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february 2012

Swan song

NHS Worcestershire brings end of life care into the community

Phone operators

A new telephone scheme is changing the future of general practice

Commissioning in view

Lessons learned and future predictions

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Editor’s letter EXECUTIVE EDITOR www.roylilley.co.uk EDITOR julia.dennison@intelligentmedia.co.uk ASSISTANT EDITOR carrie.service@intelligentmedia.co.uk REPORTER jonathan.hills@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 ASSISTANT production@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

See and be seen

As we await decisions from the top as to the future of the Health Bill, 40 practices across the country are taking things into their own hands. Patient Access is a social enterprise formed last year from a group of GPs across England who have a unique way of interacting with their patient populations.

The method they adhere to is simple: a patient calls the GP practice, the GP calls them back and holds the consultation over the phone or calls them in if need be. By phoning patients before they present themselves in surgery, these practices are saving money on referrals and clinician time, while did-not-attends go down and patient satisfaction goes up. If it works as well as chief exec Harry Longman says it does (see his interview on p22), this could be the golden ticket to improving general practice and helping to save the NHS that £20bn.

Of course, if something sounds too good to be true, it may well be. When I brought this initiative up with my newly qualified GP of a brother-in-law, he was sceptical – reminding me that face-to-face patient contact is at the heart of NHS care and he was taught to be wary of phone consultations. Longman points out that while doctors have to be careful and conservative about the patients they see, by weeding out the people they clearly don’t need to see, those they might not have seen who need to be seen can be seen. That was a lot of ‘seen’s, but hopefully you’ve seen what I mean.

In any case, it may not be right for every practice, but it’s a refreshing approach and it can be a flexible one that any practice could feasibly try. It’s good to see GPs and practice managers changing things on their own initiative, whether or not they have the support of a PCT or CCG budget. There are a lot of ideas out there of how to improve general practice, and it seems much of them, like this Patient Access scheme, relate to strategy, which is something any good practice manager knows lots about.

I’d love to hear what you think of this model, and whether you think it could work, have tried it before etc. I’d also love to hear about any other strategies you have for improving the running of your practice. Please, get in touch on editor@ practicebusiness.co.uk to share your story. In the meantime, hope you have a great extra-long (leap year!) February.

editor

see inside for our guide to managing commissioning

P.10

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

COMMISSIONING 10

12

commissioning news A practice manager’s update on clinically-led commissioning

comment A year in review Roger Hymas takes a rear-window approach to last year in a bid to understand what the next 12 months hold

18 case study

Swan song NHS Worcestershire brings end-of-life care into primary care

PEOPLE 22 interview

Access allowed Patient Access is a new scheme changing the future of

general practice – could this be the solution we need?

26 case study

Community care A new building for Cowplain Family Practice acts as a

community hub and shares services with a private clinic upstairs

MANAGEMENT 30 update

Improve your IT performance What your practice should be doing now to

update its technology

34 clinical

MFM This month: Hepatitis C

Work/life 36

38

top tips Reducing emergency admissions What your practice can do to reduce A&E visits

diary Blogger and practice manager Ann Boyle on covering for a late doctor

sector

06

CQC to inspect 10% of GP practices The Care Quality Commission (CQC) plans to inspect as many as one in 10 GP practices at “significant risk of non-compliance”. CQC officials warned the House of Commons Public Accounts Committee during an evidence session that an estimated 10% of GP practices were at risk of “non-compliance” after a series of pilot schemes last year.

When questioned by MPs on whether this meant that the CQC will visit the aforementioned practices, director of operations at the CQC, Amanda Sherlock responded: “Yes, we will.”

Chief executive of the CQC, Cynthia Bower, stated that GP practices would be investigated if their evidence differed from that of the General Medical Council, though she stated that evidence

The NHS Confederation’s Mike Farrar urges the CQC to prioritise: • focusing attention on greatest risks to patients and patient safety • giving people certainty about what the regulator is looking for • running efficient, proportionate and consistent processes • developing a well-informed workforce that understands the services regulated • delivering value for money • ensuring the public is clear about what it can, and cannot, do.

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news

from the pilots showed GPs were largely honest in confessing to non-compliance in their practices.

Bower told MPs: “One of the things we have been doing is doing some model compliance reviews and seeing where the risk areas are. A proportion of [GP practices] we will absolutely visit, as we believe they may pose a risk to patients.”

Effective regulation The NHS Confederation’s chief executive, Mike Farrar, criticised the announcement, stating that regulation in the NHS should be focused on where it is most needed and the NHS needed an effective and intelligent regulation, not “a simplistic race for more and more inspection”.

“I want to be clear that any large healthcare system needs regulation,” he said. “But we want an effective and intelligent regulator that focuses its attention where it is most needed. It is incredibly important the regulatory system carries the confidence of the public and the organisations regulated. We want the CQC to be a success.”

He said the regulator needed to earn confidence.

“Our members are telling us that the CQC is not always proportionate in its approach and its model of regulation is too generic. We hear inspectors can be inconsistent, processes bureaucratic and guidance inadequate. However, this is not a moment to engage in major structural reform of regulation. History suggests we have had too much of that already.”

Practices in England must be registered with the CQC by April next year.

Practices axe staff due to lack of funding As many as one in five GP practices may be forced to lay off staff this year, with around a third of them having to remove a salaried GP post, a workforce study has revealed.

The survey, conducted by Pulse, revealed that one in seven GP practices are preparing to make reception or administration staff redundant due to funding issues. Of the 250 practices that responded, one in 10 said they would have to make at least one redundancy. Others said they would also lose practice nurses, practice managers, specialist business managers and healthcare assistants.

Furthermore, GPs are likely to face a pay squeeze and two-thirds of practices that stated that they employed a salaried GP, one in 10 stated that they thought they would have to make at least one position redundant.

february 2012 | practicebusiness.co.uk

07

SECTOR | news

clinical news NHS 111: Lost in translation?

Clinical commissioning groups feel the new urgent care telephone number NHS 111 is in danger of “getting lost in translation”, a recent NHS Alliance survey has revealed.

According to the survey, new clinical commissioners feel a lack of engagement with NHS 111, despite the fact that they are the key people responsible for its rapid implementation across england by April 2013. Current clinical engagement appears to be poor and clinical leaders feel this is another example of top-down policy rather than local innovation. only 11% of clinical leaders stated they have experienced “good engagement; my view was taken into account”, with 32% saying there has been “some engagement, but no real ability to affect decision making” and 55% saying there was little or no DIALLING 111 engagement. Also, 77% of respondents said that “there The NHS Alliance makes a number is little scope for local clinicians to shape this service to of recommendations: meet local needs”.

• Support the DH’s plans for an Rick Stern, urgent care lead, NHS Alliance, said: objective peer learning exercise “We remain supportive of the idea and want to work in among providers of 111 pilots partnership with the Department of Health and other • Offer opportunities for wholenational partners to ensure that local commissioners system support are actively involved in the development of NHS 111.”

• Encourage local CCGs to take more active leadership on 111 “However,” he added, “our members currently feel disengaged and believe there is little room for • Make the best possible use of information coming out of the local flexibility. We need to take steps to address this formal independent evaluation now, as otherwise both the 111 programme and the of pilot sites credibility of local clinical commissioning will suffer.

• Allow CCGs to ‘pause’ current While there is support for NHS 111, in principle, there procurement processes that are substantial concerns about the speed and style of have not yet been concluded if they feel they have not yet implementation.” built in enough local flexibility A DH spokesperson insisted NHS 111 services to existing specifications. would bring benefits to patients and commissioners.

“The pilots are enabling us to provide a basis for local design of solutions, and clinical commissioning groups are already positive about how this will enable them to improve access to emergency and unscheduled care,” he said. Although it still plans for an April 2013 roll-out, the DH says it will achieve this under CCG leadership.

