Managed Practices A Useful Guide for Local Health Boards 1
Contents 1. Managed Practices 2. The Beginning 2.1 Handover Strategy 2.1.1 There are several very real scenarios that could result in Managed practices 2.1.2 There are several important actions the Local Health Board should take 2.1.3 Example of the Communications checklist 2.1.4 Note on staff 3. The Middle 3.1 Principle of Managed Practice 3.2 Developing an Action Plan 3.3 How 3.1.3 Identify and prioritise the issues 3.3.2 Identify the timescales 3.3.3 Identify specific objectives and tasks 3.3.4 Identify the resources 3.3.5 Writing up the Action Plan 3.3.6 Develop a review timetable 3.3.7 Exit Strategy 4. The End 4.1 If the application is from GPs/nurses already working in the practice 4.2 For all applicants 5. The Financial side of Managed Practices 2
About this guide Rhondda Cynon Taff tlhb and Caerphilly tlhb have faced similar challenges in regenerating primary care through managed practices and have approached the challenge in very different ways. This guide is one outcome of the two organisations working together in partnership to discuss and share the strengths of what worked and what did not work in the context of managed practices. The discussions involved those staff who were and still are actively involved in shaping and delivering services within the managed practices throughout Rhondda Cynon Taff and Caerphilly. The intention is for this guide to draw on and share the lessons learnt with others facing similar challenges. We are happy to share our experience with you. Judith Paget Chief Executive Caerphilly Teaching Local Health Board Mel Evans Chief Executive Rhondda Cynon Taff Teaching Local Health Board 3
1. Managed Practices It is really important that Local Health Boards see Managed practices as an opportunity to improve services to patients. Unless a robust structured baseline assessment is in place it is impossible to evaluate that improvement. 2. The Beginning 2.1 Handover Strategy It is extremely important that Local Health Boards are quick to identify potential problem practices. There is a very real opportunity for Local Health Boards to proactively manage this change and succession plan for the future. These practices are likely to have one or more of the following shortcomings: Staffing problems Excessive complaints Serious clinical incidents No practice manager Poor quality surgery building Low Quality Outcomes Framework (QoF) points Few chronic disease management clinics Concerns over prescribing Few enhanced services 4
2.1.1 There are several very real scenarios that could result in managed practices The GP(s) could be in poor health and be looking for a way out of general practice, whilst wishing to secure continuity of care for his patients The practice may be a poorly performing practice (see above, if appropriate) The practice becomes vacant due to a resignation/retirement In most cases the Local Health Board should be able to work with the practices prior to the GP Principal leaving. If possible salaried GP(s) and/or salaried nurses should be placed in the practice three or more months in advance of the GP Principal s exit to learn from experience and provide the patients with continuity of care. This also allows relationships to form between the incoming GP(s) and/or nurses and the staff. This is a very attractive option for the GP Principal as they can continue to earn the practice income until they leave, their patients are looked after and they can wind down over a period of several months. 2.1.2 There are several important actions the Local Health Board should take Keep the Business Service Centre informed of the situation throughout the process Discuss the situation with the Local Medical Committee Ensure that the Local Health Board receives written confirmation from the GP Principal on their exit date Write to all patients, keep them updated 5
Advise the partners, health visitors, district nurses, midwives, local pharmacists, etc Secure a lease on the surgery building Agree a price on the furniture and equipment that the Local Health Board wants to keep. Ensure the GP Principal receives early settlement Undertake the baseline assessment of the practice and decide on an action plan Ensure the action plan considers the summarisation of notes Involve Human Resources Department at an early stage to ensure that all staffing issues are dealt with (*see note below) Ensure that LHB complies with its own internal processes/policies for recruitment of practice staff, i.e. completion of approval to recruit forms, staff transfer forms, CRB checks, enrolment forms. Use an experienced practice manger to assist the process Decide whether the practice should see representatives from the pharmaceutical industry Appoint a lead clinician Develop a communications checklist 2.1.3 Example of the communications checklist Pre-takeover, ask GP Principal to keep staff informed Advise all existing staff in writing, informing them of the managed practice process and offering reassurance concerning job security Ensure that all practice staff meet with LHB involved staff as soon as possible 6
*Arrange for Human Resource staff to meet with practice staff to address any fears e.g. contracts, job descriptions, job security, development opportunities, agenda for change, benefits, etc. Inform the following of the changes: District nurses Midwives Health Visitors Local Practices NHS Trust Local Pharmacies Physiotherapist Podiatrist Social Services Community Mental Health Team Out of Hours Service Introduce regular practice staff meetings Introduce regular clinical staff meetings, to include the wider primary care team Write to all patients, keep them updated Consider posters in the Community and definitely in the surgery Consider advertising in the local press 7
2.1.4 Note on staff The Local Health Board should give careful consideration on how to handle staff. The majority of practice staff receive some remuneration for QoF achievements and their GP pays for their Christmas function. If the Local Health Board is unable to sustain these benefits, it needs to be upfront with staff and tell them. It is important that the Local Health Board prepares a vision statement for the practice. Objectives should be set for 1 year, 3 years, 5 years, etc. At this point Local Health Boards would do well to consider whether they should aspire for the practice to become a training practice, host medical students and/or be a willing volunteer for new developments/pilot projects. 8
