notch and hire support so that he had the time to think strategically about the future of the practice. Business partner Not one to turn down an Methven Forbes opportunity, he also sat on the local practice-based commissioning board as the chief business officer, which then became Leeds West CCG. He sat on the commissioning board for four years until the long hours got the better of him – he was easily doing up to 80-hours a week including his practice work. So he stepped down and turned his whole focus to his practice. With more time on his hands, he is able to do what he loves, which is learn from the best. With this in mind, he goes to conferences all over the world, including one in San Francisco run by forward-thinking US managed care consortium Kaiser Permanente, which was the source of much inspiration for him.

new Pudsey Wellbeing Centre opened its doors as a place where the local community could come and be encouraged to be healthy. The idea, inspired by an American book called Wellbeing: the Five Essential Elements, is to encourage all-round wellbeing in the local population around five areas: career, social, financial, physical, and community wellbeing. The plan is to open a cafe on the ground floor, which will serve healthy food, show movies on the new flat-screen TV mounted to its wall, and offer live music (and alcohol in moderation) to locals who want a wholesome knees-up. The upstairs will offer a kind of community hall, where locals can take classes from whoever wants to offer them (the space is free to use if the people using it are not charged a ticket fee). Forbes envisages anything from Zumba to cookery classes. The focus will be on self-help, both helping people to stay healthy, but also to allow people with long-term conditions to better manage themselves. With one in four adults in Pudsey obese, according to research by the practice (higher than the nearby Leeds average), and COPD-related admissions to hospital higher than average rates in the area, the initiative is sure to be a welcome one. Although the centre was started by the Robin Lane Medical Centre, Forbes is quick to remove their name from any promotional materials. The centre, he insists, is not something to be used solely by patients at the practice; rather, it’s a place for anyone to use. While the practice was behind much of its planning, and owns the building, a steering group, made up of community representatives like local councillors, commissioners, and social care representatives, was created to drive the wellbeing centre into fruition. “We’re testing new ways to evolve general practice and this is specifically about the wellbeing of Pudsey, so not just our patients but the wider population,” Forbes explains. As part of this local outreach and to oversee the running of the centre, Robin Lane received funding from the SHA to work with Leeds University to train community volunteers to become ‘wellbeing champions’. They will be the ones, Forbes hopes, who will drive what’s on offer at the centre. “The measure of our success will be when we don’t have to

We’re testing new ways to evolve general practice and this is specifically about the wellbeing of Pudsey, so not just our patients but the wider population

A place of wellbeing The Pudsey Wellbeing Centre has been a few years in the making. Robin Lane purchased the building next door two years ago, and, up until its transformation into the new centre, had been renting it out to local offices, as well as using its top floor to run the practice’s ophthalmology clinic. On 20 July all that changed when, with the help of a local MP, the august 2012 | practicebusiness.co.uk

»


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people | case study

create the ideas [for what to run in the centre] ourselves,” he adds. He is also working with the university and the National Institute for Health Research to measure the centre’s overall impact on the community.

practice). It only cost the practice £5,000 all-told and Forbes chose an IT company that gave him oversight on the design and the ability to make changes himself. Though he’s very happy with the first version, Forbes already has a list of augmentations he’d like to see go into the next. He’s already started to get the word out there (graphic design is another side interest for him, made evident by the wide-screen Mac computer on his desk) and with the help of marketing and promotional materials, hopes to get as many patients on board as possible.

There’s an app for that

General improvements

Local Children in Need mascot, Pudsey Bear

As expected, Robin Lane is not a practice to rest on its laurels. There are plenty of other ideas and innovations Forbes and his team are pushing forward. One such plan has been to train-up the receptionists as healthcare assistants. “Any contact about health matters and we’ve found that the dynamic between patient and receptionist and patient and healthcare assistant is very different,” says Forbes. “You just put on a white uniform and then put them out in reception and it’s an entirely different experience.” The practice has also been running a new walk-in clinic since January and has installed a selfcheck section of the waiting room for blood pressure checks and weigh-ins. But the immediate future lies in the exciting adventure that is the wellbeing centre. If all goes to plan, Robin Lane and its community will see its benefit in the improved health of Pudsey patients. Methven Forbes demos the practice’s new iPhone app

august 2012 | practicebusiness.co.uk

Featureflash / Shutterstock.com

In other news, Robin Lane is creating a smartphone app and – no surprises here – Forbes was the man behind the idea. He is a long-standing believer in using technology to reach out to patients – the practice has regularly updated Twitter and Facebook pages and 4,000 of its patients already book appointments online – so an app was not the stretch it might be for other practices. This motivation was further solidified by Forbes’s travels to America where apps for health services are more common. The idea was to get more information into the hands of patients and make interaction with the practice easier for them. “I use Ocado for my online shopping; the Trainline app for train tickets; Domino’s for fast food – I use apps all the time now, so why not? If it gets rid of the dreaded eight-o’clock syndrome for patients, then it must be a great thing and an instant way to communicate with patients,” Forbes says. The app includes, among other things, general information on the practice; a location finder; a link to the practice’s Twitter page; a space for general comments and the facility to interact with the practice, including text clinicians (with the right login details to ensure they are indeed a patient of the


