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Commissioning Success
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sept/oct 2012
Prescribing oPtimisation Why ‘medicines optimisation’ is now the name of the game
Supporting excellence in healthcare
commissioningsuccess.com
get engagedWhen patients become customers
sharing the load Specialising through integrated care
Editor’s letter
The whole point of putting clinicians into
the driving seat under the commissioning
agenda is to ensure that no decision
about a patient is made without a
patient. So it’s disconcerting to hear that
the NHS Alliance is having to remind
the Government to reinvigorate their commitment to their
favourite mantra.
Patients need a dose of reminding as well, because with
all the bad press the changes to the NHS have been getting,
patients are left not very much the wiser, and since they are, as Roger Hymas says on
p12, essentially customers, it’s important to get them on board.
Shared decision making sits at the heart of commissioning, and runs through
as a theme to this issue. On p8 we look at the area of medicines management,
which, as Richard Seal, programme consultant in medicines management for NHS
West Midlands, points out should be called “medicines optimisation”. He believes
that, much like a consultation, medicines are often left to the last minute in the
commissioning agenda, and he is adamant that this should change. Managing
medications in the right way could be a godsend to saving money and improving
patient care. A lot of it comes down, quite simply, to communication. Although
doctors are prescribing, pharmacists dispensing, there is little guarantee patients in
the community are taking the medications – and this can result in the exorbitant
amount of wasted money.
We also interview the clinical director at The Practice, which is running an
ophthalmology service at a surgery in Croydon that seeks to bring services like
cataract surgery into the community and closer to patients. This is particularly
welcomed in the case of ailments like cataracts, which can be so debilitating if
left untreated.
As long as commissioners continue to keep the patient at the heart of everything
they do, it’s unlikely they can go wrong – albeit they don’t break the budget.
EDITOR
CONTENTS COMMISSIONING UPDATE
4 News and updates The latest news, comments and views on clinical commissioning
7 NHS Confederation Conference A rundown of hits and highlights from the NHS Confederation annual conference
8 ‘Medicines management’: old news
The buzz phrase is now ‘medicines optimisation’. We look at why it’s essential
12 Get engaged: patients as customers Speak up! Your customers (read patients) need engaging now more than ever
COMMISSIONING IN ACTION
16 The collaborators Clinical commissioning groups in the southwest fi nd strength in numbers
22 Vision in the community The Practice opens a new cataract service in Croydon – closer to patients’ homes
COMMUNITY CARE
26 Sharing the load CCGs that have opted to specialise specifi c practices within their group
28 Rest and recuperation We look at ways patients are recovering in the community
INFORMATION AND TECHNOLOGY
30 Digital outreach Reaching out to patients – from social networking to surveying
MANAGING COMMISSIONING
32 Softly softly approach Is the ‘soft’ skills approach necessary for successful healthcare commissioning
34 Top tips Managing diabetes – ways you can help put a curb on the healthcare crisis
ASSISTANT [email protected]
SENIOR SALES [email protected]
DESIGNER/[email protected]
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Updatenews
04 | sept/oct 2012
NeWSThe two operations directors of the NHS
Commissioning Board Authority’s national
leadership team have been named.
Ann Sutton, currently chief executive of
Kent and Medway PCT cluster, has been made
director of NHS commissioning (corporate)
and will be responsible for devising and
overseeing the national framework for the NHS
Commissioning Board’s direct commissioning
responsibilities,. including specialised services,
primary care, public health, healthcare for
military personnel and their families and for
offenders.
While Lyn Simpson, currently NHS director
of operations in the Department of Health, has
been appointed director of NHS operations
and delivery (corporate) responsible for NHS
planning and performance, assurance of
delivery by CCGs and national lead for NHS
emergency preparedness, resilience and
response.
Ian Dalton, chief operating offi cer
and deputy chief executive of the NHS
Commissioning Board Authority, commented:
“These two posts will provide the strategic
leadership and oversight to ensure that
we have a strong, innovative and patient-
focused commissioning system that improves
outcomes, tackles inequalities and supports
the NHS in England to be the best it can be.”
FIRST LOCAL AREA TEAM DIRECTORS
The fi rst round of appointments to the 25 local
area team director posts has also been made
as follows:
North
• cheshire, warrington and wirral: Moira Dumma
• merseyside: Clare Duggan
• greater manchester: Mike Burrows
Commissioning Board: KeY direCtors aPPointed
• south yorkshire and bassetlaw: Andy
Buck
• north yorkshire and humber: Chris
Long
• durham, darlington and Tees: Cameron Ward.
Midlands and East
• essex: Andrew Pike
• hertfordshire and the south midlands: Jane Halpin
• leicestershire and lincolnshire: David
Sharp
• derbyshire and nottinghamshire: Derek Bray
• shropshire and staffordshire: Graham
Urwin
• birmingham and the black country: Wendy Saviour.
•
London
• london: Simon Weldon
South of England
• surrey and sussex: Amanda Fadero
• wessex: Debbie Fleming
• devon, cornwall and isles of scilly: Ann James.
BIT OF BACKGROUND
There will be 27 local area teams with staff
working from a number of offi ce bases across
their geographical area. All local area teams
will have the same core functions around
CCG development and assurance, emergency
planning, resilience and response, quality and
safety, confi guration, system oversight and
partnerships and stakeholder engagement,
with the senior leadership of the local area
team participating as a full partner on health
and wellbeing boards.
A Family Doctor Association survey of 100
commissioning GPs showed that GPs want to
be consulted at every stage of commissioning
in a genuine two-way dialogue with CCGs.
The study also found there to be a wish
for democracy and genuine representation of
practices and protected time for doctors to
increase their involvement.
Over 50% of GPs questioned felt able to
infl uence their CCG’s decision making, but
one in eight (13%) felt unable to do so and felt
disempowered.
There was also a clear desire for a fresh
start. National chairman Dr Peter Swinyard
said: ”The message to CCGs is clear. Talk with
your member practices and listen to them.”
gP practices want to be more involved
Hospitals in England are not supplying
accurate patient data to the wider NHS,
which could undermine GP commissioning,
a report published by the NHS Information
Centre claims.
The report found that up to a fi fth of
data returns by hospitals and councils
contained errors in patient records and cited
the ‘reorganisation and reconfi guration of
services’ as a factor leading to poor returns.
On average, hospital trusts made errors in
seven per cent of all data submissions, likely
to have affected millions
of patients’ data.
Poor hospital data threatens commissioning
sept/oct 2012 | 05
Updatenews
SeNd IN YOUR StORIeSWe are always looking for local commissioning news. If you have a story to share, email [email protected].
clINIcal cORNeR
TrusTs denying TreaTmenT are breaking The law
Patients who are denied approved drugs
by their local health trust should take
legal action, Sir Michael Rawlins, chair
of the National Institute for Clinical
Excellence (NICE) wrote in the HSJ.
He said “numerous trusts” were
unlawfully denying patients drugs
approved by NICE or were employing
“delaying tactics” to save money and that
this should not be tolerated.
He gave the example of patients with
retinal vein occlusion who would benefit
from dexamethasone intravitreal implants,
but many trusts have been refusing the
treatment for financial reasons.
There is also sometimes dispute
between the PCTs and hospitals on who
should pay for the treatment – often at
the expense of the patient’s sight.
Sir Michael called on campaign
groups like RNIB to seek judicial overview
to ensure rightful provision of the
treatment. He also called on clinicians to
“whistle-blow” on trusts failing to provide
the drugs and treatments patients are
legally entitled to.
local news
CliniCal engagement drives major savings at essex trust
Significant savings were made at Mid Essex
Hospital Services NHS Trust by clinical and
non-clinical teams working together to
reduce procurement costs in the areas of
reconstructive and trauma orthopaedics.