Photography: 2006 Channel 4

They said…

“”

“GPs are going to have to be more accommodating to all of their patients’ 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” TV’s Dr Christian Jessen of embarrassing Bodies fame on Pride in Practice, a new patient standard for excellence in lesbian, gay and bisexual (LGB) healthcare that launches this month

25%

The percentage of unfilled ‘on call’ GP shifts in NHS Suffolk since last June

Olympics The London 2012 Olympics could become a hotbed of disease, health experts warn. A series of reports in The Lancet Infectious Diseases journal points out the risks that can arise from mass gatherings such as the Olympics in London, causing “potentially serious implications to health”. The theory suggests that lots of people, packed closely together, can significantly increase the risk of disease spreading, particularly with visitors travelling from abroad. This could result in a significant increase in patients needing access to primary care this summer.

Integrated care The Department of Health is to promote integrated care within the NHS as a result of recommendations made by the NHS Future Forum. The NHS Commissioning Board is to take over the responsibility for finding means by which integrated care can be encompassed into the GMS contract in the future. The report by the independent advisory group found it to be “difficult” for local commissioners within “annual cycles” to judge the value of new commissioning arrangements. The DH recognised that handling CCGs’ multi-year settlement budgets would allow clinicians more stability to commission integrated care.

diary A NEW STRATEGY FOR NHS PROCUREMENT: SECURING THE FUTURE OF NHS SERVICES Manchester Conference Centre 17 April

SSPC ANNUAL CONFERENCE: IMPROVING CLINICAL CARE THROUGH RESEARCH Glasgow Hilton Hotel 24-25 April

(Source: Pulse)

practicebusiness.co.uk | february 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.

february 2012 | practicebusiness.co.uk

In search of a narrative

Roy Lilley asks: what is the point of life, the universe, and well, commissioning?

One of the reasons the Lansley reforms of the NHS are so unpopular is that there is no ‘narrative’. Narrative? Well, it’s a sort of jargon word used by communications and PR-wallahs. In plain English: an explanation. A reason. There is nothing to tell us why we are doing this.

Downing Street did try. At the time of the Future Forum listening exercise they came up with: outcomes were not good enough, the public isn’t satisfied and management costs were too high.

The Government has since been mired in trench warfare about outcomes. They lost the battle on public satisfaction. Indeed, their own, DH website shows a 92% satisfaction rating among the public who have recently used the NHS. That leaves management costs. In business generally, 16% of people are involved in management.

In the NHS the figure is 13%. The all-up management cost is five per cent of the total.

By the way, in the US, where they have a mixed economy of supply-side providers and the sort of system we are heading for, management costs account for 20% of the total budget. So, another fox is shot!

Nevertheless the reforms trundle on and now the management arrangements for the NHS Commissioning Board have emerged. So, in pursuit of ‘smaller management’ they have announced: The headquarters of the NCB will be in Leeds with a smaller branch office in London. I wonder how much will be spent on rail fares between London and Leeds?

The SHAs are being given the push and they will be replaced by four ‘sector’ organisations – if you call them SHAs they will come to your house and burn it down.

Primary care trusts disappear and 50 new organisations will emerge. If you call them PCTs they will come to the ashes of your house and take away your children.

There will be around 200 people working in the ‘sectors’, 860 in the NCB offices.

Two and a half thousand will be working in the ‘don’t call them-the PCTs’.

So, in total 3,560 staff where there used to be 8,000. Substantial job losses are inevitable. The total running costs will be contained within a budget of £492m. For the record that is about half of what is being spent now.

You don’t have to be a finance director to see there is a huge cut in the costs of running the NHS. However, there are hidden costs. For example, in London they have spent £7m on training for GPs to understand commissioning and rudimentary management. I expect, if you have a dig around you’ll find similar sums being spent on similar training where you are.

So, after all the brouhaha what are we left with? SHAs and PCTs but fewer of them. All of which could have been achieved without the 364page Health and Social Care Bill.

As far as I can see, we are still struggling for a narrative?

After the brouhaha, what are we left with? SHAs and PCTs but fewer of them, which could have been achieved without the 364-page Health Bill

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commissioning

10

Empowering practice managers in CCGs

all systems go for CCGs Almost 95% of all clinical commissioning groups have passed their strategic health authority (SHA) risk assessment and will be permitted to take on primary care trust (PCT) commissioning budgets in April.

Of the 243 CCGs in England, 62% were given a ‘green’ rating by their SHA cluster, six per cent were given a ‘red’ rating and 33% were rated as ‘amber’.

The CCGs were assessed by their SHA clusters on the basis of their engagement with member practices, geography and patient population, relationship with local authority boundaries and size.

The groups were required to undergo a risk assessment of their configuration by December 2011 as the first step towards authorisation by the NHS Commissioning Board.

The CCGs were rated as green, red or amber on four areas, three of which related to requirements in the Health and Social Care Bill and the fourth was designed to determine the size of the CCG in relation to its financial viability.

No London CCGs were rated as red, nearly all (96%) of CCGs in the North of England SHA were rated as green or amber, while CCGs in the

Midlands and East SHAs were most likely to get a red rating overall.

But are GPs ready?

A survey carried out by the Family Doctor Association has revealed that half of GPs would like to know more about the pros and cons of clinical commissioning groups.

Twenty-five per cent of all GPs surveyed said they would like to know what the bad points to commissioning are, and a similar number said they would like to know the good points, which indicates a level of uncertainty about what CCGs are hoping to achieve and the overall effects of the introduction of clinical commissioning groups.

The top requests for learning drawn from the results included, a Commissioning for Dummiesstyle guide book for GPs, and “nuts and bolts courses” on commissioning. GPs also requested information on how the changes will affect their patients and how their own clinical work might be affected, indicating that there is little guidance from the top on how the general running of the practice, and how GPs continue to do their day job will change.

commissioning in context

DH gives £100m to commissioning groups The Department of Health is planning to hand over £110m to emerging clinical commissioning groups to improve local services throughout the winter period.

Many CCGs already hold budgets and already £29bn has been devolved, however, Health Secretary Andrew Lansley stated that this was the first time the DH had “specifically identified funding for PCTs to delegate to prospective CCGs for patient care”.

The DH has recommended that CCGs spend the money on local services that meet the needs of their area to prevent any unnecessary hospital admissions. The DH has also stated that the funding is not to be spent on additional running costs.

The CCGs are to inform the DH on how they intend to spend their money, though decisions on how to use the funding will be made by CCG after being signed off by PCT clusters.

The DH stated that the funding had become available because of “good management” of its central budgets.

february 2012 | practicebusiness.co.uk

Practice insight

An integrated, user-friendly ‘Bureaucratic system 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.

nightmare’

Despite this additional funding, CCGs face complications over tendering for services due to EU proposals stating that CCGs must competitively tender.

If the plans are passed, CCGs will be required to perform full procurements on all services under any qualified provider, something that deputy chairman of the General Practitioners Council (GPC), Richard Vautrey, said would cause a “bureaucratic nightmare”.

However, a DH spokesperson said that the plans are not to have any effect on the NHS’s procurement requirements.

They said: “Aside from enabling patients to choose the best providers for their needs, a key benefit for PCTs and CCGs of commissioning services on an any qualified provider basis is that they will not need to undertake competitive tendering, as long as they work within DH guidance. The directive won’t change this.”

“”

They said…

“The full implications of [the Health Bill] remain poorly understood outside the NHS, partly because politicians are reluctant to stand up and explain them. The result is a sense of sleep walking into some serious difficulties. We fully expect a number of NHS organisations to fall into difficulties this year, and the problems will only grow unless action is taken.”

