professional support and expert advice for gp partners and … · 2018-05-24 · volume 4 issue 3...
TRANSCRIPT
VOLUME 4 ISSUE 3NOVEMBER 2016 UK
Practice MATTERS
Professional support and expert advice for GP partners and practice managers
INDEMNITY WHEN WORKING AT SCALE How new care models and other changes in primary care can affect your medical indemnity.
WORKING AT SCALE – THE STORY SO FAR Medical Protection examines the reality of the new care model.
THE FUTURE OF PRIMARY CARE REFORM Dr Michael Holmes, RCGP Clinical Lead for the Supporting Federations Programme, looks at what’s next for general practice.
INSIDE...
LIFE INSIDE A HUBAdvice on the top medicolegal challenges posed by new care models Page 12 SPECIAL
EDITIONNEW CARE
MODELS
Opinions expressed herein are those of the authors. Pictures should not be relied upon as accurate representations of clinical situations. © The Medical Protection Society Limited 2016. All rights are reserved.
GLOBE (logo) (series of 6)® is a registered UK trade mark in the name of The Medical Protection Society Limited.
The Medical Protection Society is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world.
The Medical Protection Society Limited (MPS) is a company limited by guarantee registered in England with company number 36142 at 33 Cavendish Square, London, W1G 0PS.
MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS is a registered trademark and ‘Medical Protection’ is a trading name of MPS.
Practice Matters (Print) ISSN 2052-1022 Practice Matters (Online) ISSN 2052-1030
Cover image @Stockbyte/iStockbyte/thinkstockphotos.co.uk
Dr Rachel Birch EDITOR-IN-CHIEF
The Medical Protection Society Victoria House 2-3 Victoria Place Leeds LS11 5AE United Kingdom
Please direct all comments, questions or suggestions about MPS service, policy and operations to:
Chief Executive Medical Protection 33 Cavendish Square London W1G 0PS United Kingdom
In the interests of confidentiality please do not include information in any email that would allow a patient to be identified.
Medicolegal advice Tel 0800 561 9090 Fax 0113 241 0500 [email protected]
Membership enquiries Tel 0800 561 9000 Fax 0113 241 0500 [email protected]
medicalprotection.org
EDITORIAL TEAM
CONTRIBUTORSDiane Baylis, Dr Helen Hartley, Martin Eades, Dr Michael Holmes, Dr Nick Clements, Dr Rob Hendry
PRODUCTIONPhilip Walker, Communications Project Manager Paul Moss, Design
MARKETINGMichelle Buckingham
Sam McCaffrey EDITOR
Rosie Wilson STAFF WRITER
Kirsty Plowman EDITOR
Get the most from your membership…
Visit our website for publications, news, events and other information: medicalprotection.org
Follow our tweets at: twitter.com/MPSdoctors
04 Noticeboard News and updates from the Practice Matters team.
06 Working at scale – the story so far Rosie Wilson examines the story so far for new care models. 09 The future of primary care reform Dr Michael Holmes, RCGP Clinical Lead for the Supporting Federations Programme, looks at what is next for general practice.
10 New care models and GP alliances: the impact on staffing HR experts at Croner provide advice on the key considerations on staffing for organisations working at scale.
12 Life inside a hub: top medicolegal challenges Medicolegal Adviser Dr Helen Hartley provides advice on the top medicolegal challenges posed by new care models.
15 In Focus: Priory Medical Group Managing Partner Martin Eades tells us about a new joined-up care model his organisation is pioneering in York.
16 Scaling up your work, scaling down your risk Clinical Risk Education Manager Diane Baylis explains how our risk education team can support GP federations and other organisations working at scale.
18 In the hot seat… Dr Rob Hendry Our Medical Director explains how we are adapting to the changes affecting primary care.
20 Indemnity when working at scale Dr Nick Clements, Head of Risk and Underwriting Policy, answers questions about how new care models and other changes in primary care can affect your medical indemnity.
22 From the case files A case that demonstrates some of the risks practices face when working at scale, and the importance of ensuring effective systems and communication across practices.
We welcome contributions to Practice Matters, so if you want to get
involved, please contact us on 0113 241 0377 or email: [email protected]
What’s INSIDE...
16
12
LIFE INSIDE A HUB
SCALING UP YOUR WORK,
SCALING DOWN YOUR
RISK
20
INDEMNITY WHEN
WORKING AT SCALE
WORKING AT SCALE
06
FROM THE CASE FILES
22
10
THE IMPACT ON STAFFING
NOTICEBOARD
ou might notice that this issue of Practice Matters is a little bit different to previous issues. We still have all the usual advice and guidance on issues from HR to risk management, but in this special
edition, we have a particular focus. We are looking at how primary care is transforming, and the new care models that are the future of general practice.
NHS England has a mandate to ensure 50% of the population is covered by a new care model by 2020/21, the end-date of the Five Year Forward View period.
The upshot of this is that everyone who works in general practice must prepare for change. Some of you may already be going through these changes, others will be preparing for it to come.
But it is not only you who has to change. We do too. As a member organisation our aim is to provide you with the best advice, support and protection, tailored for the work you are doing. This means that as you begin to work in new ways; forming groups or federations, working extended hours and weekends, providing more services in the community, and bringing new roles into the practice team, we need to find new ways to support you.
We are doing this in a number of ways, offering:
• Bespoke indemnity solutions – tailoring price, products and services to individual need• Protection through partnership – integrating our risk management approach at every level • New membership options – for multi-site working, extended access and multi-disciplinary teams• Access to expert advice at every step – so you’ll know you have the right protection in place.