Over £300,000 was saved in three months
on hip products alone, with the final savings
across all categories, including upper and
lower limb, trauma and pulse lavage, forecast
to be £500,000, representing a 28% saving.
A cross-functional commercial and clinical
team was formed that reported directly to the
clinical director, CFO and COO.
Bill Martin, consultant orthopaedic surgeon
and lead clinician on the procurement project,
said: “The initial worry that financial pressures
would lead us towards accepting substandard
implants or major inventory changes has not
been borne out, and it was reassuring to be
involved in the process as a surgeon.”
The work is part of a wider programme
of procurement cost reduction, led by
procurement consultancy Inverto.
UK MD Richard McIntosh said: “The results
clearly demonstrate the power of clinical
engagement and what can be achieved when
you combine specialist procurement expertise,
clinical and commercial expertise and the
backing of the trust board.”
national award for nHs nottingham City CCg
NHS Nottingham City Clinical Commissioning
Group (CCG) was named BMJ Clinical
Commissioning Team of the Year.
Dame Barbara Hakin, national MD
of commissioning development at the
Department of Health, sat on the awards
panel and said of the judging process: “We, as
judges, were unanimous in our decision that
the winners should be Nottingham City. They
showed strong leadership, great organisational
development and were really looking at an
enormous number of areas where they could
effect change. But most of all, what stood
out for us was that they were already making
changes and delivering better outcomes.”
macclesfield gPs receive faster a&e updates
East Cheshire NHS Trust’s A&E department
can now collate and send clinical patient
information to GPs electronically for all patients
that attend the department.
This development complements the
eDischarge Notification Forms (eDNF) to GPs
– a system that has helped them achieve an
84% compliance for meeting the NHS 24-hour
communications delivery target.
Patient information is input into
Extramed (the operational management and
coding system for all A&E attendances) this
automatically generates a discharge letter,
which is then stored and delivered electronically
to GP practices across Cheshire, streamlined by
Medisec Trust eDelivery software.
Customer service delivery manager Debi
Lees said: “Patients visiting their surgery after
being discharged from our A&E Department
the previous day can now rest assured their GP
will be fully up-to-speed with their condition
and any emergency treatment they may have
received. This marks another significant step in
our continuing drive to improve patient care.”
16-17 octoberFour nations, one Challenge – improving
Patient outcomes
Manchester Central
FMLMconference.com
dIaRY
SEPT/OCT 2012 | 07
UPDATENHS CONFEDERATION CONFERENCE
Nicholson pulls no punchesThis year’s NHS Confederation Conference tackled the major issues affecting
the NHS. Sir David Nicholson took to the stage on day two and set the world to rights. GEORGE CAREY reports
As usual there was plenty to take in over
the three days of the NHS Confederation
Conference last June, with an impressive range
of expertise on offer discussing a wide range
of topics. But it was NHS chief executive Sir
David Nicholson who stole the show as he
offered a fascinating insight into life under the coalition and his
plans moving forward.
In an extraordinarily candid address, Nicholson confessed
he had been incredulous when Lansley fi rst outlined his plans
for the structural NHS shake-up now
being implemented. He spoke of his fury
at ministers’ repeated criticism of public
sector management: “I felt angry every
time the Government came in, starting to
denigrate and criticise public sector leaders
– people like ourselves who have spent our
whole lives trying to improve public services.”
Nicholson told the audience that the NHS reorganisation had
felt like going through a bereavement. He had shared their feelings of
denial, anger and depression before moving on to acceptance of the
inevitability of the upheaval taking effect next year. On the subject
of Lansley informing him of the plans, he said: “My immediate
response was that they couldn’t possibly be wanting to do that.”
Lansley had addressed the conference the day before and
had clashed with Stephen Dorrell, the Conservative chair of the
Commons’s Health Select Committee and himself a former health
secretary, over the issue of hospital closures. While Lansley argued
that ministers should stand back from debate and decisions over
changes to services, which were a local matter, Dorrell called on
them to take a lead.
Nicholson was in agreement with Dorrell on this issue and
joined him in citing a speech in 1961 by Enoch Powell, then
health minister, in which he proposed the wholesale closure of
long-stay mental hospitals. Referring to
Powell’s speech, Nicholson said: “In lots
of ways, it’s the sort of speech we need
our national politicians to make at the
moment. It’s being honest with the public
about the nature and scale of change that’s
required in order to live in a world where
we have great outcomes for patients, universally available, but
within the resources that we have.”
He urged NHS leaders to have confi dence in their ability
to make the new system work, based on what they’d already
achieved, saying: “In my 35 years in the NHS, I have never known
a time like it. Thank you for your hard work, it’s been genuinely
remarkable.”
“I felt angry every time the Government came in, starting to denigrate and criticise public sector leaders”
UpdateMedicines ManageMent
08 | sept/oct 2012
The
doseopt mal
The phrase ‘medicines management’
is one many general practitioners
and their commissioning partners
will have heard, but what does it
actually mean? NHS Local puts
it simply as ‘enabling people
to make the best possible use of their medicines’,
while the National Prescribing Centre describes it
slightly more opaquely as ‘a system of processes and
behaviours that determines how medicines are used’.
Whichever defi nition you prefer, the main crux of the
philosophy is ensuring the population gets the best
outcomes from the medications it’s prescribed for the
lowest cost. With the Nicholson Challenge hanging
like the sword of Damocles over commissioners’
boardroom tables, cost-saving of any kind is very
much top of the agenda. When prescribing and the
management of drugs accounts for 12% of the overall
NHS budget, the King’s Fund is right to highlight
the area for potential effi ciencies. Without excessive
bureaucracy holding them back, CCGs have the
power to implement these quickly.
Medicines management is about more than
just medicines. Shailen Rao, MD of medicines
management fi rm Soar Beyond, believes that many
areas that CCGs will be trying to tackle – such as
long-term conditions and hospital admissions – can
be directly impacted by medicines. “They’re a very
integral part of the pathway,” he says. “If you look at
pathway and service redesign, you have to consider
the medicines aspect.” Historically, medicines have
sometimes sat in a different budget category to that
of, say, long-term conditions, and Rao hopes with
the umbrella of commissioning there will be the
opportunity to bring them together.
eDUCating the Masses
Two major areas to address fi rst on the path to
better value medicines is prescribing errors and
patient adherence. It is estimated that £100m a
year could be saved from patients taking medicine
correctly, while £40m could be retained by reducing
errors in prescriptions. Throughout the country
PCTs have been working hard to reduce excessive
prescribing costs, and this will now fall onto the lap
of the CCG boards.
As part of its recent focus on medicines
management, NHS West Midlands made a list of
priorities. It included reducing the number of people
being admitted to hospital due to problems with their
medicines; improving medication safety by reducing
the number of medication errors and, lastly, echoing
the National Prescribing Centre’s defi nition of
medicines management, supporting people to make
Medicines management is old news. The phrase of the day is ‘medicines optimisation’. But what does this change of wording mean for CCGs and how they incorporate prescribing into their plans? JULIA DENNISON fi nds out
UpdateMedicines ManageMent
10 | sept/oct 2012
the best possible use of their medicines through
shared decision-making and better patient education.
Programme consultant in medicines management
at NHS West Midlands, Richard Seal, believes it
is this active support for patients that will really
make the difference. He highlights the importance
of speaking to patients about the medications they
take and ensuring it’s not just a last minute add-on
to end a consultation. Up to 50% of prescription
medicines are not taken as directed and around 20%
are thought to be never taken at all. In his experience,
the more patients understand how a medication will
benefit them, the more likely they are to take that
medication in the long-term.