Chief executive of the NHS Confederation, Mike Farrar on why he believes giving family doctors control over NHS spending would make it increasingly difficult to achieve the £20bn of cutbacks expected in the NHS by 2014

Practice Business to launch new commissioning magazine The team behind Practice Business is launching a seperate commissioning magazine next month called Commissioning Success, as an off-shoot of this section. It will be targeted at decisionmakers and participants in commissioning, from board members to shadow groups. Because of its 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”.

“We are able to target specific groups of patients that we see regularly and proactively manage their care”

A practice in Nottingham is one of the latest to upgrade to EMIS Web, and staff Tony Oram there are already finding the awardThis month we talk to Tony Oram, practice winning system intuitive and user-friendly. manager at the Saxon Tony Oram, practice manager at the Cross Surgery in Saxon Cross Surgery, which serves 6,800 Nottingham, about patients, says switching to EMIS Web from how switching to EMIS their previous non-EMIS system has led to Web has helped his timesavings and improvements in the care practice to streamline data gathering and of patients with long-term conditions. proactively manage “The real stand-out feature for us is patients with long-term search and reports,” he said. “It is userconditions friendly and we get the results there and then. Previously we had to run some data searches overnight; others took three to four hours.”

Speed and ease of data gathering has helped the GPs to be more responsive to the needs of patients with long-term conditions such as diabetes. “Our diabetic lead GP asked for a report on HbA1c control. We ran the search in minutes and by the afternoon, he was contacting patients with poor control to come in for a check up,” said Oram. “With the help of EMIS Web we are able to target specific groups of patients that we see regularly and proactively manage their care.”

The GPs also like EMIS Web’s pathology module, which delivers test results immediately to their inbox, rather than to the store and retrieve facility in the previous system. And the future?

Oram plans to introduce EMIS Access, which allows patients to book and cancel appointments online, and SMS texting, to remind patients of appointments.

“That’s exciting for us and could be a real www.emis-online.com breakthrough in reducing DNAs.”

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COMMISSIONING | analysis

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 regular columnist on commissioning for Practice Business. You can reach him to clarify any issue at rogerhymas@btinternet.com

The final countdown

Forget the Olympics, or 21/12/12, are you ready for 1/4/13 – commissioning’s day of reckoning? Roger Hymas reminds us that it’s 240 working days away

february 2012 | practicebusiness.co.uk

This is the year of the countdown clock. If you’re reading this on 14 February, it’s 164 days to the opening ceremony of the London Olympics. I’m pretty sure we’ll be reminded by the media as we hit every milestone: 200, 100, 50 and 30 days to go.

But the other countdown in which we are all involved in is the run-up to the start of GP-led commissioning, scheduled for 1 April 2013. That’s 411 days away.

Of course, it’s really much closer because I’m assuming that most commissioner weeks only have five days, not seven. Then there are bank holidays, Christmas, the New Year, Diamond Jubilee celebrations – all of which have to be deducted – plus four weeks’ annual leave, which means that there may be as few as 240 working days between now and 1.4.2013.

Regular readers will know how much I witter on about how complicated commissioning is. Why I make this point is that it’s going to be a huge challenge for most CCGs to be in good enough shape to be effective commissioners by the due date. There is so much that has to be learned and implemented and for those involved – GPs and practices included – and on top there are the competing and familiar demands of the day job which just won’t go away.

The other big issue is the shrinking resource to execute the commissioning challenge. If we go back two years ago to the halcyon days of PCT commissioning, you’d find that 250 people would have been employed in commissioning in each trust. Multiply 240 days by 250 people and you get close to 60,000 man days a year. Since then, PCTs and SHAs have been clustered and practically, but not quite, decimated. I’d guess headcount is around 40% of the numbers involved at their peak. This means that the 60,000 man days might now be no more than 36,000, about 7,000 per PCT cluster.

Now it doesn’t stop there. The number of NHS administrative people actively involved in commissioning proper is destined to fall again. A critical milestone in the countdown process is the passing of the Health and Social Care Bill, which has to happen in the next 60 days or so before this session of Parliament ends. The passing of the act will be the starting gun for the inception of the NHS Commissioning Board and for the appointment of around 4,000 jobs at board headquarters and across the NHS in England. Most of these will be current PCT staff. It also means that if there are 100 CCGs by the year-end (and I’m betting it could be even fewer) there would be 40 NCB supervisors for each CCG. Perversely, this means that we could find ourselves with a headcount number that is greater than for individual CCG staffing. Think of it as a bit like the Navy having more admirals than ships.

NCB people will have to fill their days with ‘useful’ work. Expect, then, that there will be lots of important authorisation questions that need to be answered by CCGs. The NCB will invoke good governance and due process, so I’m expecting that there will not be a lot of time for a great deal of real commissioning to get done in CCGs. Of course, it’s not the job of the NCB to do commissioning. Its job is to supervise the commissioning process, which is the job of the CCGs. All this means that there’s going to be significant disruption for CCGs just when they need lots of time in the run-up to taking over commissioning.

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COMMISSIONING | analysis

Sorry, but it gets worse. A huge amount of commissioning talent will also start to leak out of PCTs into the NCB. By the autumn, this could have become a significant black hole as a lot of PCT commissioning staff would have quite reasonably and pragmatically exited for the more secure, higher paying jobs at the NCB. Well, I would, wouldn’t you?

As this happens, commissioning expertise and memory will start leaking away: more commissioning capability destined for the ether. The worst case scenario is that there will be very few high quality experienced commissioners left in and around CCGs to provide the direct hands-on support for GPs and PMs. Now, to return to the knotty question of exactly how many CCGs there are going to be on 1 April next year. Certainly, not the current 250. I’d estimate it is going to be 50 or 100. This implies the possibility of even more musical chairs as people are reassigned or clustered into super CCGs. Just imagine the impact of all of this upheaval on the people currently toiling to get their CCG going. It’s beginning to feel like the great migration across the East African Rift valley, with literally thousands on the move. All of this uncertainty is not, of course, the sort of work environment that gets the best out of people, particularly when they have no idea of where their next job will be – or whether there will be one at all – as all the jockeying for the available posts takes place.

The bottom line is that in all of this merry-(or not so merry)-go-round, I really do hope that many of you PMs are going to find some time to be involved in the commissioning challenge. If I’m right – and I really hope that I’m not – I think there’s going to be a huge pull away from GP commissioning by many of those currently involved. Indeed, it’s just possible that we might have already reached the zenith of enthusiasm for GP-led commissioning. The whole point of the white paper and the strategy around it is that GPs and their practices have to stay fully engaged and gain control. This means that there is a large army to be mobilised and motivated – about 9,000 practices and the best part of 40,000 GPs. That’s vital because there is just so much to do. Hundreds of outcomes measures have to be delivered and scores of local care pathways to be designed and installed. Then there are practice budgets to be set and allocated, and performance measures to be put in place.

Throughout all this upheaval, the countdown clock to 2013/14 will just keep ticking. And with the passing of time, real, maybe irrecoverable, commissioning opportunities are already starting to slip away. This year’s ‘Commissioning Intentions’ either never happened or did so without much practice involvement.

I did a check on Google and there was very little evidence of even PCT participation. The public and patients seemed to get no look in at all. The Operating Framework – published in December 2011 – says that GPs and practices should be involved right now in drawing up the 2012/13 commissioning landscape. But, are you?

In last month’s Practice Business, I hinted at how much we will rely on PMs as the people to pull us through. Tell me just how many of you in practices

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With the passing of time, real, maybe irrecoverable, commissioning opportunities are already starting to slip away february 2012 | practicebusiness.co.uk

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COMMISSIONING | analysis

are currently involved with the real nitty-gritty of commissioning? Bringing the commissioning annual calendar up to date, PCTs and CCGs should at this moment be knee-deep in the contracting season, when commissioners are locking horns with providers, negotiating the ‘terms of trade’ for 2012/13. Get this wrong at this time of year and you’re lumbered with the contract for 12 months.