For more on how we are adapting to the changes in primary care, and what we can offer your practice, see our Q&A with Medical Director Dr Rob Hendry on page 18.
This issue is packed full of information, advice and guidance for members working in new care models, and those who
are still considering the best way forward. We know one of your biggest areas of concern is how these new models may affect your indemnity arrangements, so on page 20 Dr Nick Clements, Head of Underwriting Policy, answers your questions.
On page 6 we put the new reality of general practice in context and take a look at the story so far for new care models. We then look to the future on page 9, as Dr Michael Holmes, RCGP Clinical Lead for the Supporting Federations Programme, examines what is next for primary care.
HR experts Croner provide advice on the key considerations on staffing for organisations working at scale on page 12, while on page 14 one of our expert medicolegal advisers provides advice on the top medicolegal challenges posed by new care models.
As we move forward together into this new future it is important to remember that we are here to support you. We are experts on medicolegal issues and indemnity, something that can become complicated when you’re merging practices, moving staff around, setting up a new organisational structure or care model, and bidding for and developing services.
We are here to help if you have any questions. Our local representatives can help you assess and define your indemnity needs and potential solutions. Our medicolegal advisers provide expert advice to help members with any worries, questions and concerns arising from general practice. We also have a specialist team on hand to help with complaints handling.
I hope you enjoy this edition. We welcome all feedback, so please contact us if you have any comments or questions.
Dr Rachel Birch Editor-in-Chief and Medicolegal Adviser
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WELCOME
Snippets and hot topics from Medical Protection’s general practice team
CCGs HAVE SPENT MILLIONS
TO SUPPORT FEDERATIONS
CGs around England have spent millions on helping
practices form larger organisations.
Across the 92 CCGs that took part in the investigation
by Pulse, almost £15m has been spent on helping GP practices
to federate or work in networks or clusters.
Some of the figures revealed include:
• NHS Warrington CCG has spent £268,000 specifically
towards practices moving towards seven ‘clusters’.
• NHS North Staffordshire CCG and NHS Stoke on Trent
CCG set up a £300,000 facility under which practices
could claim 60p per patient to set up GP federations.
• NHS Portsmouth CCG has spent £227,000 on the
development of an alliance.
• NHS Leeds South and East CCG made £3m worth
of ‘resilience’ funding available on the condition that
practices work ‘collaboratively’.
• NHS Oxfordshire CCG spent £5m on the setting up of
three federations.
NHS England said in April’s General Practice Forward View that
it will ask CCGs to provide £171m of ‘practice transformational
support... to stimulate development of at-scale providers’.
For more information, visit pulsetoday.co.uk/hot-topics/
general-practice-forward-view
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NHS ENGLAND TO MAKE TRADITIONAL CARE MODELS ‘PROGRESSIVELY LESS ATTRACTIVE’
HS England will make it “progressively less attractive” to continue working in traditional care models, according to the general practice magazine GP.
It is reported that Jacob West, National Lead for the New Models of Care Programme, said NHS England was looking at ways to encourage local healthcare systems to adopt new models of working.He said that NHS England had a mandate to ensure 50% of the population was covered by new care models by 2020/21.“The mandate from NHS England said it wanted to see 50% of the country covered by new care models of one type or another by the end of the Five Year Forward View period. That’s a hugely ambitious trajectory.“I think we’ve learned from change programmes in the past that you probably can’t just put out a document and hope other people read and implement it. This is about a multifaceted and quite sophisticated approach to supporting and encouraging local health and care systems who want to work differently.“Some of it is pull, that’s things like funding and so on – and there will be further funding in 2017/18 for new sites who want to adopt these kinds of models – but there is also some push – how do we make it more attractive to work in these different ways and less attractive progressively to work in the prevailing clinical models? That is the challenge we need to answer.”
To read the story on GPonline in full, go to: https://goo.gl/gWuCEl
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IS BIGGER BETTER? RESEARCH ON LARGE-SCALE PRACTICES REVEALED recent report from The Nuffield Trust has revealed that 75% of English practices have now joined large-scale GP organisations to help cope with
rising pressure and policies demanding longer hours and new
services.This research summary presents the findings from a 15-month study of large-scale general practice organisations
in England. The key findings noted in ‘Is Bigger Better? Lessons
for large scale general practice’ include:• working at larger scale can help to improve sustainability in core general practice;• board accountability to member practices is important in
order to build trust and engagement;• marked differences in quality of care compared to the national average were not detected;• patients had mixed views about large-scale general
practice;• staff were broadly positive about working in a large-scale
organisation;• relationships with commissioners and providers
influenced the ability of general practice organisations to extend their remit beyond core services; and
• national and local policy-makers and commissioners need to have realistic expectations of what large-scale primary care organisations can achieve.
The full report can be accessed at: nuffieldtrust.org.uk/large-scale-general-practice
A MEDICAL PROTECTION OBTAINS
COURT RULING THAT SHIELDS
GPS AGAINST RELEASE OF FITNESS TO PRACTISE DATA
High Court judge has ruled in favour of Medical
Protection and has ordered the GMC not to release
an expert report obtained during an investigation
into the fitness to practise of a GP. The case sets a precedent
that should protect the privacy of doctors under investigation.
The legal dispute arose when a patient, whose complaint
was not upheld, requested a full copy of a report obtained
by an expert which was partly relied upon by the GMC case
examiners to dismiss the case with no further action.