Of course, these are just estimated percentages,
as it is often difficult to track the true numbers.
Why this happens often comes down to two factors:
intentional and unintentional non-compliance.
Reasons for not wanting to take medications can
be attributed to anything from cultural preference
to hearsay or taking the wrong advice. Meanwhile,
unintentional non-compliance can derive from
forgetting to take it to side effects standing in the
way. Both types of non-compliance can be somewhat
rectified through better communication and
information at the point of consultation, but wider
education at a locality level can only be of further
benefit.
ManageMent v. optiMisation
In our conversation, Seal introduced me to
the phrase “medicines optimisation”. The
slight change in wording belies the significant
change in culture that he believes needs to occur
throughout the health professions as we move
into the commissioning landscape. Rather than
thinking reactively about the management
of medications, commissioners should be
thinking proactively about optimising their
use to improve patient outcomes as well
as reduce spend on conditions in the
long-term. Using the right medications
in the right way could hold the answer to
many of our financial woes. “In philosophy,
the shift is to making it more outcomes driven
and patient-centred,” Rao explains of the difference.
“Medicines management has become really a
population-based bean-counting exercise, though
that wasn’t its intent, whereas optimising medicines
is more about the individual and the outcome.”
‘Optimisation’, he believes, gives commissioners more
freedom to find the right solutions for different patients
and take a more bespoke approach to their care.
partnership working
It is important that CCGs take as much support as
they can when managing medicines. Pharmacists,
for example, play an important role with medicines
reconciliation – where they check and amend
errors in the clinician’s prescription – and act as
an important safety net in the prescribing process.
By working closer with pharmacists, hospitals,
patients and even pharmaceutical companies where
appropriate, GPs and commissioners will come that
much closer to optimising the medicines.
Raymond Lee, chairman of Central Lancashire’s
Local Pharmaceutical Committee, says it makes
sense to include community pharmacy at the earliest
opportunity when considering care pathways. “There
are nationally commissioned services such as the New
Medicine Service (NMS) and Medicine Use Reviews
(MURs),” he explains. “By joining these services to
the care pathways, it reinforces the messages of taking
medication appropriately and helps to promote healthy
lifestyle interventions such as smoking cessation,
alcohol awareness and weight management.”
Putting clinicians in the driving seat looks to
prove favourable for medicines management. It is
now up to the CCGs to take the opportunity, see the
medicines budget as the investment it should
be and ensure patients have the right tools
to treat their conditions responsibility
and sustainably. “In order to achieve the
level of cost savings that CCGs need to
deliver, a whole systems approach is
required,” concludes Lee. “Adopting
previous QIPP savings will simply
not be enough. Having an integrated care
pathway approach whereby all clinicians have
input and are able to work together, particularly
at the interface between services is where the
real savings can be realised. Clinicians need to
have the moral courage that services may be
better served by utilising the skills of others
rather than trying to protect existing services
and income streams.” Commissioners, medicines
management is in your hands. Use it wisely.
“Medicines management has become really a population-based bean-counting exercise, though that wasn’t its intent; whereas optimising medicines is more about the individual and the outcome”
Updatecomment
12 | sept/oct 2012
Speak up! Your customers (read patients) are having trouble hearing you. ROGER HYMAS looks at what clinical commissioning groups could do better in terms of patient communication and engagement
The other day I read an interesting piece on the
Guardian website about the NHS having diffi culty
dealing with the word ‘customer’. The general
thesis was that a lot of well-meaning and system-
changing DH initiatives would have a greater
chance of success if patients and public were
co-opted into the decision-making process. Engaged patients would
then help co-create solutions for both their medical advisors and
institutions in the same way that many other industries now manage
their customers. It’s the phenomenon we see every day in the way we
use the internet to buy goods and services. Healthcare is different, of
course, and needs a special approach. To start with we need to deal with
three extraordinary cultures that act as powerful barriers to progress.
1. doctor KNoWS BeSt
The fi rst and possibly the easiest one to deal with is that ‘doctor
knows best’. A huge amount of effort has been made globally to
provide information about conditions and reduce the knowledge
asymmetry between patient and clinician. This has principally
been the result of the ubiquity of information on the internet.
The Department of Health has spent hundreds of millions
AUTHOR BIORoger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is also the founder of the Commissioning Community website, www.commissioningcommunity.co.uk
When patients become customers
Get eNGaGed
Updatecomment
14 | sept/oct 2012
through its investment in NHS Direct and
NHS Choices. They now get hundreds of
thousands of hits and calls a year. Inevitably
there are positive benefits from these
programmes, though nobody seems to be
in a position to tell us what the impact is
on health outcomes or patient engagement
yet. This is, of course, the challenge for all
communication activity. How much does it
cost, what parts of it work and what is the
financial (and non-financial) return on the
investment? Also, we need to know whether
each part of the communication mix is
being optimised. Do we know if it’s reaching
and engaging the audience at a personal
level and persuading them to change their
behaviour? Often, it’s communication style,
but sometimes the choice of medium, that
makes the difference. Let me give you just
one example: I put “bunions” into the NHS
Direct website and WebMD, the leading US
healthcare site. Which do you think gets its
message across better?
2. NHS: A commiSSioNiNg orgANiSAtioN
The second cultural barrier that needs
attention is persuading the NHS that
it is now essentially a commissioning
organisation and this is where the bulk of
its management effort needs to be applied.
Tinkering with the provider landscape is the
NHS establishment’s natural inclination, but
it will not save the day. I’m not sure the
penny has dropped yet that going flat-
out with commissioning is the only
way we can affect the changes that will
transform and modernise the NHS and
make a real contribution to delivering the
financial savings that have been targeted.
System redesign in any complex
organisation starts with a focus on culture
change. Until we have built a position where
experienced commissioners occupy senior
positions on the most important bodies,
particularly the NHS Commissioning Board,
then we will not make the progress we need.
Imagine a bold leap like the appointment of
a senior executive from a US health plan to
the NCB board so that he or she can bring
his or her insights and experience. The King’s
Fund came very close to recruiting a US chief
executive a few years ago, and it has always
struck me that NHS healthcare policy in this
country might have moved quite differently if
he had taken up the position.
3. Let tHe gPS LeAd
The third culture is dealing with a top-
down NHS. With the arrival of GP-led
commissioning, this is potentially going to
be much easier to change. The great benefit
is that GPs who see thousands of patients,
face-to-face, every day are the best placed to
make proper commissioning decisions. Just
this move to a micro-managed environment
presents the opportunity to change the NHS
from an institutionally-oriented provider
organisation into a consumer-centric,
customer sensitive, delivery organisation.
Consumer-facing industries exploit
these contact benefits and the data they
produce to develop increasingly effective
customer relationship programmes, enabling
them to stay in touch and improve the
customer experience. These involve a mix
of techniques, including media selection,
behavioural targeting, data about previous
contact/purchasing history, learning style
and response analysis, to build algorithms to
optimise communication and, most critically,
influence behaviour change. All of these
programmes are designed to meet the specific
needs of a single individual, a target of one.
Getting the NHS to this point would
mean we would have a much greater
chance of delivering ‘No decision about me,
without me’. There are huge benefits for
better engagement with patients. Improved
involvement by the individual in self-
care, better compliance with treatment
programmes are just a couple examples. What
a lot of this adds up to is a lighter version of
case management built on communication
preference rather than traditional case
management, where a care worker is assigned
to supervise the patient’s treatment.
All this means that effective contact
strategies should be matched to the patient.