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business intelligence and management sense for practice managers

management

32

3PD vision Contemplating a third-party development? Read this. It is estimated that GP practice premises need a major refurbishment every 10-15 years. Lawyer Stewart Gregory discusses issues over personal liability, rent reimbursements and transferring of leases As is widely reported, the role of the general practitioner is evolving at pace. The Health and Social Care Act 2012 indicated that all GP practices need to be registered with the Care Quality Commission by 2013. This aims to ensure that standards of quality of care, patient safety and treatment are transparent across both health and adult social care. Outcome measure 10 in the CQC compliance schedule refers to the safety and suitability of the premises in which GPs provide care. For example, GPs must ensure that treatment rooms are up to NHS

august 2012 | practicebusiness.co.uk

standards in regards to infection control and patients must be able to access the premise easily. This is easier said than done and some doctors are finding that the space in their surgery is not fit for purpose or is not being used to its maximum potential – especially if their practice is located in a converted property which was not initially built for clinical use. Increasingly we are finding that doctors or groups of doctors are turning to new purpose built premises. If you are considering a similar development for


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management | legal

experience shows that caps on liability will only be entertained in return for an increase in rent and compliance with onerous obligations.

Withdrawal of rent reimbursement

Some doctors are finding the space in their surgery is not fit for purpose or is not being used to its maximum potential your own practice, here are some issues that crop up regularly for practices considering a redevelopment of their premises through a third-party developer (3PD).

Liability and risk The lease document to be granted by the developer on completion of the building works will be signed by up to four of the partners in the practice who will then hold the lease on trust for all the partners. A developer normally requires that the liability of those signing partners is “joint and several” and is unlimited. Thus the signing partners are prima facie personally liable (together and individually) for payment of rent and performance of all obligations of the practice under the lease. This is understandably seen as an onerous commitment on behalf of the signing partners. It is therefore important that the practice’s partnership agreement is reviewed to ensure that there are adequate indemnity provisions to “spread the risk” around the whole partnership, so no individual partner is exposed to undue personal risk. Ideally, a practice would also wish to cap its liability to the assets of the partnership from time to time. However, developers are very reluctant to agree to any cap on liability of their tenants. Recent

Once a practice has signed the lease with the developer, it becomes liable for payment of all rent for the whole of the term of the lease. In the (unlikely) event that rent reimbursement was to be removed, the practice would remain liable for rent to the developer even though that may not be reimbursed by the PCT. In that scenario the practice may wish to terminate its lease. However, developers are very reluctant to grant break rights to practices – it weakens the strength of the lease and may make it very difficult to obtain funding for the development. Recent experience shows that developers are only willing to grant break rights in return for the payment of additional rent and compliance with a series of onerous obligations before the break can be exercised. There may be similar concerns if a practice’s list size falls below a certain number. Again, may the practice wish to terminate its lease in that event? If so then that would need to be agreed at an early stage with the developer as it is another factor that would affect its ability to obtain funding for the scheme.

Lease transfer A developer always wishes to impose some control over what a tenant can do to transfer its lease or grant sub-leases. Typically the landlord’s consent will be required to any proposed transfer of the lease or to the grant of any sub-lease. The NHS and the provision of services to it is often subject to reorganisation, so flexibility should be sought to enable NHS tenants freely to transfer their lease without prior landlord consent, if the lease is to remain within the NHS umbrella. Likewise, partners in GP practices come and go, so provisions should be negotiated that allow partners to be appointed or to retire without needing landlord consent each time the partnership changes. Furthermore, an outgoing partner who is a party to a practice lease would wish to see his or her liability released upon retirement from the practice. Whilst developers in the market for 3PD developments are aware of these issues, care is needed in drafting the relevant lease provisions to ensure that the practice’s interests are properly protected in these key areas. Stewart Gregory is a partner at Browne Jacobson LLP practicebusiness.co.uk | august 2012