The GMC initially agreed to release the report on the
basis that the patient had a right of access under the Data
Protection Act 1998, despite the express refusal of consent
from our GP member. It is an accepted principle that where
two parties’ personal information is inextricably linked, a
balancing exercise must be done to decide whether to release
data.
Medical Protection successfully argued in court that the GMC
had “unfairly prioritised its and [the patient’s] interests over
the [GP’s] privacy rights”.
The judge stated that GMC’s balancing exercise had “fallen
into error and got the balance wrong”, ruling that it “never
gave any real weight to [the GP’s] privacy rights as a data
subject; and instead focused on [the patient’s] rights and the
issue of transparency”.
We hope that the judgement will protect doctors privacy in
future cases and ensure that the GMC properly considers the
interests of doctors.
Read more on this story on GPonline: https://goo.gl/yEYCJu
A
WORKING AT SCALE THE STORY SO FARWith increasing pressure on GPs, many practices are looking towards super-practices and federations as solutions. In theory, working at scale makes for better contracts, more funding opportunities and the benefit of shared resources. But is this the reality of the new care model? Rosie Wilson investigates
NEW CARE MODELS here have been a number of factors in the rise of demand for new care models; the Prime Minister’s Challenge fund of 2013, higher expectations from patients and the evolution of
CCGs being the prevalent few. In order to develop new care models, many general practices up and down the country have been required to consider working at scale.
To work at scale, practices are presented with several different choices, including becoming part of a super-practice or federation. A super-practice is a comprehensive merge in which practices could lose their autonomy – and can therefore experience problems in terms of opting in and out of specialities. Practices that federate, on the other hand, retain more flexibility and can operate largely as single entities, but generally with a shared common interest. If a company is formed to enable the federation to operate, it does so independently from the practices’ day-to-day operations. If there are areas that individual practices want to lean towards or stay away from as part of a federation, they can, but they still benefit from the increased resources that make it possible to develop different ways of working.
Thanks to an ageing population, rising patient demands and concern over funding and GPs being stretched to capacity, working in a new care model is becoming an increasingly attractive prospect for practices. By joining together to share resources, practices can pitch for increased funding – and it’s often a case of strength in numbers.
It’s not always just a voluntary lean towards the benefits though, and particularly smaller practices are finding that the traditional ways of delivering general practice are no longer proving effective. According to one member, the manager of a small, rural practice, “We didn’t really have a choice [on joining a federation]. There was no way we could deliver the services expected from us with our funding going down and down each year. And they were expecting us to offer more in the community.”1
And even large practices are feeling the pinch with a set of
different pressures and considerations that are nonetheless proving challenging. A GP at a larger practice said, “[Federating] is the only way we will cope with the demand to make healthcare at a primary level better.”
MAKING IT A REALITYWhile NHS England’s claim that 50% of the population will ideally be registered within a new care model by 2020 sounds like a lot, sample research carried out by the Nuffield Trust and RCGP2 indicated that 73% of GPs and practice staff in England were already part of a collaboration, although not all of these were formal and registered at the time of response. 44% of these collaborations had been established in the previous 12-month period.
And other new care models are also proving successful. According to a study by the University of Sussex3, which took a sample of 34 practices in central London, A&E attendance was reduced by 10% on weekdays and 18% on weekends, thanks to the introduction of seven-day GP access pilots.
So perhaps the initiative is not only about working bigger, but working smarter. With CCG and government funding, there are myriad options available to practices looking to scale up their care model – but the fact that it is not ‘one size fits all’ has proved a challenge to some.
CHALLENGES TO THE NEW MODELTypically, it is the larger practices that flourish under a federation. For these, extended opening hours, big contracts and enhancing the skills of their GPs is not only driven by the Five Year Forward View, but a natural progression of the business. For other practices, though, collaborating can prove difficult.
Speaking to Medical Protection, one federation board member said: “We’ve not been able to do anything because nothing is being passed down from the CCG; there are no contracts for us to apply for. So we’re now looking at how to make savings from any economies of scale.”
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Economies of scale might seem like a minor aspect of forming a new care model, but they’ve been taken as somewhat of a ‘quick win’ by federations and super-practices whose funding and profits are taking time to come to fruition.
“It’s a delicate balance but we’re getting there,” said a different board member. “We are going into A&E to offset patients being unnecessarily kept in hospital overnight, which saves costs all round. We try and manage referrals within the community via satellite consultants, and we’re planning a whole list of new services and opportunities which help the community and manage our costs.”
While the advantages are recognised, there are hurdles to overcome; there have, for instance, been technological issues to combat. Many practices have complained of IT systems that do not integrate well with the systems of the other member practices, and the need for a single IT platform that is difficult to provide.
Indemnity is another concern for a lot of practice managers and board members, who have found that while professional protection for GPs is relatively straight forward, it can be a lot more complicated to indemnify a whole organisation, or nurses and healthcare assistants working across multiple sites. Medical Protection is currently working with members who have elected to work at scale in order to ascertain the most appropriate way of providing indemnity and supporting members through change.
On page 20, Dr Nick Clements, Head of Risk and Underwriting Policy at Medical Protection, answers questions about how new care models and other changes in primary care can affect your medical indemnity.
LOOKING FORWARD
Overall, the future looks promising for federations and super-practices that have elected to work at scale – although there remains a lot of work to be done. As profits begin to turn in the next few years, it will become evident what has been successful – and what hasn’t – in the formation of super-practices and federations. As the Nuffield Health survey2 surmises, while there is no marked improvement in the quality of care provided by federations compared with the national average in the initial stages of the project, large scales are found to “improve sustainability in core general practice through operational efficiency and standardised processes, maximising income, enhancing the workforce and deploying technology.”