My advice, though, is not to attempt
to fix what’s not broken. If a personal
visit to the GP is preferred, it should
happen. But other patients will
be happy with the phone, text
and emails. Many of these are
still relatively untried and tested
media for the NHS. But there is
the potential of significant efficiency gains
if unnecessary consultations – both with
GPs and specialists – are avoided. Many US
healthcare systems are already relying on
telehealth solutions, Skype, and even email.
As my best ever boss always told me:
“Strategy is execution.” What the DH needs
to do is move its considerable resources to
focus beyond strategy to implementation.
My recent experience with GPs and CCGs
has convinced me that they are ready to
deliver. The missing piece is professional
communication advice for CCGs.
I read that both the district general
hospital and the doctor’s surgery are now
at least 150 years old, but are still the main
contact points for hundreds of millions of
patient encounters every year. We live in a
digital world where ‘clicks’ replace ‘bricks’.
Isn’t it time to consider them as part of our
healthcare future?
“A lot of well-meaning and system-changing DH initiatives would have a greater chance of success if patients and public were co-opted into the decision-making process”
THE CHALLENGE
McKinsey’s 20091 report to the previous government identifi ed changes in drug spending could deliver 10 to 15 per cent of the overall savings and indicated this might be achieved by reducing variation in prescribing practice and increasing the use of generics over branded products.
In 2011 The King’s Fund ‘The quality of GP prescribing’2 report highlighted the need to address variation in prescribing practice variation and encourage adherence to best practice.
Earlier in 2012 the GMC PRACtICe3 study into the prevalence and causes of prescribing errors in UK general practice revealed prescription drug errors for one in six people, with the elderly and young being almost twice as likely to experience an error.
Bruce Guthrie’s recently published study in The Lancet4 found that the number of morbidities and the proportion of people with multi-morbidity increased substantially with age so that by age 50 years, half of the population had at least one morbidity, and by age 65 years most were multi-morbid with physical and mental health comorbidities.
In 2011 First Databank (FDB™) undertook extensive independent research to drill deeper into the current suite of clinical decision support available to understand:
• why GPs reject the clinical decision support alerts available, • why GPs don’t always adhere to best practice, and • what extra support is required to assist the new CCGs and
their component GP practices to achieve their saving targets?The research showed that currently available technology and
tools did not specifi cally 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.
THE SOLUTION
FDB has developed its new Medicines Optimisation solution specifi cally 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 specifi c 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 specifi c patient.
FDB’s Medicines Optimisation analytics provides a current view on prescribing behaviour across CCGs providing access to:
• population level analytics, which can be drilled down into the individual patient record to allow interventions,
• best practice guidance – reducing prescribing variations, and• the information required to build condition specifi c
formularies.These tools will free up Medicines Management team time for
direct clinical care or local initiatives.The next generation of medicines related active clinical
decision support is here now, complemented by unique patient level analytics capabilities. For more details on FDB’s Medicines Optimisation solutions email [email protected] or visit fdbhealth.co.uk
References1. ‘Achieving World Class Productivity in the NHS 2009/10 – 2013/14: Detailing the Size of the Opportunity’, McKinsey & Co, March 2009.2. The Kings Fund – ‘The Quality of GP Prescribing’A study by Dr Martin Duerden, Professor David Millson, Professor Anthony Avery and Dr Sharon Smart, 20093. ’Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a cross-sectional study’ Karen Barnett, Stewart W Mercer, Michael
Norbury, Graham Watt, Sally Wyke, Bruce Guthrie www.thelancet.com Published online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-24. ‘Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study’, May 2012Professor Tony Avery1, Professor Nick Barber2, Dr. Maisoon Ghaleb3, Professor Bryony Dean Franklin2,4, Dr. Sarah Armstrong5, Dr. Sarah Crowe1, Professor Soraya Dhillon3, Dr. Anette Freyer6, Dr Rachel Howard7, Dr. Cinzia Pezzolesi3, Mr. Brian Serumaga1, Glen Swanwick8, Olanrewaju Talabi1
[email protected] fdbhealth.co.uk
MEDICINES OPTIMISATION WITH FDB
IN ACTIONCASE STUDY
T H E C O L L A B O R AT O R S
SEPT/OCT 2012 | 17
IN ACTIONCASE STUDY
Clinical commissioning groups in the southwest have found strength in numbers. POLLY ELLISON looks at how federating has helped their smaller practices survive
The GP federation model
adopted by Somerset
Clinical Commissioning
Group, although still
evolving, must be one
of the most successful
approaches to commissioning being carried
out around the country.
A nominated GP from each federation
sits on the CCG board, ensuring that each
federation has equal representation, in the
well-organised over-arching structure of
the CCG. The key to the CCG’s success
is in its recognition that the nine GP
federations in Somerset differ from each
other geographically, and that they have
very different patient populations. In order
to tackle this, each federation has adopted
a different way in which they operate; a
different working style and their aspirations
vary tremendously from federation to
federation. Recognising this, and supporting
it, by allowing the appropriate management
funds to flow through to local level, the
CCG has empowered its GPs to become
actively part of the commissioning process.
One example of this is the South
Somerset Healthcare Federation. The
federation is made up of 17 practices serving
108,000 patients across a region from
Langport to Yeovil, through to Wincanton.
As Len Chapman, treasurer of South
Somerset Healthcare Federation, explained:
“What we have developed is a federation
of the South Somerset practices, with our
focus on the commissioning agenda, with a
view to interacting with the Somerset CCG
in order to do that.” Aiming to provide
effective, coordinated commissioning and
healthcare provision via existing and new
services, the group is used to working
together, having originally been a co-op
providing out-of-hours services and part of
WyvernHealth, delivering practice-based
commissioning. Those involved have a
wide range of skills and local knowledge.
They are also establishing close working
relationships with other stakeholders in
the area, such as Yeovil District Hospital
Foundation Trust, Somerset NHS, Somerset
County Council and Somerset Partnership.
POWER TO THE PM
The federation currently has a monthly
evening meeting for GPs and practice
managers plus a monthly steering group
meeting to facilitate the implementation
of agreed work plans. They are proposing a
change to regular meetings of a smaller GP-
and practice manager-led working group,
bi-monthly federation evening meetings and
task groups as required for specific subjects.
The federation holds educational
workshops, such as a recent reablement
programme, which gives the group more
information on the new reablement service
and telehealth and provides it with an
opportunity to learn more about the aims of
the joint NHS/local authority programme.
Another development has been to assign
practices to one of three working sub-groups
to cover important areas of work, such as
paediatric emergency admissions, zero- and
short-length-of-stay admission, as well as
identifying local commissioning priorities.
The close working of the GPs with their
practice managers is the key to success, as
practice managers are involved in all that
is going on. In some areas of the country,
practice managers would not necessarily
know who the GPs on the CCG board were,
never mind being involved in working
with them and assisting with the
development of services. Tapping into
the expertise of practice managers is so
important as they form the essential link
IN ACTIONCASE STUDY
18 | SEPT/OCT 2012
between GPs and practice staff and their
wealth of expertise should not be allowed
to go to waste. Somerset CCG has clearly
recognised this and is benefitting hugely
from this management resource.
PROJECTS IN ACTION
A variety of PCT projects to improve
patient services have already been
supported by the federation.
One example is an urgent care GP pilot
at Yeovil District Hospital (YDH), where a
GP and practice manager have created and
delivered a service to provide GP expertise
to patients in the emergency admissions
unit. The aim is to help identify people
whose healthcare could be managed in
the community. A small group of local
GPs deliver the service with the support
of healthcare assistants Monday to Friday
between 1.30 and 6.30pm. An experienced
GP works with the on-call medical team.