Hospitals are now formidable business- and negotiating-machines. Given half a chance the trusts will walk all over you. PCTs were getting better at holding their corner up to 2010, but the white paper and its aftermath has taken all the wind out of their sails. With the shrinking of the PCTs, the drive, the energy and the negotiating power have seemed to ebb away. Left to their own devices hospitals will destroy NHS finances as they hoover up as many of the pounds that are available in the local health economy. Many of us were relying on effective commissioning to put a brake on their natural tendency to treat, grow and expand, but this opportunity is now in real jeopardy. If you want a concrete example, go into the fine print of this year’s national contract and what you will find, which is particularly scary, is that hospital activity cannot be capped for 2012/13. This means that only GPs can have any real impact on managing demand. The real imperative for commissioners – sorry I make it in nearly every column – is that reducing hospital usage is the principal challenge of everyone involved in commissioning and potentially the only route to salvation.

So the countdown is under way and the momentum of events seems unstoppable. Our last chance is for commissioners, whoever they will be, to make bold interventions in a year when nearly everything is changing around them and the forces of disruption could easily tip and take us to destruction. I’m sorry but I really do see it as seriously as that.

So what needs to be done? I’d like to suggest the following: • The DH should leave as much commissioning resource in CCGs as possible for as long as possible. Arguably, the authorisation process should be driven from inside CCGs; it should be achieved through accomplishment, not by passing spurious tests. Also, there’s no point in having more checkers than do-ers.

• Focus on change that makes a real difference, putting effective commissioning processes and programmes that really deliver in place.

• The NCB should second their staff to CCGs until 31 March 2013 so that the maximum support can be available to deliver quality commissioning.

• The system should cherish GPs and practice managers. It needs to lighten their admin load, not increase it. The powers that be should send them lots of help; they should curb their natural tendency to ask for even more reports and returns.

• Everyone should be looking for simple standardised, but quality, commissioning tools to help deliver the major commissioning challenges of securing the best outcomes and lowering care pathway costs without compromising quality. Every CCG inventing its own solution is not the right answer.

Finally, if the process is in danger of disintegrating, somebody needs to make the bold decision to put GP-led commissioning back by a year to April 2014, and ensure that in the meantime the commissioning basics are securely put in place in every CCG. If we get this wrong I think we could ruin the NHS for all time. I don’t fancy a countdown to Armageddon. Do you? february 2012 | practicebusiness.co.uk

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COMMISSIONING | case study

Swan song NHS Worcestershire brings end of life care out of anonymous hospitals and into the community. HELEN NORTHALL, CEO of PCC, explains how better commissioning can improve people’s lives until the very end

» february 2012 | practicebusiness.co.uk

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COMMISSIONING | case study

Health services have an understandable focus on getting sick people better, but recent years have seen a drive to improve the care of dying people.

NHS Worcestershire has put itself at the forefront of that drive, partly by signing up to the Marie Curie Delivering Choice (MCDC) Programme. One of the key indicators for improving end of life care (EoLC) is how many people are able to die in the setting of their choice.

Although most people say they would prefer to die in a setting other than hospital – usually their own home – more than half of deaths still take place in hospital.

Using the MCDC programme as a starting point, NHS Worcestershire has reduced acute admission costs by an estimated £400,000 in 18 months by introducing a range of initiatives covering primary care, community nursing, ambulance services and acute care.The percentage of deaths taking place in hospital has fallen from 45% to 42% as a result. Both the savings in acute care – which are reinvested in community services – and the improved record in meeting people’s wishes to die at home are particularly impressive.

Felix Blaine, the local GP who has been one of two clinical champions for the initiative, says: “We really wanted to engage with primary care and that is why we came up with a local enhanced service specification. In the LES we are trying to enshrine standard good practice but also highlight new ways of doing things and change the culture.”

The LES draws heavily on the national tool for EoLC in the community, the Gold Standards Framework. It includes a requirement for a lead GP from each practice to attend a full day’s training and for other GPs to undertake two one-hour modules developed by consultants in palliative medicine.

The primary care initiative is credited with a three-fold increase in the numbers of patients on the palliative care register in 18 months. Being on the register appears to significantly increase the prospect of a patient dying in his or her preferred setting. Fewer than one in five patients on a register die in hospital. The registers help ensure that anyone involved in making decisions about an individual’s care is aware that they are nearing the end of life. It is an important factor in encouraging professionals, the individual and family to engage in advance care planning.

Such advance planning can help professionals and carers respond to a deterioration in the individual’s condition in a way that respects their wishes and preferences. Too often the response

to such crises is an emergency admission to hospital.

The project and local commissioners have targeted the high rates of emergency admissions out of hours that meant people were admitted to hospital to die. Regular meetings with clinical staff from the out-of-hours provider and district nursing teams, coordinated by the MCDC project team, identified how such admissions could be reduced and the education needs of OOH GPs. Every OOH GP completes an EoLC module developed by the palliative care team.

The initiative has also created new posts or expanded roles and responsibilities, particularly for several specialist palliative care nurses and health care assistants.

Nurse specialists in palliative care now provide a weekend service that is aimed at preventing emergency hospital admissions.

The nurses have averaged around 100 contacts a month, assessing and supporting patients face-to-face but also advising clinicians.

In response to demand from both clinicians and relatives, two health care assistants are available each night to support patients and families where planned care arrangements had suddenly become untenable. The Rapid Access to Trained Carers at the End of Life (RACE) service has cared for 60 patients in six months and is thought to have prevented at least 20 admissions – with overwhelmingly positive feedback from service users.

Other steps include: n New forms filled in by GPs and held by the ambulance hub.

These inform crews of any advance care plans or the preferences of any patient nearing the end of life. This information can influence whether the person is taken to hospital by ambulance – resulting in the form saving £74,000 in its first six months. n Supporting the local Dying Matters campaign to encourage more conversations – and therefore planning – about death and dying. n Improved anticipatory prescribing – including the use of justin-case boxes containing drugs that are kept in a patient’s home in case their needs change suddenly. An audit at six months showed 48 of 66 patients had accessed the drugs – saving £65,000 through admission avoidance, fewer calls to OOH pharmacies and hospice admissions. n Improved arrangements for dying patients being discharged from the acute trust.

The memory of how a loved one dies stays with relatives and friends for many years. There is only one chance to get it right and health services are working together in Worcestershire to ensure that happens for a lot more families.

The memory of how a loved one dies stays with relatives and friends for many years. There is only one chance to get it right

practicebusiness.co.uk | february 2012

ABI testing in just five minutes Peripheral arterial disease is present in 20% of men and 12% of women over 50, and it becomes increasingly common with age.

Testing for the ailment forms an important part of primary care and can take up to halfan-hour of a clinician’s time. Now, with the help of technology, a healthcare assistant can make the diagnosis in just five minutes.

Peripheral arterial disease (PAD) is a common condition in the UK. Around one in five men and one in eight women aged 50-75 years have the illness, which equates to 1.6 million men and 1.1 million women. The disease becomes increasingly prevalent as the population ages and the nation’s GP practices must be prepared for an increased demand for testing and treatment of PAD. PAD, also known as peripheral vascular disease, is the narrowing of one or more arteries in the body, and mainly affects the arteries that take blood to the legs. Symptoms include pain in one or both legs when the patient walks. Increased risk factors for the condition include smoking, obesity, age, ethnic group and a strong family history of PAD. If PAD is left untreated it can lead to infection, tissue damage and, in some cases, amputation. It can also cause atherosclerosis in the carotid artery, which delivers oxygenated and nutrient-rich blood to the brain. This can cause a stroke.