CONTINUED PAGE 8...
Nuffield Group’s essay ‘Is bigger better? Lessons for large-scale general practice’ contains recommendations for the success of practices working within new care models. GPs working ‘at scale’ may wish to consider the following:
• Agree the purpose, value and short to medium term goals of the organisation
• Consider creating specific and measurable quality improvement targets consistent with local commissioning projects
• Develop staff roles across practice boundaries, create career pathways and peer support and learning opportunities
• Design the simplest governance arrangements possible for delivering agreed goals.
For the full essay, visit the Nuffield Health website.
“
“
[Federating] is the only way we will cope with the demand to make
healthcare at a primary level better
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REFERENCES
1. Corporations and Federations research findings; Medical Protection and Compass Research (2016)2. Collaboration in general practice: surveys of GPs and CCGs; The Royal College of General Practitioners and Nuffield Trust (2016)3. Journal of Health Economics (2016) www.sciencedirect.com/science/article/piis0167629616300236
Simon Boycott is the Head of Services at the Leeds West Primary Care Network. Here, he discusses with Medical Protection his experience of the relative merits and pitfalls of establishing - and maintaining - a new care model.
IN PROFILE: Leeds West Primary Care
e applied for the Prime Minister’s Challenge fund to run an enhanced access service across Leeds West, but the scheme didn’t choose our proposal so we didn’t get government funding initially. However, the CCG was very keen to see it happen and so it was funded that way. For the past
couple of years, we’ve been running an enhanced access service in two localities of Leeds, whereby the patients of several different practices can come to a hub site at the weekend; 8-4 on a Saturday and a Sunday.
It has forced us to look at the way we each run our services and find the best way, regardless of individual preference. And once you start reassessing general practice, you have to consider the current model of delivering care, and whether it’s still fit for purpose. And I think our experience of delivering enhanced access at scale has shown us the models that we might use and the approach that we might have to that, so it’s been very useful from that perspective.
When we saw the opportunity to scale it up across the whole CCG, though, we knew we were going to have to do something a bit more robust. We’re working towards introducing video consultations and better access to putting online services at the ‘front door’ of primary care.
Since then, we’ve been awarded an APMS contract as part of wave two of the Challenge fund, so we’re currently rolling it out across the whole CCG. To receive the money, we’ve registered as a limited company, and each practice in Leeds West had to buy shares in order to become a part of the group. So it has developed – we’ve gone from providing services at scale in smaller schemes to providing services at scale within a federation company.
Federating has thrown up a lot of interesting challenges, particularly around corporate and clinical governance. Indemnity arrangements can become more complicated and expensive when we’re looking at employing more staff to deliver unscheduled care, including nurses and healthcare assistants.
Medical Protection is helping us to find solutions – but we’re aware it’s been a national difficulty, not just for us. It’s fine for doctors, who are generally covered, but to get different staff members indemnified – particularly if their current indemnity is with different companies – has been problematic; and we’re aware that nursing staff are key to making new care models more efficient and effective.
So it’s been very successful, but not without its challenges. When you run something from the centre of a group, there are issues surrounding ownership, and this has repercussions on the practice managers, especially in the early days. I know of practice managers in our region that had a hellish few months while we were setting it up, because they were essentially doing two full-time jobs. It wasn’t until we used some of the scheme funds to employ a hub manager that we really started to see the benefits. It was the first indication that if you recruit separate staff for the middle, things will get done a lot more efficiently. I think that’s been integral to our delivering services at scale.
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WHAT DO YOU THINK?We would like to hear from you. Send your comments and questions to: [email protected]
CONTINUED FROM PAGE 7...
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THE FUTURE OF PRIMARY CARE REFORMDr Michael Holmes, RCGP Clinical Lead for the Supporting Federations Programme, looks at what is next for general practice
he overall perception of general practice appears to be that we are faced by significant challenges. Challenges that may ultimately change the way we deliver care. The
workload we face has increased dramatically since the introduction of the nGMS contract in 2004. The growth in the number of consultations provided, and the amount of correspondence and results we process, has been striking.
Additionally, the lack of growth in GP numbers, our ageing population and an increasing desire for instant access to healthcare professionals, along with squeezed NHS budgets, are all providing the basis for a seismic shift towards 21st century general practice.
This shift is already underway. The Royal College of General Practitioners has partnered with the Nuffield Trust to examine General Practice At Scale,1 and has seen an increasing desire to work at scale at practice level. We see that 73% of practices are either working at or thinking about working at scale. Numerous models are emerging, from large super-partnerships (of varying structure), to a myriad of corporate entities each aiming to bring financial and system efficiency to the way general practice is provided.
We see a focus on access with the introduction of longer or more diverse opening hours. This is often achieved through shared responsibility and the use of technology to shift the demand out of the surgery. This allows patients to interact with their general practice at a time, place and in a way that suits them, whilst maximising the use of GP time.
WORKFORCE EVOLUTIONWe are also seeing a workforce evolution, clinically and non-clinically. Greater diversity of types of clinician and mode of clinical care is beginning to emerge with the introduction of Advanced Practitioners from a variety of professional backgrounds. They are starting to work hand in hand with GPs to see patients at the front-line in a safe and well-governanced way.
This is being supported by the professionalisation of back office functionality, delivered at scale with increasing efficiency. To maintain the core qualities of general practice we are seeing the preservation of local delivery units, manned by diverse clinical teams with support, both clinical and non-clinical, from co-ordinated at scale organisations.