There is also the facility to manage DVT
patients where there is a problem with
the timing of blood collections. The aim
is to provide safe, good quality care for
patients while reducing the workload of
the DGH. During the shift, the GP receives
all requests for medical admission. One
good idea in this scheme is that in order
to support a rural community, a dedicated
transport service has been set up to bring
people in quickly, so that they can have the
appropriate assessments and tests. Patients
can also be returned home promptly in
the early evening if it is agreed that they
are safe to be managed at home. A recent
audit on this service highlighted the fact
that 38% of patients have been discharged
from YDH the same day. Twenty per cent of
patients have been transferred out of YDH
where prior to the service being set up, they
would have spent at least one night in the
hospital. There is now a plan to implement
increased ambulatory care for patients
where they can be seen, assessed and
discharged the same day. An effective link
to primary care will be crucial to this.
CARING FOR THE COMMUNITY
On a smaller scale, but no less important
for the elderly, is a toenail cutting service
that has been set up in five different
locations. This is being advertised widely
across the practices but it is hoped that
eventually more practices will decide to
host a service so that services are available
across South Somerset. The federation is
also helping facilitate the centralisation of
leg ulcer services by September, which were
previously provided by individual practices.
The group has also done some excellent
work for its region’s carers. It has set up
South Somerset Healthcare Federation
Carers’ Champion Resource Packs to
support carers in their caring role. Primary
and secondary carers’ packs are available
at GP surgeries and contain a mass of
information to help support the carer.
These initiatives are examples of what
each federation is doing within its own
locality. Dr Helen Kingston, the CCG GP
delegate from East Mendip Federation, is
equally enthusiastic about the process as
Dr Chapman is, seeing federations as ideal
ways of taking commissioning forward.
Though the process is evolving, the
results are positive. Dr Kingston is a partner
at the Frome Medical Practice, which
also has a branch surgery in Warminster.
This has meant that she has a wealth of
expertise not only in Somerset but also in
Wiltshire and continues to work across
both health communities as joint chair
of the West Wiltshire, Yatton Keynall
and Devizes Clinical Commissioning
Group as well as the Somerset Clinical
Commissioning Group. Such expertise and
exchanges of information are invaluable
to the CCGs in their evolution. The solid,
step-by-step approach of the federations will
undoubtedly prove to be beneficial in April
2013, as will the local engagement of GPs.
One of the most important aspects
of the federation work is not just GP
engagement, however, but the engagement
and utilisation of the expertise of
practice managers. While in some areas
of the country PMs will have little or no
information on their CCGs, in Somerset
their active role makes all the difference.
“The close working of the GPs with their practice managers is the key to success, as practice managers are involved in all that is going on”
DR HELEN KINGSTON AND LEN CHAPMAN
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With reforms underway, is the NHS
turning into a marketplace?
CUttING red tape
How to establish a clinically-led
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ON wIth the shOw
Commissioning Show 2012: a guide
22 | SEPT/OCT 2012
IN ACTIONCASE STUDY
A community vision
Independent primary care provider, The Practice has launched a cataract service in the Croydon community. JULIA DENNISON speaks to locality manager KIRSTY HARBORNE and clinical director DR JEREMY ROSE to find out how it’s helping patients
I was given the opportunity to see just how cataract
treatment had progressed last month when my mother
underwent a corneal transplant. It was an in-and-out job
that required only local anaesthetic and a course of drops
for a short period afterwards. The speed at which she
was treated came as a relief since, as a costume designer,
her eyes are essential for her line of work. As someone who edits
a magazine for commissioners, I was curious as to the kind of
opportunities there must be for moving this kind of less invasive
surgery out of hospitals and into the community.
SEPT/OCT 2012 | 23
IN ACTIONCASE STUDY
I was therefore interested to find out
about a new community cataract service
in Croydon, which was promising a high
quality service closer to patients’ homes
while aiming to limit waiting times to less
than eight weeks. The service, led by Mr
Nick Jacobs, a fellow of the Royal College
of Ophthalmologists and an experienced
consultant ophthalmic surgeon, was
commissioned by NHS Croydon, provided by
The Practice and run from a newly built day
case theatre at Parchmore Medical Centre in
Thornton Heath.
SEEING EYE TO EYE
With the aging population and cataracts
being an age-related condition, their
incidence, alongside other vision problems,
is set to be a growing issue for the NHS.
With this in mind, The Practice’s cataract
service is part of a larger community-based
ophthalmic service. “I think a great deal of
conditions related to eyes traditionally seen
in a hospital setting are actually equally, if
not better provided out in the community,
closer to patients’ homes,” says Dr Jeremy
Rose, clinical director for The Practice.
This, in his experience, makes the service
more convenient, faster and to a much
higher level of patient satisfaction.
One of the reasons, historically, that
ophthalmology was banished to a hospital
setting was because of the associated
specialist equipment – such as a slit lamp
or visual field machine – which most GP
surgeries don’t have. “I’m a GP and if
someone comes to me with an eye problem
and I can’t cure it with some eye drops,
I would refer them to the hospital where
they could be examined,” says Dr Rose.
That was until he set out on the project of
establishing a community-based service
with this machinery in practice. “The
machines you can easily bring out into the
community setting; you can train GPs to
use them and do a proper assessment and
examination of someone’s eye in their own
locality,” he explains. This, in his view,
could reduce eye-related hospital referrals
by at least 70%.
The benefits of such a reduction are
plentiful: “It’s better for patients because
it’s quicker, nearer to home, a more
personal service, and they like being seen
in a GP surgery; it’s better for the health
economy because it is cheaper and in terms
of the pressure of living within our £100bn
NHS budget whilst improving the scope
and type of services we deliver, this is a real
opportunity,” Dr Rose says. “Community-
based services are more cost-effective; more
patient-friendly; and deliver better patient
outcomes – why wouldn’t you be doing it?”
OPERATION IN THE COMMUNITY
Once they had seen how beneficial
community-based eye services could be
on referrals, the team at The Practice
decided to look next at minor operations.
Offering corneal transplants was one of the
first steps towards offering slightly more
invasive types of eye surgery. “If you look
across the world – at places like India –
they will do cataract surgery on a patient
who walks in, gets done and walks home
in a village setting,” he explains. “So it is
possible to do cataract surgery safely – I’m
not suggesting in a village setting but in
the right setting, choosing the patients
carefully – so someone who is essentially
well but has cataracts.” Dr Rose believes
around 80% of cataract surgeries occur
on this kind of patient. In other words,
the need for using hospitals for certain
eye treatments could never be eradicated
completely, but could certainly be reduced
by taking these kind of minor ops into a
primary care setting.
In terms of continuity of care, a GP
setting is also an ideal place to manage
patient expectations before and after the
surgery. “General practice is quite good
at informing patients,” says Dr Rose.
“Sometimes better than hospitals are.” Of
course, there are other benefits, as locality
manager Kirsty Harborne can attest to:
“Patients feel nervous and apprehensive
going into hospital and being in a
community setting feels like going to see
their GP, so they’re more comfortable.”
From a patient’s perspective, the main
benefit of a community-based service such
as that in Croydon is a reduction in waiting
times. Where in a hospital waiting
“Community-based services are more cost-effective; more patient-friendly; and deliver better patient outcomes – why wouldn’t you be doing it?”
DR JEREMY ROSE AND KIRSTY HARBORNE OF THE PRACTICE
IN ACTIONCASE STUDY
24 | SEPT/OCT 2012
times for services like cataract surgery
have been known to be up to 18 weeks
for an assessment and another 18 weeks
for treatment, the length of time between
assessment and treatment at Parchmore
averages at only eight weeks.
This is important when you’re dealing
with something as vital as someone’s
vision. “It can be quite worrying for
patients and having to wait up to 36
weeks is not something a patient would
choose to do,” says Harborne. “They want
improvement straight away.”