3. The Middle 3.1 Principle of Managed Practice As mentioned in the previous section once a practice is acquired by the Local Health Board as a managed practice the Baseline Assessment Workbook should be completed. When audits, Welsh Assembly Government and other organisations ask the Local Health Board in the future for details of improvements made during the managed practice process the Workbook will give the answers. The Baseline Assessment Workbook has been designed by a team who have experience of dealing with several managed practices. One of the major concerns expressed by the team was that it is virtually impossible to measure progress unless you have a start point. The workbook is not meant to be prescriptive and will be made available as a Word document to enable you to make amendments to the information you wish to capture. The workbook will allow you to undertake and record the first two annual reviews against the baseline assessment, although if the Local Health Board so wishes the dates of these reviews could be shortened. Included in the workbook is an inventory, which if used correctly can serve two purposes. It can be used as a record of the equipment purchased from the GP principal and the equipment that was discarded. If the inventory is kept up to date to include Local Health Board purchases it can be used as a vehicle to sell equipment/furniture to a new partnership as and when that happens. All health organisations are quite rightly keen to record actual measurable achievements e.g. movements against QoF. It is important however to record 9
the staff views/atmosphere within the organisation. Included in the workbook is a section on staff interviews with suggested questions which we think will capture the mood of the practice and give a baseline to be measured upon at the reviews. It is recommended that Local Health Boards use an independent interviewer, e.g. a member of the local Community Health Council or the Community Lay member of the Board. 3.2 Developing an Action Plan Following the completion of the baseline assessment the lead clinician should bring together all clinical and non clinical members of the team to develop a flexible action plan for the practice. This work can be a very productive team building exercise. The clinical lead should manage the process and be fully supported by the LHB. Good communication is essential and a clear communication strategy should be developed to ensure effective dissemination of information. This will include communication within the practice, between the practice and LHB, and for patients, carers and other users of the surgery. Aims and objectives must be agreed with all stake holders and their clarity will contribute significantly to the success of the project. 10
3.3 How 3.3.1 Identify and prioritise the issues The action plan should be based on the practice s Baseline Assessment which will have gathered all the available evidence and summarised the existing concerns. This should be reviewed by all the team members. A number of serious concerns may have led to the need for an action plan, but it is important to consider all the possible areas of concern to ensure that these are identified. Each issue needs to be risk assessed and prioritise. It may be helpful to do this under three headings: Those which must be done Those that should be done Those that the team could address should time and other resource issues be sufficient 3.3.2 Identify the timescales The timescale of the project as a whole needs to be clear. In general action plans for managed practices tend to fall into three main categories: Phase 1 Dealing with immediate problems (3-6 months) e.g. team building; accommodation; staffing concerns; basic systems and processes Phase 2 Improving standards (6-18months) e.g. chronic disease management; staff development. 11
Phase 3 Polishing e.g. New developments; additional services; planning LHB exit strategy. 3.3.3 Identify specific objectives and tasks These should be S.M.A.R.T: Specific, Measurable and Achievable in a Reasonable Timeframe. The Action Plan should identify roles and timescales against particular actions with clearly identified contacts both within the Practice and the LHB. 3.3.4 Identify the resources The available resource needs to be considered and mapped against the specific actions in conjunction with the LHB and financial availability. There may already be particular work being undertaken that can compliment the need of the action plan. Staffing resources should also be considered. 3.3.5 Writing up the Action Plan This may be best undertaken by a small group and then circulated for comments. The final Plan should be agreed by a fully representative meeting to ensure engagement of all stake holders. 3.3.6 Develop a review timetable There should be clarity about what action will be undertaken if objectives are not achieved. It is important to have a strategic view of the project with 12
membership that has sufficient authority to revise objectives where necessary and also to access appropriate resource. This group or individual should also clearly understand the actions needed when objectives are not reached 3.3.7 Exit Strategy Unless the involvement with the Practice is to be very long term an exit strategy should be considered and developed wherever possible. This helps to give structure to the overall project and helps to minimise any uncertainty for staff members at the Surgery. Where possible the longer term aims for the Practice can be outlined and movement towards this position should be integral to the objectives of the plan. This is also a good opportunity to set high standards and the Local Health Board should consider aspiring to become a training practice and/or hosting medical students. Local Health Boards should use the managed practice process as a way of transforming a practice in difficulties or one that is poorly performing into a well organised practice providing a wide range of quality services. It is no doubt a challenging agenda, however if managed correctly it is extremely rewarding. It is extremely important that Local Health Boards make an immediate difference and show their good intent. There are a few very quick wins for both patients and staff e.g. Local Health Boards should ensure staff have job descriptions, contracts and are graded appropriately. They should also provide quality equipment, furniture and furnishings. 13