INTEGRATIONThe remainder of the health sector is also under pressure with many similar issues. There is a move to deliver care more efficiently with a patient-centred ethos and greater integration between health and social care sectors – sectors that have been commissioned separately, governed by different contracts and have grown further apart over recent years. The shared challenges are equally providing opportunities to rebalance these inter-sector relationships. The Five Year Forward View has suggested new ways of working – new care models, including multi-speciality community providers (MCPs) and
primary and acute care systems (PACS), which have been evolving within NHS England’s Vanguard programme.
Sustainability and transformation plans (STPs) are being developed for publication later in the year, and in many areas are likely to suggest the formation of accountable care organisations as a means to financial and system stability.
The General Practice Forward View has promised support to general practice but to date the details remain unclear and much uncertainty remains about how funding and resources will materialise at practice level.
WORKING AT SCALEIt feels like we are at a critical point in general practice – to stand still is simply not an option. Working together at scale seems to be the direction of travel and the mechanism to financial efficiency and sustainable clinical delivery. Sadly, we are seeing many practices facing closure – recent data suggests as many as 600 by 2020.2
GPs are sensing the need to be proactive and there is gathering momentum towards working at scale. However there is more to this than just at scale working between practices – collaboration is required at system level too. Larger practices and organisations must now begin to work in partnership, formally or informally, with other health and social care sectors to deliver seamless cost-effective care for patients. Examples of this are beginning to emerge, and hopefully the learning from these early pioneers will be disseminated so that risks can be minimised and benefits enhanced.
Listening to colleagues the difficulties we face now are palpable and the direction of travel feels like a path we have not been down before – although history tells us that practices have been gradually getting larger since the very early days of the NHS.
However as I speak to people around the country I am beginning to feel a sense of hope – magnified in those already dipping their toe into the waters of at scale practice. At a recent event, I heard the current landscape described by GPs as a “once in a career opportunity” – whilst it feels daunting and shrouded with uncertainty I am beginning to believe that it is true.
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REFERENCES
1. www.federations.rcgp.org.uk
2. www.rcgp.org.uk/news/2016/september/patient-safety-in-general-practice-could-be-at-risk-unless-chronic-shortage-of-gps-is-turned-around.aspx
WHAT DO YOU THINK?We would like to hear from you. Send your comments and questions to: [email protected]
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n accordance with the aims of the NHS Five Year Forward View, a number of new care models have been developed and each have different implications for staffing which
require consideration and careful management to ensure a smooth transition. While many of the models support acute care collaboration or the integration of health and social care, this article focuses on the models which recognise the benefits of ‘scaling up’ to support the integration of primary healthcare (namely GP federations and super-practices), and the likely staffing issues GP partners and practice managers will need to consider. KEY STAFFING ISSUES/OPPORTUNITIES Not all of the resulting staffing implications carry risk; in fact many provide positive opportunities. The level of legal risks/staffing implications will depend on the specific changes being proposed or implemented, which will impact on any existing employment relationship or working arrangements.
MANAGING CHANGE/STAFF ENGAGEMENT Irrespective of the new care model being implemented, a staffing issue which impacts across the board is the critical need to manage change effectively and engage and empower staff to lead the development and delivery of new care models. As summarised by Samantha Jones, Director of the New Care Models Programme, in New Care Models and Staff Engagement: All Aboard, the core principles for success identified from the work of the vanguards were:
• Enable different groups of staff across health and social care to work together
• To ‘break down barriers’ between existing organisations and professional groups and break out of old working patterns.
• Leaders can set the example by investing in relationships at the highest level, with partners across the local health and care system so staff at the front line are inspired to do the same.
• Put staff at the heart of designing and implementing new care models
• Share leadership and responsibility, talk and most importantly listen, to unlock the ambition and harness the energy of staff.
• Staff on the front line of care often have the best ideas how to improve it, but need to feel empowered to do so.
• Communicate
• A clear, shared vision delivered via a consistent message across all in the leadership team, so people want to see change happen and see themselves as part of it.
• The details of the change effectively, including the benefits it can bring, the underpinning strategy and the details of the action plan to make it happen.
• The opportunities to get involved, provide different opportunities to do so and make it easy for busy staff to join in where possible.
• Value the contribution of staff
• Ultimately if staff feel their contribution is valued they will want to do all they can to make new care models a success.
GP FEDERATIONSThe key staffing issues and/or opportunities for GP federations are likely to be:
• Redesigning staffing arrangements
• Implement the federation leadership structure, following discussion with practice partners to ensure there is the capacity and capability to lead the federation within member practices, or determine whether leadership skills are required from external sources.
• Review existing support function staffing and system requirements to identify what, if any, practice resources could be pooled (for example, shared back office functions such as HR/Payroll/Procurement).
• Review the feasibility of sharing delivery/use of education and training resources throughout the member practices with a view to reducing clinical variations.
• Job design/job description and recruitment
• Across member practices, share existing job designs and job descriptions with a view to identifying best practice and opportunities to reorganise tasks and responsibilities as appropriate to improve efficiency.
• As a result of the strengthened capacity of practices to develop new services, review whether to introduce new or
I
NEW CARE MODELS AND GP ALLIANCES: THE IMPACT ON STAFFING Croner provides advice on the key considerations on staffing for organisations working at scale
OBTAINING ADVICE ON STAFFING ISSUES Medical Protection members who are part of a Practice Xtra group scheme have telephone access to the Business Support Advice Line at Croner, who provide specialist advice on employment-related, legal and commercial matters. To ensure a smooth transition and to minimise the risks of employee litigation, practice partners/practice managers are encouraged to telephone Croner for advice at the outset of any proposed changes for advice relating to their specific staffing issues.