SEE CLEARLY NOW
While The Practice is planning to roll out
similar ophthalmology services beyond the
confines of Croydon, investing in the right
equipment to at least bring assessment
into primary care is something that could
easily be emulated by CCGs. Optometrists
already have access to necessary equipment
and many commissioning groups may well
decide to work closer with them. “We like
to engage quite closely with optometrists,
not just because they can refer cataracts,
but actually because they’ll often see a
patient, send the patient to the GP and ask
the GP to refer them onto us, which is an
unnecessary step in the referral pathway,”
explains Dr Rose. “I think in the more
modern world we should allow ourselves to
direct-refer them to a service when they’re
happy they have the right skills to do it.”
Of course, GPs can be up-skilled to do this
as well: “If you’ve got the equipment in a
surgery, then GPs could take on some of the
lower-level services themselves but that’s a
slower roll-out service.”
Made up of a group of GP surgeries,
The Practice is one of those organisations
that sits on the same wavelength as the
‘Liberating the NHS’ whitepaper. Other
services the group has actively moved
into the community include dermatology,
ENT and sexual health. Dr Rose believes
the same model applies: “If you can get
the kit out into the community, bring
some specialist care and up-skill GPs with
special interests, you can manage an awful
lot of conditions in a community setting.
When we look at other specialties, we
should always ask ourselves: ‘Why does
that have to be done in a hospital? Are
there not ways we could bring it closer
to the patient in the community and
hopefully run it quicker and to a higher
level of patient satisfaction and, as far as
the health economy is concerned, more
cheaply?” For visionary clinicians like Dr
Rose, the changes to the NHS certainly
offer a wealth of opportunity for improving
patient care, and if they save money along
the way, so much the better.
“A great deal of conditions related to eyes traditionally seen in an hospital setting are actually equally, if not better provided out in the community, closer to patients’ homes”
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26 | SEPT/OCT 2012
COMMUNITY CARESHARING SERVICES
Sharing services between practices sounds like a practical way of ensuring patients have access to a range of treatments in their local area. So why aren’t we seeing more CCGs implementing the idea? CARRIE SERVICE investigates
Sharing services should be
easy and effective. In theory,
a GP who is trained to
provide a specific treatment
should be able to provide
this to anyone within the
local community who needs it. It should
be as simple as a couple of clicks on a
mouse and a taxi to take the patient to
the nearest provider. However, for one
reason or another, this has not been the
case for many. I spoke to David Thorne,
chief executive of Newcastle West
Clinical Commissioning Group, about the
challenges involved in sharing services.
PRACTICALLY IMPOSSIBLE
Newcastle West is a small but extremely
proactive CCG for one of the most deprived
inner city populations in the country.
Thorne explains that although the group is
well engaged they have still not managed
to get around some of the practical issues
that prevent practices from sharing services.
One service that Thorne believes does have
the potential to be shared is contraceptive
implant fitting. Some patients may prefer
to be fitted by a female GP and the CCG
recognised the potential for the service
to be made available to patients from
outside practices where a female GP wasn’t
&SHARE
SHARE ALIKE
available. With this in mind, Newcastle
West trained up around 30 of their female
GPs in hope of allowing patients from
practices in surrounding areas to use the
service. However, the project didn’t achieve
the level of success that Thorne believes
it could have, and has now fallen by the
wayside. When I ask why, he explains that
there are practical issues that may seem
trivial, but have a profound impact on the
success of this sort of project: “The practical
difficulties you always get with things like
this are the clinical IT systems that practices
have. We’ve only got 18 practices, but we’ve
got four different systems and they don’t talk
SEPT/OCT 2012 | 27
COMMUNITY CARESHARING SERVICES
to each other.” Not having a universal IT
system across the CCG meant that medical
notes could not be easily shared, creating a
clumsy process that in theory should have
been pretty straightforward. There was
also the issue of payment and who should
be acknowledged for having provided the
service. “It’s always the same things that
come up about systems, permission, and
contractual issues around payment,” reflects
Thorne. “It’s just the sheer complexity of the
NHS and the arcane nature of the system.
Can you get a £25 payment for putting that
contraceptive implant in, even though it
wasn’t your patient?”
Another drawback that has made
many wary of referring patients to a
different practice is the danger of losing
them altogether – do practices really
want to risk sending their patients off to
a GP that they might prefer? “That is a
concern [of many],” says Thorne. “But
in our practices it isn’t.” He puts this
down to good teamwork and collaboration
across the group. An issue that he believes
does warrant some concern, however, is
transport: “Because most of our patients
don’t own cars and they are on very low
incomes, there are practical difficulties
about how you get someone from one place
to another. In theory, there’s no problem at
all, we’ll get some kind of small contract
with a taxi company to take people back
and forth.” In practice though, this never
quite came off, but Thorne stresses it is
something that will have to be addressed
for services to be successfully shared in
deprived areas.
THE FUTURE
Despite not seeing much success with it
so far, Thorne does believe there is a bright
future in sharing services; commissioners
just need more time to tackle some
of the practical issues involved. With
authorisation taking up a great deal of
time over the past six months, there has
been little left over to spend on planning
“Everybody knows what we want to do, but not how to do it”
new projects. “We’re frustrated,” he tells
me. “We were making more progress on
clinical projects last year than we probably
are now. And we’re a very active group
– although we’re small we have forty
clinical commissioning projects going on
at the moment.” As well as relaunching
the contraceptive implant shared service,
there are other projects that Thorne is
hoping to see develop nicely after the
storm has settled, including a new nurse-
based ENT service for syringing ears. This
would work in the same way, with nurses
based in peripheral sites so that if the
practice nurse isn’t available that day, the
patient can be referred elsewhere. What
commissioners need now, says Thorne,
is some success stories so that they can
follow suit: “Everybody knows what we
want to do, but not how to do it. It’s getting
the right people together, going through
it and cracking all of these permission
issues and transactional-type boundary
issues, and then using that in a way that
you can replicate as a template for other
specialties.”
28 | SEPT/OCT 2012
COMMUNITY CAREREDUCING ADMISSIONS
Home comfor ts
CARRIE SERVICE takes a look at how patients can be encouraged to manage their health outside of the hospital setting and whether or not the NHS is
prepared for the change in attitudes that this requires
One of the most
effective ways of
reducing emergency
admissions is to
encourage patients to
take a self-managed
approach to their care. In the last issue
of Commissioning Success we talked
about the power of telehealth, and how
giving patients the tools to manage their
own conditions from home allows them
to be masters of their own destiny (and
subsequently, masters of the NHS as a
whole’s destiny). This concept of treating
long-term illnesses in the home has been
flagged time and time again as a way of
reducing emergency admissions and saving
the NHS money in the long term. So how
can patients be encouraged to recover in
the community, and is the help being made
available for them to do this?
UNCHARTED TERRITORY
Jean Lewis, professional lead for adult
nursing at Central London Community
Healthcare NHS Trust says that district
nurses are absolutely vital to both patients’
recuperation and maintaining their
health in the longer term. “This is even
more important for patients in the most
vulnerable groups – such as the elderly and
people with long term conditions,” explains
Lewis. “District nurses support patients
to recover in the community by providing
holistic assessments, patient centred care
planning and by liaising with health, social
care and voluntary agencies to meet the
patients’ needs.”
Ensuring patients have access to
help when leaving hospital after a
major operation, injury or illness can
clearly reduce readmissions drastically
and as Lewis points out, the role of the
SEPT/OCT 2012 | 29
COMMUNITY CAREREDUCING ADMISSIONS
district nurse in providing high quality
intermediate care is essential. However,
with decreasing numbers of nurses signing
up for district roles, implementing care at
home is going become ever more difficult.