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management | mfm

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

Cirrhosis

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: Cirrhosis Cirrhosis of the liver occurs when the normal cellular structure of the liver is destroyed and replaced by fibrous tissue (scarring) preventing it from working properly. It is well-known that the most common cause is excessive consumption of alcohol but it is by no means the only cause. As the liver cells are replaced the function of the liver declines and the body’s ability to metabolise drugs, manufacture proteins and destroy toxins is diminished. The liver also makes an important contribution to digestion and that too is impaired. Cirrhosis is caused by long-term continuous damage and is a life threatening condition. The liver damage produced is irreversible. Frighteningly, only 30% of patients will survive for five years once diagnosed. The survival rates for patients in whom the damage was caused by alcohol is even worse. The majority of cases of cirrhosis are due to excessive consumption of alcohol. However there are other causes. Viral hepatitis B and C also destroy liver cells and it is important to treat the diseases, particularly hepatitis C, when identified, although treatment does not always protect against the damage. Some drugs and chemicals, which are broken down by the liver, can also cause cirrhosis as can a variety of disorders which can cause the accumulation of toxins, the commonest of which is haemochromatosis. Rarely, the disease may be caused by primary biliary cirrhosis, which is an autoimmune disease when the body’s immune system attacks the liver. The liver has amazing capacity and patients usually show no signs of liver disease even when a significant part of the liver has been destroyed. However, as the disease progresses, the patient may develop a number of non-specific symptoms, such as weight loss, loss of appetite, nausea, tiredness, lethargy, skin irritation and loss of energy. If the disease is not diagnosed or the cause is not treated, later symptoms will include jaundice (yellowing of the skin and the ‘whites’ of the eyes as a result of accumulation of bilirubin which the liver can no longer remove), oedema because the liver is not able to produce the plasma proteins which stop fluid from accumulating in the tissues, bruising and nosebleeds because clotting factors are not manufactured, spider naevi on the skin and breast development in men because the liver cannot destroy the female sex hormones which are produced. In the late stages of the disease patients may vomit blood from ulcers or oesophageal varices and they become confused, drowsy and finally they lapse into coma. The disease is diagnosed by taking a careful history and clinical examination, which will usually raise the suspicion of cirrhosis and this is supported by taking blood to assess liver function and imaging using ultrasound or CT scan. Usually the confirmation of diagnosis is made by liver biopsy. Once diagnosed, treatment is by the management of the cause. In those patients consuming excessive alcohol abstinence is essential. The Government publishes maximum figures for alcohol

Once diagnosed, treatment is by the management of the cause. In those patients consuming excessive alcohol, abstinence is essential august 2012 | practicebusiness.co.uk


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How do you like your news and analysis? consumption and women are more susceptible to the damage that alcohol causes than men. Once the cirrhosis is established, the liver may be further damaged by even small amounts of alcohol. Patients who are exposed to toxic chemicals should be protected from them and those patients with viral hepatitis should be treated to try to eradicate the virus. Haemochromatosis can be managed by regular bloodletting. Medical treatment will include the prescription of diuretics to control oedema and of vitamin and mineral supplements. The elimination of causal agents should be supplemented by lifestyle adjustments. Diet should be controlled with high protein and low salt intake. Treatment, however, often does not stop the progression of the disease, especially in patients who do not have the will or the ability to stop drinking alcohol. Some patients with advanced cirrhosis will be considered for liver transplantation and around 750 operations are carried out a year but sadly about 1,000 people die from the disease annually. It will be important to see whether the introduction of minimum pricing for alcohol influences the disease profile in the longer term. Prevention remains essential in the protection from liver disease by education about maximum alcohol limits and the avoidance of the acquisition of hepatitis B or C through unprotected sex or injecting drugs with infected needles. Although there is a vaccination for hepatitis B, no such vaccine exists for hepatitis C. Without successful educational measures the number of patients with cirrhosis is likely to increase.

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work/life

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Training evaluation why do it? Gabby Prowse, a trainer and freelance PM working at Harbourside Family Practice in Portishead, writes about the importance of course evaluation and how, done correctly, it can be a powerful tool How do you know if the training your staff has impacts positively on your business? Can you prove it or measure it? Why should you want to and how do you go about it? There are many very good reasons for evaluating training, including: checking impact on job and business performance maintaining staff motivation tracking development of staff knowledge and skills informing future training investment decisions Justifying/expanding training budgets Identifying high/low-performing courses. Although courses are generally evaluated on how well the trainer performed and how much the learner felt they learned, rarely is the impact on the learner or their organisation ever followed up or quantified. If each business had their own process in place to evaluate how well this learning impacted on their business as a whole, they would have a very powerful tool for informing their training strategy and ultimately their business plan.

advice for busy lives

• • • • • •

Research evidence There’s a huge amount of information available on the subject and one of the best methods is the Kirkpatrick Return On Expectations (ROE) model of training evaluation evolved out of Donald Kirkpatrick’s ‘Four Level Model’. This was originally developed in the 1950s and was, for many years, regarded as the industry standard in training evaluation. By progressing through each of the levels, training evaluators can build a ‘chain of evidence’ that links learning with organisational

august 2012 | practicebusiness.co.uk

performance. Similarly, if the outcomes of a learning programme are not as expected, the model provides the evaluator with a diagnostic framework. By checking back through responses to the evaluation at each of the levels the evaluator should be able to identify any key barriers to training effectiveness and impact. The Kirkpatrick ROE Model In recent years the model has evolved to become both more sophisticated and more powerful. Kirkpatrick’s four levels model Level 4 Business impact Application of learning in the workplace enables the desired changes in organisational performance to happen