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extended roles in any individual practice. Arising from revised job descriptions, there will be the need for a recruitment exercise and the issuing of relevant contractual documentation to the successful candidate for new roles. If unable to fill the new vacancy internally then extend the opportunity to other member practices prior to advertising externally. Where it is proposed that existing roles are extended, such a change will trigger the need for informal consultation with affected staff to ensure the extended responsibilities are reasonable, understood and agreed, and any resulting training needs are identified and managed.
• Updating/sharing policies and procedures
• Review the practices’ key policies and procedures and consider standardising across the locality. Any subsequent revised policies will need to be clearly communicated to staff and any training undertaken to ensure consistent understanding and application.
• Identify opportunities to standardise performance management/staff development systems at practice level to share best practice, specifically relating to staff appraisal systems, delivery of training, reward and talent management.
• Data Protection
• Any sharing of personal data with the GP federation will require the federation to register with the Information Commissioner’s Office and an understanding of the rules of dealing with personal data.
SUPER-PRACTICESThe key staffing issues and opportunities for super-practices are likely to be:
• Redesigning staffing arrangements
• Implement the new leadership structure. Ensure discussion with all parties to ensure there is the capacity and capability for the new partnership board to lead the super-practice. Ensure fair representation of partners on the board and ensure all are aligned with the vision and agree the strategy and action plan.
• Identify a proposed new structure across all areas of the super-practice to ensure the right skills mix; staffing levels and flexibility to deliver effective population based health approach. This may result in the creation of new and/or extended roles and will result in the establishment of centralised support functions.
• Look to improve training and education, and nurture talent through the establishment of a dedicated central training and development team.
• Transfer of Undertakings (Protection of Employment Regulations 2006)
• Assess the need for the application of TUPE Regulations, and the associated obligations relating to information and consultation processes, and post transfer limitations on contractual changes. Each branch surgery will be required to provide employee liability data to the super-practice in advance of any transfer of staff (see ‘Data Protection’ below).
• Plan and implement a post-merger staffing integration plan.
• Contractual changes
• Staff will transfer to the super-practices under TUPE on their existing terms and conditions of employment which are protected under the TUPE Regulations. Therefore there will be requirement to manage differing contractual obligations.
• Under the TUPE Regulations, any contractual changes post
transfer are only permitted where there is an “economic, technical or organisational” (ETO) reason entailing changes to the workforce (such as changes in headcount, job function or to change work location). Where there is an ETO reason, the proposed contractual change will trigger the requirement for consultation with all affected staff in order to obtain express agreement to implement the proposed change. The consultation methodology and legal requirements will depend on the numbers of staff affected and may require either individual or collective consultation.
• Job design/job description and recruitment
• As a result of the strengthened capacity of the super-practices to develop new services, review whether to introduce new or extended roles, either at branch surgery or central support level. Arising from this, for new roles there will be the need for a recruitment exercise and the issuing of relevant contractual documentation. Vacancies should be advertised internally to all existing staff in the super-practice, providing the benefit of career development opportunities; new career pathways and opportunities for staff to specialise. Where it is proposed that existing roles are extended, such a change will trigger the need for informal consultation with affected staff to ensure the extended responsibilities are reasonable, understood and agreed and any resulting training needs are identified and managed.
• Policies and procedures
• Standardisation of non-contractual policies and procedures across the locality. Any subsequent revised policies and procedures will need to be clearly communicated to staff and any training undertaken to ensure consistent understanding and application.
• Standardisation of performance management/staff development systems, specifically relating to staff appraisal systems, delivery of training and talent management.
• Data Protection
• Any sharing of personal data with the super-practice by branch surgeries will require the super-practice to register with the Information Commissioner’s Office and an understanding of the rules of dealing with personal data.
For more information about using Croner services, visit medicalprotection.org/uk/croner
o safely deliver new care models it is essential that practices adapt their processes and structures. Processes that successfully deliver safe and effective care in a small,
single partner practice are not likely to cater to all the risks faced by a practice in a new care model, or working at scale in a group or federation.
For example, many new care models extend the roles for other health professionals, including paramedics, physiotherapists, mental health workers, physician associates and pharmacists. Any practice bringing in these new roles will need to have clearly defined scopes of practice and supervision arrangements, and that is just the start.
Below are some of the top medicolegal risks that we have identified in new care models, along with advice on how to counteract these risks and continue to deliver safe, coordinated care.
ACCESS TO PATIENT RECORDS FOR CONTINUITY OF CARE AND TRIAGEWhere practices join together, either tightly in a formal federation, or loosely in a hub network, it is likely that patients will receive some care away from their usual practice. Safe and effective care from a different practice is more achievable when healthcare staff can access records held by the patient’s base practice, so that they are aware of the patient’s past medical history, medications and any recent attendances. Access to patient records is particularly important when a patient attends another practice with an acute medical problem.
Effective collaboration and communication between practices will enable GPs to resume care seamlessly, minimising the delays sometimes seen when patients attend A&E departments or Urgent Care Centres. Explaining to patients the motives and expected benefits of sharing medical records with partnership practices is likely to help when seeking to obtain patients consent to do so.
However, you should remember that GMC guidance (Confidentiality, 2009, paragraphs 25-27) advocates respecting the wishes of any patient objecting to the sharing of particular personal information within the healthcare team, unless disclosure is considered essential for providing safe care.