It is understandable why fewer nurses are
willing to leave the hospital environment
and move over to district nursing, because,
as Kathryn Godfrey from the Nursing
Times acknowledges in her blog, there
is enough pressure on nurses as it is:
“It’s already a tough job without all the
increasing pressure currently being loaded
on. Working in a ‘hospital without walls’ is
a challenging role. Making decisions about
frail and elderly patients with multiple co-
morbidities in their own home takes skill
and training.” At the annual Royal College
of Nurses congress earlier this year Lansley
received a substantial grilling in the Q&A
session after his address. In answer to a
question posed about how to tackle the drop
in district nurses, Lansley is reported to
have responded by saying that the numbers
of health visitors will be increased, which
Godfrey says is “a good initiative – but
it’s not the same thing”. Can one really
be replaced with the other? The need for
health visitors and healthcare assistants
in the NHS is clear, but in the “hospital
without walls” environment as Godfrey
puts it, isn’t training and experience even
more critical?
DISTRICT COUNSEL
Moira Fraser, director of policy at Carers
First, an organisation that provides support
and information for people caring for a loved
one, held a session at the RCN congress
this year. After the event she discussed in
her blog the issues that had been raised by
delegates during her session: “They were
talking about feeling inadequate if they
identify a carer but then have nothing to
offer them, or not knowing the up to date
information on what’s available. They
also described being so rushed for time.”
Fraser suggests that a better approach to
district nursing would be to allow nurses
the freedom to treat patients holistically,
rather than simply concentrating on the
individual clinical tasks they have to
carry out on each visit, and being forced
to overlook social issues due to time
restriction: “Explaining to a carer how to
best look after the person they care for, and
dealing with their concerns about treatment
– those are clinical issues in my book.
Supporting carers with their own health
and stress issues – well that too, I would
say, is verging on clinical – or at least will
likely become so. I don’t see the problem
with measuring this and counting it as a
valued part of the nurse’s role.” Perhaps if
nurses could be allowed the freedom to do
their job in the way they see fit– in a way
that seems to be in line with a holistic
and patient led approach to health – then
perhaps more would be willing to step out of
the hospital environment and provide highly
skilled care within the home. How nurses
roles are shaped is key to the future of
community care – nurses are going to need
a wide enough skillset to work in a range of
settings in order for the NHS to allow them
to have a real impact.
TAKING CONTROL
More and more treatments that would years
ago have been restricted to the hospital
ward are now taking place within the home
as they become increasingly routine, and
this has the potential to have a significant
impact on admissions. The outcome rests
on how well and to what extent this type of
care is invested in over the next few years
as commissioning changes hands. Nurses
and other care workers need to be given
the skills-training and right equipment to
administer home treatment for community
care to become truly integrated. Telehealth
is an area which has positive results, or
so the findings from the Whole Systems
Demonstrator programme suggest. Allowing
patients to feel empowered in their own
homes could help change public attitudes
towards health. By making patients feel
they can actually have an effect on how
their illness is managed and can see tangible
improvements such as being able to spend
more time at home with family and less
time in hospital waiting rooms, they
might start to realise that their health and
happiness lies in their own hands.
INFORMATION TECHNOLOGYDIGITAL COMMUNICATION
30 | SEPT/OCT 2012
D I G I T A L D I S S E M I N A T I O N
The myriad communication possibilities opened up by the power of the internet offer a cost-effective
and relatively simple way for commissioning groups to release information and gain feedback
from the patient population. GEORGE CAREY finds out what options are available
From surveys to digital services and social
networking, there are now more ways
than ever to inform and keep in touch
with your patient population. While
some elderly patients may have resisted
the move to disperse more information
through digital channels, this method is constantly
increasing in popularity and will only do so at a faster
rate in years to come. So what are the best ways to
harness the internet to enable your commissioning
group to benefit its patients?
SURVEYS
Surveys in healthcare are nothing new but the digital
age has made them significantly easier to carry out.
The entire process has been streamlined and the
difference in costs is huge, with no paper or expensive
postage to consider. Making patients aware of the
surveys is now simple through email and the increased
feeling of anonymity can result in a higher rate of
survey completion and entirely uninhibited answers
from those who do choose to participate. Collating
the data has been simplified as well, with software
available to analyse and interpret the information
supplied at the click of a button and present it clearly
and attractively in a range of different formats. It
can then be distributed among all members of a
commissioning group with ease to aid a discussion of
the results.
DIGITAL SERVICES
The NHS has embraced the chance to enrich patients
lives with digital services and a great example of
this is the NHS Information for Parents service,
launched in May. It gives new parents information and
advice they can trust, covering a wide range of issues
related to staying healthy in pregnancy, preparing
for birth and looking after their baby. By signing up
to the service, parents-to-be and new parents receive
regular emails and text messages containing relevant
and timely NHS-approved advice as their pregnancy
develops and as their child grows. Links to videos
showing midwives demonstrating practical advice such
as bathing babies, and parents discussing issues that
affected them and how they supported each other, will
also be sent at appropriate times.
“New parents receive regular emails and text messages containing relevant and timely NHS -approved advice as their pregnancy develops”
SEPT/OCT 2012 | 31
INFORMATION TECHNOLOGYDIGITAL COMMUNICATION
SOCIAL NETWORKING
With 50% of the UK now using Facebook and the
increasing prevalence of Twitter in everyday life,
social networking can be an incredibly effective tool
for commissioning groups to communicate with those
whose care they are responsible for. One of the biggest
challenges is using social media and other digital
channels without breaching confidentiality rules and
regulations, when you are potentially talking about
people’s very private healthcare needs. Alex Talbott
is digital communications officer for NHS London
and founder of NHS Social Media (nhssm.org.uk), a
blog designed to help NHS staff and those interested
in healthcare and the web communicate. He believes
that confidentiality is not under as much threat from
social media as some would make out: “It’s something
we’ve discussed a lot on the NHSSM blog and time
and again people try to knock social media out of the
comms toolbox because of confidentiality issues. Of
course there are issues around that, but we shouldn’t
just throw it out because of this one concern, there
are too many positives that we can get out of it.” He
goes on to explain: “The standard rule applies that if
you don’t want to say it in public, don’t say it through
social media.”
It is important to bear in mind that CCGs do so
much more than treat people and there is a duty to
inform patients of vital public health messages. This
is where social media is at its most useful. Already,
initiatives such as NHS Smokefree are using a
Facebook page as a place for people using the
service to keep up to date with important
information and discuss their experiences with
other people trying to give up smoking. It’s these
kinds of applications of social networking that use all
of its strengths and avoid its potential pitfalls. While
these pages can be vulnerable to trolling – perpetual
posting of abusive messages – and other internet
abuses, it doesn’t use any confidential information
and therefore poses little threat to those using the
service. Talbott concludes: “There needs to be an
understanding that social media isn’t big and scary and
only for big companies to mess around with. There
is a possibility here for the NHS and other healthcare
providers to increase the service offer that they
currently have for patients.”
It’s time to digitise your interaction with patients
and ensure that you are getting full value from the
huge range of communication tools available. Research
carried out in June by NHS Local involving 328 people
found that more than half of those questioned would
be happy to Skype their GP. Proof if it were needed
that these advances in communication will continue
to diversify. The most progressive CCGs will grasp the
chance with both hands.
MANAGING COMMISSIONINGADVICE
32 | SEPT/OCT 2012
Communication skills, assertiveness, team-working, and delegating are just some of the challenges facing commissioners that could go overlooked. Development and training expert MARIA KORDOWICZ discusses these ‘soft’ skills
Commissioning is defined
by the Department of
Health as a process
that incorporates
assessing population
needs, prioritising
health outcomes, procuring products and
services and managing service providers.