Treatments for PAD include quitting smoking; taking regular exercise; cholesterollowering medications; aspirin or reducing blood pressure.

Diagnosis of PAD is confirmed by doing an ankle brachial index (ABI) test, which helps screen for patients who need to be referred for a CT, MRI, or ultrasound scan to assess the severity of the condition, which can be expensive.

Save 25 minutes per patient Currently, ABI testing takes considerable time and needs to be carried out by a qualified clinician. Normally, it involves using a vascular Doppler ultrasound device and an aneroid blood pressure monitor. This takes up 30 minutes of the patient’s and clinician’s time. For example, in a three-hour surgery, six patients could be tested. Furthermore, these Doppler test results require clinical interpretation, adding to the time required to fully diagnose patients.

New technology on the market promises to reduce this time significantly, while taking the clinical interpretation out of the equation.

The Huntleigh Dopplex ABIlity takes just five minutes per patient without the need for a clinician, so in that same three-hour surgery, 33 patients could be tested by a healthcare assistant.

The Dopplex ABIlity also features a built-in thermal printer and is supplied complete with batteries, printer paper and a set of standard cuffs from Williams Medical Supplies, which also offers onsite training and technical support for users.

We are treating patients with compression earlier since the waiting time for Dopplers has reduced

ADveRTORIAL

THe BUSIneSS CASe Davinia George is a practice sister at Regis Medical Centre in Rowley Regis and has been using the Dopplex ABIlity for six months. She has found it easy to use and has been enjoying the three to four minute reading times.

Her practice mainly uses the device for the treatment and management of leg ulcers, but is receiving more referrals to assess arterial flow as part of vascular assessment. They are hoping to reduce the occurrence of leg ulceration by encouraging GPs to refer patients with venous eczema and oedema, thus saving nursing time and resources, as well as patient discomfort.

While a full leg and holistic assessment are also required at the time of the Doppler exam, Davinia has found the whole procedure, including a quality assessment, can be completed in 30 minutes with the Dopplex ABIlity, where previously it would have taken an hour.

The other benefit of the ABIlity is that it is much quicker to test patients with healed leg ulcers using compression hosiery, as guidelines suggest regular assessment and monitoring when compression is used. “We previously found it difficult to find time to do this,” she says. It only takes one nurse to use the ABIlity at Regis Medical Centre, whereas before it took two. Furthermore, the practice has been training healthcare assistants to use the device as well.

“A recent leg ulcer audit has found we are treating patients with compression earlier [since] the waiting time for Dopplers has reduced as we are able to do more Dopplers in the same amount of time,” Davinia concludes. “In turn, this reduces healing rates, [which is] great!”

10 ReASOnS TO CHOOSe ABILITY 1. extremely easy to use and fully automatic – minimal training required 2. no need to rest patient for 15 minutes – thus reducing total test time 3. Rapid bi-lateral ABI measurement in three minutes – simultaneous measurements reduces time 4. ABI can now be undertaken by healthcare support staff – makes the measurement more cost effective 5. no need to remove patient’s socks or tights – maintaining patient comfort and dignity 6. easy to apply four-cuff system – improving patient experience 7. Portable and powered by mains or rechargeable battery – for home or clinical environments 8. Integral printer for documentation of results and waveforms – instant hard copy for patient notes and reimbursement 9. Automatic interpretation of ABI – reduces operator error 10. Accurate reproducible results.

To order the Huntleigh Dopplex ABIlity, priced at £2,300, contact Williams Medical Supplies on 01685 846666 or visit www.wms.co.uk.

Access allowed

one-to-ones with the people making a difference

people

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february 2012 | practicebusiness.co.uk

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PEOPLE | interview

Patient Access is a movement created by 40 practices and serving 350,000 patients. When practices join, they find working practices transformed. It works by GPs speaking to patients before they come in – reducing appointments and DNAs, while making patients happier. JULIA DENNISON speaks to chief exec HARRY LONGMAN

GP practices across the country are taking revolutionary steps to resolve the kind of issues that have been plaguing primary care and the wider NHS for years – longer waiting times, soaring A&E visits and dwindling patient satisfaction. The solution to these problems for a pioneering few, comes in the shape of Patient Access, a group of 40 practices from across England that have discovered a way to reduce emergency referrals, wait times and didnot-attends (DNAs), all the while leaving clinicians, practice staff and their patients happier for it. They do this through a remarkably simple process of getting GPs to field patient phone calls.

Patient Access was formed as a social enterprise in 2011 and its method works like this: the patient calls the practice, the receptionist takes their details and the GP calls them back at a time convenient to the patient. Through this process, the GP is able

to determine whether they need to see the patient, diagnose them over the phone or send them elsewhere for tests. Evidence has found that only around one in three patients actually need to be seen.

It’s not rocket science, but the results have been extraordinary for the participating practices: on average, patient visits to A&E have dropped by around 20%, there has been an 80% reduction in waiting days for the patients and an 80% drop in DNAs. It also saves the GPs’ time, ensures they’re seeing the patients who need to be seen and helps improve doctor-patient relationships, as well as the patient’s overall satisfaction with their surgery.

The man behind the initiative is Leicestershire-based chief executive Harry Longman. An engineer by training, he was working on a research project on behalf of the NHS when he came across practices that had found success with this access model. He worked to bring those practices together for a conference, sponsored by the Department of Health, which would lead to the mandate for a social enterprise. All of this has pretty much occurred within the last year, so the group of practices is just now in the process of telling its story.

A BIT OF BACKGROUND “The idea for the method was invented by probably 18 different GP practices at different times over the last 10 years,” Longman tells Practice Business. “Because it happened in isolation, they didn’t know about each other and locally they thought they were seen as quite weird.

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practicebusiness.co.uk | february 2012

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PEOPLE | interview

But I discovered them initially because I was investigating the links between A&E attendance and access. I found some GP practices were particularly low on A&E admittances and I started digging into the reasons. I must have phoned over 200 practices.” He soon discovered that a number of these practices had remarkably high numbers of patients who, when surveyed, admitted that it was very easy for them to speak to their doctor.

He also found that at the top-end, around one in five had the same idea of having the GP phone the patient back before seeing them in person.

It was these practices that he started grouping together to become Patient Access. “The interesting thing is they were very diverse,” he says of the group. “We had people from Tower Hamlets in East London; people from rural Gloucestershire; quite a lot in Cornwall; Manchester; and Middlesbrough – all saying the same thing. “This is not some kind of centralised, anonymous call centre system,” he continues, “it’s the ordinary patient calling their ordinary surgery.” It also means patients are better able to get through to the practice in the morning.

longer the patient waited, which meant the rate for same-day appointments was very low. The access model allows for all appointments to take place on the same-day because only the necessary appointments get through, so DNAs fall as a result.

The receptionists like it because the pressure of disappointed patients is taken off them. “This idea of the dragon receptionist is not really about receptionists – it’s really

COST SAVINGS Practice managers have reported cost savings in salaries and locum sessions as a result of the method – with one 6,500-patient practice reporting savings of £80,000 a year. “The means of dealing with a patient is so much more efficient, so that excessive clinician time requirement goes,” explains Longman.

If this way of working is so successful, what’s stopping more practices getting involved? Longman says it’s not the technology or the software that puts practices off – most practices’ existing technology will suffice, rather a concern for patient safety.

With fielding so many patients on the phone, some worry that patient conditions risk getting looked over.

“Practices that have been doing this for 11 years know it’s a safer method because they’re seeing the people who otherwise might not get an appointment.”