Collaboration has allowed some vanguard practices to expand service capacity, including during extended and unscheduled hours. As well as shared records access, effective triage is vital: technology can assist here to prioritise patients by the urgency or complexity of their clinical needs.
Alongside telephone triage, video or email consultations have enabled some practices to target specialised services at some patients who might otherwise find it difficult to access care, for example, travellers and patients with substance abuse. When using new methods of communication with patients it is important to consider matters of consent, confidentiality, maintaining professional boundaries and retention of all patient communications in the medical records.1,2
INDUCTION, TRAINING AND SUPERVISIONIncreased collaboration between practices requires consideration of the benefit of harmonising policies and protocols, including the induction of new staff and the training needs of existing staff.
Staff, especially those working across practices, require clarity regarding their roles, reporting arrangements and resources, including access to supervision. This is especially important for new healthcare roles in primary care, in order to determine professional accountability. It also assists patients to understand who is treating them and what they can offer. Collaborating practices can benefit from economies of scale in providing for the training and CPD needs of primary care teams, including ensuring appropriate supervision of those staff subject to regulatory requirements for workplace reporting and supervision.
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LIFE INSIDE A HUB TOP MEDICOLEGAL CHALLENGES
Medicolegal Adviser Dr Helen Hartley provides advice on the top medicolegal challenges posed by new care models
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How did the Headingley HUB come about?
It was initially driven by the CCG in response to the Prime Ministers Challenge Fund. We put in a bid for funding but that was actually turned down by the government. After that the CCG took a look and decided they could afford to fund it themselves.
So we set out to open three hubs across the CCG for 11 practices, of which one is based at our site, Burton Croft Surgery. Since January 2015 we have worked with five other practices, sharing staff and resources, to offer weekend appointments out of our building.
What has been the biggest success of the HUB so far?
It has to be the service we’ve been able to provide to patients – not only are we
opening on weekends, but we now open in the evening till 8pm.
We’ve also been able to adapt our system so that any GP can access a patient’s entire clinical record at the weekend.
It’s not an out-of-hours type of approach, it’s a full practice approach, with real GPs working from real patient records, and advising patients just like they would during a normal weekday appointment.
What has been your largest challenge?
Getting started was certainly difficult. We had different doctors that were not necessarily used to working in a practice coming in to help (such as out-of-hours doctors), but we tried to embed a culture of communication and safety.
If I had to pick one challenge, it would be
trying to get one appointment system that suited all the practices in the HUB.
Across the five practices we work with, some use SystmOne, while others use EMIS Web. We chose SystmOne for HUB appointments, and every practice uses this, whether or not it is the same system they use for their regular appointments.
When any practice in the HUB gets a request to book a weekend appointment, they open up our HUB appointment system instead of their own, and book the patient into the available slots within that.
Unfortunately this means we’re not able to book the appointment straight into the patient record, and that has been one of the issues. Having one true booking system that we all use across the Hub, day in and day out, would be the ideal solution, but we’re a little way away from that.
Burton Croft Surgery in Leeds has been operating at the centre of Headingley HUB since its inception in January 2015. The practice works with five others in Leeds West CCG to offer weekend appointments for all of their patients out of its premises. Simon Beer, Burton Croft Surgery’s Practice and Business Manager, answered our questions about how the HUB works, and the risks and challenges they faced in setting it up.
HANDLING PRACTICE CLINICAL ADMINISTRATIONSharing best practice regarding processes and policies allows clinical protocol harmonisation – a good example of which is handling investigation results. Reducing the risk of failing to act on abnormal results, for example in relation to INR monitoring, PSA testing and renal function testing, is likely to decrease adverse events and have a beneficial impact on complaints and litigation.
Similar benefits are possible from sharing best practice in relation to handling medication reviews and repeat prescription requests. Doctors signing prescriptions should satisfy themselves that the drugs will appropriately meet a patient’s clinical needs (GMC Prescribing guidance, 2013, paragraph 61).
LEARNING FROM COMPLAINTS AND SIGNIFICANT EVENTSAs well as helping with the implementation of approved national guidance and the undertaking of an audit through shared clinical governance support staff, hub-working provides for effective and objective complaints handling. This is because a practice is able to obtain independent peer reviews of its complaints and significant events from a hub partner. Further, any lessons learned can be shared across the network, allowing central modification of protocols or processes to minimise the recurrence of similar complaints or adverse events.
INDEMNITYGood Medical Practice requires doctors to have adequate indemnity cover (GMC, 2013, paragraph 63). Occurrence-based indemnity provides cover for claims arising from medical malpractice which occurred during a period of medical defence organisation membership. A doctor’s individual professional indemnity is personal to them, although a GP partner employing staff may be able to extend the protection to vicarious liability for employee negligence. GPs should always check the provisions of their indemnity to make sure it is suitable for their needs.
Federations may require corporate indemnity against clinical negligence, and while such indemnity should protect employed staff, any employed doctors should check the adequacy of the indemnity for their own needs. Corporate indemnity insurance is often provided on a claims-made basis, meaning that it applies to claims reported, and care given, during a period of corporate membership. As corporate claims insurance does not usually protect employees for ‘non-claims’ events such as complaints, inquests, disciplinary, regulatory or criminal investigations, or the provision of medicolegal advice, we recommend that doctors consider maintaining personal membership of a medical defence organisation for ‘non-claims’ protection.
For more information regarding indemnity when working at scale, see our article on page 20.
IN PROFILE: Burton Croft Surgery
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How were you able to set up the patient record sharing across practices?