Each one of those components, while
naturally requiring high-level specialist
knowledge, also demands the skills needed
to build successful working relationships.
With inevitable team restructuring, new
providers and the need for new CCGs to
establish themselves within the wider
community, now is the time to reflect on
our ability to meet those demands.
Good interpersonal skills are essential
to interacting with others effectively. They
can be seen as the invisible glue that binds
our working processes. They comprise our
ability to communicate with confidence
while employing active listening to
make decisions and problem-solve. Most
importantly, highly developed interpersonal
skills help us to manage our own reactions
and personal stress appropriately.
There are workshops in interpersonal
skills for clinicians aplenty, and with good
evidence to justify their existence. Time
and time again, we hear that patients value
healthcare professionals’ interpersonal
skills above everything else. Indeed,
the ‘interpersonal’ has become almost a
managerese term akin to ‘upskilling’ and
‘co-collaboration’, ever-present in training
manuals and management textbooks.
Although the ‘Liberating the NHS’
whitepaper does not use the term directly,
there is no doubt that, in particular,
putting patients and public at the heart
of commissioning decisions requires the
ability to listen, collaborate, communicate
information and guide others in the
decision-making process. These are all key
elements of our interpersonal domain and
clearly we all have these skills to a greater
or lesser extent. The new challenge is to
further develop and broaden those skills,
through self-reflection and practice.
Taking it interpersonal
SEPT/OCT 2012 | 33
MANAGING COMMISSIONINGADVICE
ASSESSING POPULATION NEEDS
Beyond the economic analyses and
numerical terms, assessing need is very
much a listening exercise. It is about
getting to know your patient population.
Here it is apt to emphasise the often-
repeated distinction between ‘listening’ and
‘hearing’. Listening depends on your ability
and willingness to focus and pay attention
to various messages representatives of
your local population are trying to impart.
It is also about giving your population a
platform to be listened to. This means that
appropriate communication pathways need
to be developed so a dialogue with your
local population is facilitated. Beware of
how your prior experience can lead you to
jump to conclusions and how stereotyping
can be a harmful barrier to understanding
true need. Be sensitive to cultural and
language differences. Avoid using jargon
and acronyms. Assessing population need
should be as much about statistical analyses
as market research ‘at the coalface’.
Remember that in the first place, it was the
genuine interest in listening to and helping
those in need that got you where you are.
PRIORITISING HEALTH OUTCOMES
Priorities are, in part, built on the
foundations of in-depth stakeholder
consultations. It is important to be clear
in the way you communicate with your
stakeholders, so as not to confuse the issue
or be misunderstood. Feedback should be
sought regularly to ensure your message
has been taken on board. The consultation
process should be an inclusive space to
exchange views, free from manipulation.
At the same time, assertiveness is required
for clear agenda setting. Being assertive is
expressing views in a way that is neither
passive nor aggressive, but harms no one,
and preserves your rights and the rights of
the organisation you are representing.
PROCURING PRODUCTS AND SERVICES
Assertiveness feeds into our ability to
negotiate. This is a process by which a
fair agreement is reached while avoiding
dispute. The ability to negotiate is often
listed in specifications for procurement
positions, as fairness, achieving mutual gain
and forging successful working relationships
are the keys to a successful procurement
outcome. To negotiate effectively you need
to accept that disagreement will naturally
be borne out of procurement processes.
Negotiating with others should, where
possible, take a structured approach where
goals are clarified and a mutually agreed
course of action is decided upon. The aim is
a ‘win-win’ outcome – this means all parties
involved will feel positive and have a sense
ownership over the outcome.
MANAGING SERVICE PROVIDERS
The ability to manage is necessary to
be an effective commissioner. With
service providers potentially being
more heterogeneous than ever before,
commissioners need to be flexible in the
way they manage others. Empathy plays
a part in allowing us to be adaptable.
Commissioners need to understand that
others may have different points of view
and ways of working. Gain trust by showing
that you can see things from the perspective
of your providers. Furthermore, by opening
services to a wider range of providers, we
in turn become open to learning about
working in new fresher ways.
These management and leadership
challenges of commissioning are rarely
stress free. Increased stress can have a
detrimental effect on joint working. The
bottom-line of high-level interpersonal
skills is the ability to recognise stress in
yourself and others and knowing when to
take stock to reassess a project.
In sum, one should not underestimate
the part that interpersonal skills play in
furthering the commissioning agenda. We
need to be aware that the interpersonal is
the binding force behind effective working
relationships. In order to nurture those
skills, it is important to take time to reflect
on our own strengths and weaknesses.
Maria Kordowicz is founder of Akord People
“Listening depends on your ability and willingness to focus and pay attention to various messages representatives of your local population are trying to impart. It is also about giving your population a platform to be listened to”
MANAGING COMMISSIONINGTOP TIPS
34 | SEPT/OCT 2012
Diabetes management
Diabetes has hit crisis point, so what can be done to help your population better manage the disease and bring down costs? We ask three experts what measures could have a positive impact on how diabetes is managed in the UK
DR PAUL GRANT, DIRECTOR OF COMMUNICATIONS AT THE YOUNG DIABETOLOGISTS FORUM (YDF)
“The future of diabetes relies on an investment in integrated care – ensuring that patients with
difficult to manage diabetes see the right professional, be it diabetes specialist nurse, GPwSI
or diabetologist, at the right time, without inappropriate delays relating to worries about short
term cost savings. The YDF recommends the use of a strong IT infrastructure, with a powerful
enough database to capture all the requisite information about patients, which can be shared
between healthcare professionals. Patients should be empowered to know about the standards
of care they should expect such as the Diabetes UK ‘15 healthcare essentials’. Whatever form
a diabetes service takes; it should be open to peer review and ongoing assessment to make
sure that patients are being managed effectively. On a practical basis, practices can ensure that
adequate information and support are available – posters, information leaflets and details of the
local Diabetes UK voluntary support group for example are crucial.”
SUE MARSHALL, TYPE1 DIABETES SUFFERER AND EXPERT AND FOUNDER OF DESANG, A
SUPPLIER OF DIABETES KITBAGS AND A WEBSITE/INFORMATION CENTRE FOR DIABETICS
“Action now – in terms of diabetes education and supplying blood test meters and strips –
will prevent later hospitalisation of patients, yet there are often reports that GPs surgeries
are restricting the prescribing of test strips. Access to strips is a basic way to improve health
outcomes in those interested in their health enough to bother to use them. An interested
patient should not be deterred in this, it is a trifling cost next to that of being hospitalised,
although that cost will be on someone else’s budget, it still comes out of the NHS as a whole. It
is a case of prevention.”
ALAN EASTWOOD FROM ONLINE DIABETES FORUM DIABETESSUPPORT.CO.UK
“Diabetes is a very individual condition and people need to learn how their bodies react to
and tolerate different foods, and the only way they can do this is to be able to monitor their
reactions. On countless occasions highly-motivated and capable members of our support
forum have been refused this facility and have had to either self-fund or simply rely on periodic
HbA1c tests which, if not good, will provide no clue as to where the problems may lie. In
contrast, those who are able to self-monitor had shown great improvements – often resulting
in reduction in medications and non-diabetic blood sugar levels. The argument against self-
monitoring is cost, yet complications from poor management cost the NHS considerably more.
Diabetes is 99% managed by the individual, as it is a 24/7 disease. Without the proper tools and
guidance to manage it well, complications are far more likely.”
“Diabetes is 99% managed by the individual, as it is a 24/7 disease. Without the proper tools and guidance to manage it well, complications are far more likely”