Patient Access does charge a fee (equivalent to a few days of locum cover).

Of course, it is something practices can do themselves. “There’s nothing to stop them, and I’ve put lots of material and research on the web,” admits Longman, who says the benefit of working with the group is speed and a tailored transition to the new working method. “There will be times when you think: ‘Crikey, this is chaos, I can’t manage this.’

It’s about having confidence [in the fact] that others have gone through it before.” Under the model practices have to be prepared to become more available to their patients.

Evidence shows that the flow of patients will go up at first under the model, but soon plateaus. One of the greatest benefits, he says, is that practice staff are going home on time.

Longman is dedicated to promoting the Patient Access way of working to GP practices all over the country, while continuing his research into improving healthcare and the NHS. He has been appointed as a fellow at York University and is in conversation with the DH about further collaboration. CCGs and PCTs are asking him to help support their practices. If this system works as well as he says it does, it could just be the solution everyone’s been looking for.

There will be times when you think: ‘Crikey, this is chaos, I can’t manage this.’ It’s about having that confidence that others have gone through it before

REDUCING EMERGENCY REFERRALS During his time researching the NHS, one of the biggest problems Longman noticed was the rise in demand for emergency care – despite the health sector’s best efforts to curb it. He decided to investigate why there was this variation between practices and whether it could be affected by the way practices operate. “It’s all very well saying low deprivation, or patients with a long way to hospital have lower emergency demand, which is true, but so what? It’s true that the elderly population has more demand on A&E, but you can’t change that,” he says. It was then he started looking for something that could be changed at practice level.

REDUCING WAITING TIMES AND DNAS Longman researched DNA rates against the number of days the patient had been waiting for an appointment at several different practices. He found the DNAs went up the february 2012 | practicebusiness.co.uk

about the system that they have to work in,” says Longman. “They’re really lovely people who love talking to patients, but a lot of them are between a rock and a hard place.” Under the new system, the role of the receptionist becomes about putting the patient in touch with the doctor, and therefore, the GPs can spend longer than 10 minutes in-person with the patients who need it. “Patients love it, because they think it might be saving me a trip – or from taking time off work. There’s a huge amount of frustration [out there],” he adds.

A MATTER OF LOGISTICS Under the system, the GP starts the day with a blank sheet – apart from the odd appointment booked ahead by a patient unable to attend on the same day. How GPs divvy up their day is up to them. Most patients call in the morning, so participating practices tend to put doctors on the phones then. “You organise your day to meet that expected demand,” explains Longman.

“The GPs are broadly going to spend the early part of the day doing phone calls and broadly the middle and the later part of the day seeing the patients who they spoke to earlier – but you don’t have to make it rigid. The whole point is you’re shaping the service around the patient’s need.”

G N UP T H O

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YO U R G U I D E TO

commissioning HAS LANDED A new bi-mo

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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.

Be one of the first to sign up and receive a six-month subscription for free (worth £69.99) commissioningsuccess.com editor@intelligentmedia.co.uk BROUGHT TO YOU BY THE TEAM BEHIND

PRACTICEBUSINESS

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people | case study

Community care Cowplain Family Practice was operating in just a third of the space it required. With an anticipated increase in patients, the requirement for a new premises became very evident. Practice manager Karen Jeffries tells Julia Dennison about her recent new-build project This time last year, Cowplain Family Practice was not fit for purpose. The 7,900-patient practice in Hampshire was operating out of what the staff likened to a shed, which was falling apart around their heads and couldn’t accommodate the practice’s patients – particularly when a recent merge with a local practice saw numbers soar.

It’s no surprise Cowplain had the worst-rated facility for a GP practice in Hampshire. For years, the four-partner february 2012 | practicebusiness.co.uk

practice had been dreaming of occupying a space that was adequate and could give them the capacity to expand. This dream became a reality when, thanks to a joint venture with health and social care property provider Ashley House, a new building was finally built.

When I visit business manager Karen Jeffries, the new building is just over three months into its opening, which was seven years in the making. The new site

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people | case study

FACT BOX Practice Cowplain Family Practice Partners Four (increasing to five soon) Clinical staff Four GPs, a GP registrar, healthcare assistant, and four nurses (a salaried GP is about to start) Support staff 10 Patients 7,900 Business manager Karen Jeffries Time in role Three years Background Prior to her role at Cowplain Family Practice, Karen Jeffries was practice manager of a local practice.

comprises 10 consulting rooms and two treatment rooms, alongside a back-office space. Finally, after being ranked as the most recommended GP practice in the country on NHS Choices, thanks to its top-notch customer service and non-appointment-based system, it can live up to its reputation.

This project has certainly been long deserved. Prior to the most recent project, the practice had been lined up for a LIFT development project funded by the PCT. As a prelude to this, the PCT had bought two bungalows on the current site that it marked for demolition to create a new site. The project fell through when money was redistributed to another PCT project and the practice was left to deal with the bungalows, the land, and a retiring GP who occupied a building on the site.

The partners approached Ashley House hoping the firm would help them with the development of a new premises to lease, and the rest was history.

When Jeffries joined the practice in 2009, she arrived at the right time to help with the proposed merger with the retiring GP’s practice and the new building. “I came here because I was excited by the project,” she remembers. “I wanted a challenge.”

Her first task was to oversee the integration of the 1,000 extra patients into the practice after the amalgamation. This required her to be organised and ensure everything worked to plan, with as little impact as possible on patients and staff. “I knew it was going to be a real challenge,” she says of taking on 1,000 patients. “Not only because they were coming from a single-handed practitioner where they had very different expectations, but also because we were accommodating them in a building that was crumbling with no extra staff – we couldn’t put any more staff in because of the space, and we were constrained by that the whole time.”

With this in mind, she was particularly motivated to help the GPs fulfil their vision of a new practice. “I saw my role as bringing it all to fruition,” she explains, “actually being the project manager from the practice’s point of view.” This included overseeing the project and ensuring it was built to plan, as well as organising the move and making sure that went smoothly.

Although it now has the space, the practice is taking staff recruitment slowly due to limited funds.

“Obviously, the money follows the patients,” comments Jeffries. “We want to increase our patient base, and with that will come the funding.” As a first step, the practice is taking on a new salaried GP, who is due to start shortly.

Having a constrained budget is a challenge the practice has had to contend with for quite a while, much like other practices across the country. Jeffries has been

proactive about making savings where she can. She meets monthly with a group of seven practice managers from the Waterlooville area and this has proved profitable when they needed a new phone system. “We have good links with other practice managers in this area so we looked for who else was looking for phones and went in together,” she explains. “As a result of that I think we’ve got a much better deal. So it’s looking at how we can do that with lots of big spends.”

A private practice Cowplain Family Practice occupies the ground floor of the new, purpose-built primary care centre. This has left the upper floors of its multi-storey building available for use by a separate organisation that hopes to run a number of private and complimentary healthcarerelated services out of its treatment rooms, including an NHS dentist (it’s currently still a building site when I visit). Two of Cowplain’s GP partners have shares in the venture, so there may be future opportunity for collaboration. This and a planned pharmacy on site will put Cowplain on the map as a veritable community hub.

Jeffries works closely with Julieanne Page, the operational manager for the upstairs development.

“Although it’s separate – we’re NHS and they’re mostly private – we’re going to be sharing a building,” Jeffries comments. “So it’s looking at the facilities management side of things – she’s going to be using the same caretakers as us and the same suppliers for certain services. I know that they’re looking at some NHS contracts as well, so any additional services on site are going to be good for our patients.”