The Local Health Board should consider staff away days and/or team bonding sessions. It is important to allow the staff to develop and build sound foundations for the future. The Local Health Board also needs to realise that these salaried GPs will be taking on more responsibility than a normal salaried job; it is almost a partner/principal role. As a consequence the salaried GP will need more support. It should be remembered that this transition period could lead to more complaints, especially over issues such as sick certification and the prescribing of antibiotics. The Local Health Board needs to be extremely supportive of the stance taken by the new GPs. If the surgery building is poor the Local Health Board will need to look for a long term solution, although the Estates Strategy should already have covered this. If the Local Health Board is looking to attract young GPs into the area it will need to provide a quality building and might wish to consider taking the head lease on the new development. This removes an added pressure on GPs, especially in deprived areas. There is no set period of time that a practice should be Local Health Board Managed, although in some cases it could take up to three years to establish a well organised, well resourced practice, providing a range of quality services and scoring well under QoF. At this point the Local Health Board needs to consider the future of the practice and has only three real options: Continue with salaried GPs Advertise the practice Allow the salaried GPs working in the practice to go into partnership 14
The third option may be the most attractive option given that the Local Health Board has recruited the salaried GPs in the first place, and therefore one would hope that these GPs are very good quality primary care professionals. In addition, these GPs have worked hard to improve the practice and are familiar to both patients and staff. It is important that the decision making process should not be made onerous. (The Local Health Board recruited the salaried GPs into the practice in the first place). The Local Health Board should provide all available financial data and proactively work with those GPs to prepare a business plan for consideration. Should those GPs fail to agree a partnership, the Local Health Board should consider advertising the partnership, however this will probably require a solution to the surgery building prior to undertaking this process. 15
4. The End The Local Health Board should set up an internal process to consider any application to take over a practice as a partnership, whether it be from the current salaried GPs, other GPs or a commercial provider. The individuals included in the decision making process should probably include the Chief Executive, the Director of Primary Care, the Medical Director, the Nurse Director, the Community Lay member of the Board, Community Health Council Representative, and a Local Medical Committee Representative. The list below details potential information that this panel might wish to consider and it is for each Local Health Board to decide on the content of the application; 4.1 If the application is from GPs/nurses already working in the practice Details of performance to date, with areas identified for future improvement Outline the practice s Strengths, Weaknesses, Opportunities & Threats (SWOT analysis) Provide details of training requirements for current workforce Provide a copy of the practice Clinical Governance Assessment tool 4.2 For all applicants Identify the major health needs of this area 16
Identify those services/clinics you would wish to provide and a time scale for implementation What ideas have you for the surgery in regard to health promotion Identify any potential increase in staffing to provide these extra services and how the increase would be funded Provide details of your proposed staff contract, job descriptions and personal development plan process How would you integrate Clinical Governance into the culture of the practice Provide a list of the audits carried out by the applicants during the past 3 years, your findings and the changes made as a result of the audit. Details of ideas for future audits Identify the risks on taking on this practice and how you would deal with them Explain your policy for monitoring and disseminating Significant Events Provide details of your proposed Complaints Procedure Detail a plan for achieving Advanced Access in the new surgery, taking into consideration the increase in patient list size. Provide full details of the appointment system that would be implemented with timetable Provide a plan for developing paperless working Provide a plan for increasing patient involvement in the practice Prepare a marketing plan for the new surgery 17
Prepare a vision for the new practice 5.0 The Financial Side of a Managed Practice The important message to all Local Health Boards is do not micro-manage these practices, they must be allowed to develop. Review the last years practice income Identify which type of income with a payment date relates to Local Health Board managed practice and which relates to the exiting GP Work with the Business Services Centre so cut off dates for certain payments to the exiting GP are agreed Set two budgets, this years and the next, taking into consideration that the Local health Board may need to commit non-recurrent funding to get those quick wins. This also allows you to estimate the resources in terms of GP, nurse and practice management time that can be put into the practice. Explain the Local Health Board standing financial instructions and standing orders to the practice manager Concepts such as obtaining three quotes are important, so communicate these requirements to the practice Ensure the practice manager understands the process for claiming enhanced services fees 18
Involve Human Resources Department in the process as all practice staff need to be set up on payroll Ensure the practice manger has details of the budget and is set an expenditure limit Give the practice a realistic petty cash float Continue to review the earning potential of the practice, it may allow you to invest more in staff and resources Establish robust budget monitoring procedures Involve your Finance Directorate and use their experience 19