Level 3 Job impact The learning lays the foundation for the transfer of knowledge to the workplace

Level 2 Learning Enabling learning to take place

Level 1 Participant reaction Having the right conditions for learning


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work/life | HR

The focus of the updated ROE model, focuses on ensuring that training objectives are strategically relevant to the organisation in the first place, clearly defining the expectations of the outcomes of the training, and then evaluating against both the training objectives and the agreed expectations. The main principles of the ROE model can be summarised as follows: • Business/organisational objectives are seen as a starting point – To ensure training processes deliver real value to the organisation, it is critical to establish what the organisation’s strategic objectives are and precisely how the training should contribute to their achievement. • ROE is key – Clarify with stakeholders what the expectations are regarding training outcomes. Clear and precise success indicators should be developed in-line with these expectations. The training evaluation should then assess and report on both the actual changes that have come about as a result of the training and the extent to which these changes have met the organistaion’s expectations. • Collective efforts are needed throughout an organisation to achieve success – For training to achieve a positive ROE, team leaders, managers and others in an organisation all need to be involved in supporting the training process before, during and after training begins. They can do this by, for example, helping prepare participants for training; providing support/coaching and, crucially, providing the opportunities to apply, consolidate and reinforce what has been learnt in the workplace after the formal training has ended. The third element Then there’s the training provider. Evaluation should be a three-way process of communication and continued improvement between training provider, trainee and organisation. How do we as managers help the training provider to continue to provide effective courses that really hit the mark both for the trainees and the business? And if you want to encourage people to send their staff on courses, then you need hard evidence that will help convince the budget holders/business owners that there’s a worthwhile return on investment. Getting it right Getting the evaluation right is critical. But without being an expert, how do you devise an evaluation

form that gives you the depth of understanding and knowledge you need? Remember that learners can’t evaluate the teaching if they aren’t teachers themselves, so they need evaluation forms that tease the relevant information out. There are many software packages out there to help you on your way, but the one I’ve found most useful is at TrainingCheck.com/training-evaluation and it’s free. They have embedded the Kirkpatrick ROE model into their software package, providing a powerful framework for evaluating training impact. What I like about it is that it allows the followup evaluation to be carried out back at the office after the training, allowing time for reflection and honest feedback. It also allows that three way process of effective communication and continued improvement between training provider, trainee and the organisation. It’s very easy to compile and the software will collate all sorts of information and evidence for the trainee and business. It is also a powerful tool for demonstrating value for money of the training provided. There are two packages and for a small business the basic free package is more than adequate. If the training provider wanted to use this to ensure course cost effectiveness then the paid package would offer a good solution.

Training and Evaluation should be a continuous cycle

what do you want to achieve?

Draw conclusions and feed into business plan

evaluate the impact the training had on your business

what’s available and what sort of training would suit needs best?

after training, evaluate if the professional development met your needs

practicebusiness.co.uk | august 2012


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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 august 2012 | practicebusiness.co.uk

General practice blogger Ann Boyle explains how to take a good appointment

It is important when making an appointment for a patient that you are clear about the time, date and even the month. Often hospital appointments can be months in advance. If the patient is booking their appointment in person at the reception desk always try and make an appointment convenient to the patient. Often if you give an appointment and it’s not convenient the patient will either not turn up or phone to cancel and re book. Try to get it right first time. When you book an appointment at the reception desk always give the patient an appointment card – or put the appointment on a piece of paper. Often patients will insist that they will remember their appointment but quite often they will end up phoning to check when it is – or worse still not turn up. Always put on the appointment card: • The day (Monday) • The date (16th) • The month (September) • The time (11.00 am) • Who the appointment is with (doctor/nurse) If the patient is making the appointment over the

telephone again please give clear instructions on when their appointment is. Again repeat as above. If you don’t give the day (Monday) quite often people will get their date (16th) mixed up and often turn up the day before or after – this is quite a common thing especially with some elderly people. People will remember a day rather than a date. When giving an appointment over the telephone always speak slowly and clearly – the person on the other end of the phone might be writing it down. At the end of the conversation ask if they are happy with the appointment – this will give them every opportunity if they are anyway unsure. Every doctors’ surgery and hospital have a high volume of DNAs (did-notattends) throughout the year. Therefore it is essential to try and avoid any unnecessary misunderstanding over appointments. When making any appointment always make sure that you have the correct patient. You will often have patients who have the same name or similar names. If unsure ask for their date of birth. But please remember confidentiality at all times.


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