As operational manager, Page is tasked with promoting the empty rooms upstairs, as well as ensuring everything runs evenly once they are occupied. She’s currently been working with local clinicians who are in need of the extra space. “It must have a medical perspective to it,” she says when I speak to her about the businesses that might be renting the space. “We have a client that specialises in electrolysis. She is keen to work with the gynaecologist [as] women who have polycystic ovaries and hormone problems often need help with professional hair removal. Many of our clients want to work closely with local hospital consultants.”

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We want to use the building, not just for the practice, but also as a community hub practicebusiness.co.uk | february 2012

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people | case study

Page also sees definite crossover between the GP practice and what she has to offer. “Karen and I are two separate organisations, but it’s very much a partnership.

It’s a case of I get things into the building that could benefit the GP practice, or Karen gets enquires that could help me.”

Unique selling points Cowplain is a unique GP practice in a number of different ways. One of those being that it operates walk-in surgeries without appointments. This proves very popular with the patients – 80% are happy to keep it that way – and it was this that Jeffries believes contributed to the practice being ranked as the most recommended practice in the country, thanks to its positive feedback on NHS Choices. However, it can be difficult to manage.

For example, if 10 patients walk in the door five minutes before the end of a surgery, they will all be seen. But she sees this non-appointment approach as the practice’s “unique selling point”, so is determined to keep it going.

“It’s what differentiates us,” she adds.

When the practice took on the additional 1,000 patients, it had to cancel its phlebotomy clinics due to space constraints. As soon as they moved into the new premises, the clinics were reinstated and have been extended further. The practice is now also able to host a counselling service on behalf of the community called italk. “We’ve also had approaches from other practitioners asking what they can do,” she adds. A large boardroom on site allows the practice to open its doors to community events too. She adds: “We want to use the building, not just for the practice, but also as a community hub.”

The project has certainly allowed the practice to extend its outreach into the community, and a number of local businesses are supporting this. The reception’s granite top, for example, was donated by a local firm, while another local community group is donating stained glass for the screens in the waiting area. Some enthusiastic patients even volunteered their fundraising services to raise over £3,000 for the practice. As a by-product of this initiative, the surgery is looking to set up a ‘Friends of the Cowplain Family Practice’ group. “I think the patients see this as a community hub as well,” says Jeffries. Two weeks after the practice opened in October, it held an open day and flu vaccine clinic, which saw an excess of 500 attendees. “What we’ve wanted to do all the way through is take people with us,” she says, “because our patients have been waiting for this for seven years as well, and were also disappointed when the previous scheme failed.

So it’s exciting for the patients too.” february 2012 | practicebusiness.co.uk

Top to bottom: New reception, staff room and Cowplain logo

business intelligence and management sense for practice managers

management

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Improve your IT performance How innovative are your practice’s IT solutions? Is email about as revolutionary as it gets? Carrie Service looks at how practice’s can improve their IT performance by integrating new technology into their daily routine, and maybe even improve their QOF quota too

february 2012 | practicebusiness.co.uk

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MANAGEMENT | technology

With greater responsibility being placed on GPs and GP practice managers with CCGs and the CQC on the horizon, it is now more important than ever to ensure your practice is using the most efficient methods for completing even day-to-day administrative tasks. By incorporating some of the intuitive new IT solutions available, developed specifically for GP practices, not only could you improve the general running of your surgery, your practice could also take advantage of valuable QOF points.

GOT YOUR BACK So how can you improve your practice’s IT performance? One of the most important contributing factors to consider is the back-office software solution you are using. The systems available now are completely multifunctional, offering services that cut out a substantial amount of effort from relatively simple yet time-consuming tasks, for example patient mail-outs, booking appointments and data entry.

Elizabeth Scott, practice manager at Nova Scotia medical centre in Allerton Bywater, Leeds, trialled a mail system by Emis, and found that when considering all the processes that would usually go into sending a mail-out, using this sort of system meant she could get a lot more done. “We calculated that to send an average letter out, from selecting the patient, setting up the required letter template, inputting the details and updating the medical record, to actually filling and posting the envelope, takes between three and four minutes. Now we can process around 200 in the same time.”

Clinical back-office systems now include handy tools, such as a task manager, so that you can send tasks to individual staff members and keep track of when they have been completed, and also more detailed management of the appointment book so that appointments can be arranged further in advance.

These may sound like minor contributions, but in the long-term, these small adjustments can make a real difference to the running of a practice.

DICTATING YOUR FUTURE Another performance-enhancing product that practice managers could be taking advantage of is the digital dictation recorder and speech recognition software.

These products have really come along since the basic dictaphone and now offer a whole range of benefits for practices, allowing staff to produce and store documents accurately and efficiently. “The accuracy of speech recognition technology has improved enormously over the last few years,” explains Anne Durand-Badel, international marketing manager at Nuance Healthcare. “Modern speech recognition software is up to 99% accurate, which is probably more accurate than most people’s typing.” She believes that combining a digital dictaphone with speech recognition software that translates the recording into a text document for you, rather than typing it up by hand, can make a huge difference in document turnaround.

“GP practice managers report that speech recognition technology is the ideal complement to the investment they have made in digital dictation solutions.” By implementing this sort of technology, you can free up clerical staff’s time to be better spent elsewhere.

Secretaries can create accurate patients notes and letters without the need for laboriously typing out muffled tape recorded dictation, which has to be checked and altered numerous times. But the thing that really makes these products a triumph in a demanding office environment, such as a GP practice, is that they cut out one whole step of the back-office process altogether, allowing the GP to do their job. “One stage has been removed; the letter no longer needs to be sent back to the doctor for correcting, which frees up their time, too,” says Durand-Badel. “Patient letters

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MANAGEMENT | technology

can be stored electronically on a shared drive and called upon almost immediately by the secretarial team after being dictated by a doctor, should a patient call in unexpectedly for their referral letter.”

The procedure for speech recognition transcription is relatively simple too. “To create a letter, doctors simply open up a document, and dictate their name, the date and time, along with the patient’s name and number, and tag the letter as ‘urgent letters’, ‘routine letters’ and ‘occupational health letters’. From that point on, the doctor can simply dictate the letter or patient referral note, before it is sent to the secretarial team to put in the appropriate document template,” explains Duran-Badel. So once you’ve got GPs and clerical staff on-board, it really could make a difference to the administrative workload at your practice.

QOF UP Of course, it’s not always that easy to convince staff at a long-established practice to disregard their oldfashioned, tried and tested method in favour of a new-

fangled one. If the system works, why change it? Well the answer to this question is QOF points. There are sections in the QOF criteria that are directly linked to the processes and systems used in a GP practice, and all of the examples below could be more easily achieved by targeting your practice’s IT performance, and investing in the right technology. Here are some examples from the organisational domain indicator groups, that improving IT might have a positive effect on: • The practice has up-to-date clinical summaries in at least 805 of patient records • There are 80% of newly registered patients who have had their notes summarised within eight weeks of receipt by the practice • There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes and authorisation for loading programmes where a computer is used • The practice has a system for transferring and acting on information about patients seen by other doctors out of hours

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MANAGEMENT | technology

•

•

There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded For repeat medicines, an indication for the drug can be identified in the records.

Mail-out systems can also be used to gain QOF points by allowing practices to target the required groups of people, for example; contacting the parents of children who have missed their MMR vaccine, launching a stop-smoking campaign, or contacting people who are eligible for the flu jab, or any people who fall into the ‘additional services’ target groups.

Keeping all of the information required for QOFs in order needs a system that is streamlined and efficient, but at the same time has to be easy to implement and not confusing for users. Emis decided that in order to achieve this they needed to ask what users wanted from the system, and then use this information to further develop the product. Dr Shaun O’Hanlon, clinical development director for Emis, explained: “it [was]

clear from users’ feedback that Word is regarded as an essential daily tool for practices and that learning to use a new solution was slowing them down.” As a result, the healthcare software firm now integrates Microsoft Word into their products so that admin staff are already half-way there when they first learn to use the software.

Durand-Badel believes that investing in technologies that speed up the running of a practice “accelerates a practice’s ability to deliver a higher quality of care” and pays off in the long run. She concludes: “Whether it’s through the rapid turnaround of patient reports and letters, the increased accuracy of the medical record or the extra time it gives doctors to spend with their patients, [it] is central to practices achieving their QOF objectives.”

Modern speech recognition software is up to 99% accurate, which is probably more accurate than most people’s typing

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management | MFM

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

MFM: Hepatitis C

In his regular series, clinical editor Paul Lambden provides easy to read skills-ups on key clinical areas. This month: Hepatitis C Hepatitis C is a viral infection that attacks the liver. While everyone knows about hepatitis B, hepatitis C is a more shadowy disease. In fact it is estimated that between a quarter and half a million people in England and Wales have the disease and it is more common in other parts of the world. Millions of people are infected with the virus every year.

The big problem with identifying hepatitis C is that 80% of those people who contract the disease don’t have any symptoms. When symptoms are present they are usually non-specific and vague. They include flu-like symptoms, tiredness, weight loss, general aches and pains, low-grade fever, headaches, episodes of sweating, nausea, loss of concentration and intolerance of alcohol, which may cause pain in the liver area (below the ribs on the right side). Patients with hepatitis C do not develop jaundice, which occurs with other liver diseases.

Infection usually occurs through blood-to-blood contact, so sharing needles or using recreational drugs is a common route. Other methods are through body piercing of various types. It can be transmitted by sharing toothbrushes or razors and also through sexual intercourse, although sexual transmission is uncommon. Because of the (often) very long period between acquisition and diagnosis, the route of infection may not be known.

Following infection, the course of the disease is unpredictable. About a quarter of patients clear the virus from their bodies with their own immune system in two to six months. However, if the body’s defence system does not destroy the infection within six months, it will persist indefinitely. The consequences of the infection are very variable.

Some patients will remain well and experience no liver damage. In such patients, diagnosis is usually by chance. Many of the sufferers will, however, develop mild to moderate liver damage. About 20% of patients will develop cirrhosis (the destruction of normal liver cells, which are replaced with scarring) within about 20 years and the number of sufferers will increase steadily with time. In severe cases the cirrhosis may lead to liver failure, in which case a liver transplant may be the only option for treatment.

Other factors that speed-up liver damage are alcohol consumption and a co-existing HIV infection. Patients with cirrhosis also have a greater risk of developing liver cancer.

Hepatitis C can be treated with drug therapy. The decision to treat may be made after the particular strain of the virus has been identified and the degree of liver

While everyone knows about hepatitis B, hepatitis C is a more shadowy disease february 2012 | practicebusiness.co.uk

management | MFM

damage has been assessed using blood tests and, often, liver biopsy. Recognised therapy includes interferon and ribavirin, drugs that help the body’s immune system to overcome the virus and which are usually used in combination. The therapy is effective in about half the cases treated. Some patients are not cured but the treatments may be partially effective by reducing liver inflammation. There are also newer drugs which act directly on the virus blocking enzymes which are necessary for it to replicate.

Of course the best approach is not to catch the infection and simple precautions such as avoiding sharing needles, ensuring that any tattoo or piercings are carried out at reputable centres with appropriate sterilisation procedures and avoiding casual sexual relationships with barrier contraception are effective. A person infected with hepatitis C cannot act as a blood donor.

Doctors are required to inform the local authority if the diagnosis is made because the disease is notifiable.

work/life

36

Cut emergency admissions now Under the new commissioning agenda, practices have a large role to play in reducing expensive trips to A&E among their patient populations. Julia Dennison looks at seven things surgeries can do to reduce emergency admissions

1

Roll out telehealth

Telehealth helps reduce emergency hospital admissions by 20%, according to the DH. In fact, the Government’s telehealth trial last year, dubbed the Whole System Demonstrator (WSD) Programme, was so successful, they plan to roll out the use of telehealth and telecare technologies to the homes of three million people over the next five years. John Dyson, chief executive of Telehealth Solutions, estimates this could save over £1bn per year.

3

GET GPs on the phone

The Patient Access model (see p24) shows that if GPs phone patients back instead of automatically booking them in for an appointment, A&E visits can be reduced by one-fifth. This stems from patients finding their GP easier to get a hold of and therefore less tempted to run to hospital with the smallest of concerns.

2

let patients pick their GP

Patients who see their preferred GP are less like to be admitted to hospital in an emergency, according to a study in the Emergency Medical Journal.

4

Educate the patients

When patients realise how much money they cost the NHS when they go to A&E unnecessarily, they may think twice about going again. Mark Carlile of communications technology firm Boomerang believes mobile technology plays a part in this. “The patient community will need encouraging to change how they interact with hospitals/surgeries etc. especially those of an older generation – 55-plus – who still prefer face to face communication,” he says. “Unfortunately this age group is the one that probably has more call on emergency admissions.”

It also helps to stay in touch with elderly and vulnerable patients.

5

Extend your hours

advice for busy lives

If you don’t have convenient and flexible hours to meet demand, a 24-hour A&E ward is going to look more appealing to patients, even for minor injuries.Consider opening late as many nights as you can, as well as on the weekend, then make sure patients know about it.

7

Get kitted out

Practices may wish to extend their services and upgrade their premises to become more emergency-friendly.

Emergency equipment, from defibrillators to resuscitation equipment, has popular in general practice. Steve Dunn of Williams Medical Supplies reports an increase in surgeries asking for help with ways to reduce emergency admissions.

february 2012 | practicebusiness.co.uk

6

Reach out to the community

Connect with as many community health professionals as possible, as they can help in an emergency. “Increase and integrate community staff resources with practice teams,” says Annette Given, practice manager of the the Spa Surgery in Harrogate. “The most valuable resources we have are the rapid response teams and community specialist nurses.”

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Work/life | diary

Practice diary Ann Boyle ‘Ann Boyle’ is a pseudonym for an anonymous practice manager blogger who started working as a receptionist and worked her way up to become manager for a large GP practice in the North. 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 february 2012 | practicebusiness.co.uk

Practice Business welcomes a different columnist each month to share their experiences and provide their view from the practice manager’s desk.

In the first of a three-part series, anonymous PM blogger Ann Boyle asks: How do you manage appointments when the clinician is running behind?

When a patient books in at the reception desk and you identify that the doctor/ nurse or other healthcare professional is running more than half an hour behind schedule, do you inform the patient before they sit down? If not why not?

No one likes to be kept waiting, but everyone would rather be told and given the option to wait or to rebook another appointment.

Lack of communication can often lead to a complaint or even worse someone getting aggressive.

When a patient comes to the desk you could say: “I apologise, but Dr Smith is running about 35 minutes late this morning – he had an emergency/visit to do. Would you like to wait or would you like to rebook another appointment?”

By doing this you are giving the patient a choice. If they choose to wait then they cannot come back to the reception desk after 25 minutes and complain – which they more than likely would have done if they had not been informed.

Good reasons to keep them informed are as follows: • It gives the patient a chance to go to the shop/car to get something to keep them occupied while waiting.

• They might want to make a phone call to tell someone they are running late.

• They simply might need to go to the toilet.

They would be reluctant to do any of the above three things if they did not know they were in for a wait – they would sit there waiting to be called in at any minute.

If the patient cannot wait for various reasons, it gives them the opportunity to rebook at a time suitable to them. By patients booking another appointment, it will lessen the already late doctor/nurse and give them a chance to catch up.

Always try to defuse any potential complaint. It is always better to try and solve a situation sooner rather than later.

Always look ahead.

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