One of the most important systems we’ve got in place is that which allows our clinicians access to the patients complete medical record at the weekend. We did this by installing the two clinical systems that the HUB practices use on all the PCs that are used for HUB appointments. Then, when a patient comes in for a weekend appointment, whichever doctor is seeing them logs into the correct clinical system with the details for the practice the patient is registered with.
This allows the doctor to access the notes and to update them with the details of the consultation. It also means that any investigations, tests or referrals are sent to the correct practice for the patient.
Did you encounter any issues with consent for this record sharing?
We haven’t had to ask patients for their specific consent to share records between practices. Instead we’ve signed up the GPs who work in the HUB to all the practices involved, in terms of information governance.
It’s like getting a locum into your own practice, the doctor is only consulting the notes for an individual patient in relation to that consultation. There is no other access to those records by HUB staff.
Patients are informed of this when they ring up to make a weekend appointment. A recorded message informs them that they might see a doctor who is not from their usual practice, but who will have access to their full record and the practice’s system. The information is also available in practice and on the websites of the practices.
Did you have to harmonise any policies or protocols across the practices?
When you bring together a group of doctors who are all used to different ways of working, you’ve got to have an approach that satisfies safety and risk criteria. One of the big issues that concerned us was referrals and how we might deal with them.
Our solution was to create a HUB inbox within each practice. For example, following a patient consultation at the weekend, a message would be sent to that patient’s home practice’s HUB inbox, which is picked up the following week in order to process the referral.
Other priorities were complaints and significant events. We’ve put processes in place so that these can be reported and discussed regularly across the practices in the HUB. We’ve also employed a HUB manager, someone at practice manager level, whose sole responsibility is managing the HUB. This involves monitoring staffing, events, risks, health and safety – everything your standard practice manager does.
They then report back to all the practices involved, and we have monthly meetings to discuss ongoing matters.
Were there any new training needs for staff working across practices?
The main training need we identified was staff inductions. This is a requirement for every member of staff who comes to work in the HUB at the weekend, including all doctors and clinical staff from other practices. The induction includes fire safety, health and safety, emergency drugs, oxygen – all the aspects you’d
go through with a new member of staff. We’ve also created a handbook to accompany the induction.
Did you have to clarify roles, reporting arrangements and supervision?
In addition to the HUB manager that we employed, we also have HUB supervisors who work at the HUB on the weekend. They deal with anything that goes wrong, and raise it with the HUB manager if necessary.
We also have clinical leads for the HUB who are responsible for looking into any clinical issues that arise. The most important aspect for anyone who comes to work in the HUB is that they are made aware of the way we work and the reporting structure.
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REFERENCES
1. Communicating with patients by text message (MPS factsheet) www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-eng-communicating-with-patients-by-text-message 2. Making audio and visual recordings of patients (MPS factsheet) www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-eng-making-audio-and-visual-recordings-of-patients
WHAT DO YOU THINK?We would like to hear from you.
Send your comments and questions to: [email protected]
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IN FOCUS PRIORY MEDICAL GROUP
In this issue we focus on Priory Medical Group, which is pioneering a new joined up care model across the City of York. Managing Partner Martin Eades explains
the initiative his organisation has put forward in the past two years
ur new model of care started two years ago, when we were approached by the Clinical Commissioning Group (CCG) and asked how we could have an impact on reducing the number
of people that were going into hospital unnecessarily. We were also asked how we could address the difficulty that some patients – particularly the elderly – have in being discharged from hospital, despite being medically fit to do so.
FOCUS ON THE 500We initially created a project called ‘Focus on the 500’, which looked at 500 patients and the process they followed to get into hospital then out again, and some of the difficulties that arise during the process. We worked in partnership with the local hospital and care homes on the project.
Some of the issues we focused on include why they were going into hospital in the first place, what common issues they were facing, and most importantly, whether there was a way we could support them better in the home itself, rather than in hospital.
Focusing on this catchment of 500 quickly made a difference. This was the first group of patients to have an individualised care plan, which included their wishes regarding hospital admission. We identified some common themes like infections of the chest, bladder or skin that could be easily treated in the home. However, because the project expanded so quickly, we realised that a sample of 500 wasn’t big enough to make a difference, particularly as these people were already receiving a reasonable level of support in nursing homes.
HIGH-RISK PATIENTSWe extended the project to include high-risk patients and those most at risk of hospitalisation – particularly the elderly and people with multiple chronic diseases. We were fortunate enough to have the technology in place that helped us ascertain who these people might be, and from there we developed a register to be monitored and maintained by our integrated care team. We recruited a care coordinator to work at the centre of the team, liaising with all the different providers in York that might be able to help a patient in crisis or who is at risk of going into hospital.
There is a litany of service providers involved; the list includes GPs, community nursing teams, social services and major charities like Age Concern and Diabetes UK. Just as important are the small local providers that might have been overlooked before. We had no idea what was out there until we started looking – for example there is an organisation that provides slippers for people. If patients have the correct fitting slippers, they’re less likely to fall and therefore are less likely to break a hip and end up in hospital. It’s all the little things that add up to make a big difference.
The project engaged with the public from its early stages; we attended a number of meetings with the City of York and asked people what they actually wanted and expected from their care providers. A lot of the feedback we got was that patients were feeling inundated with visitors – that a district nurse might arrive in the morning to do a routine blood test, then someone from social services would come and get them out of bed and then someone else might
come later. The service these people were receiving was fragmented and there appeared to be a lack of communication between the providers. While some of the challenges around sharing records and the technology that accommodates this are still present, we’ve managed to coordinate a lot of the visitation through recruiting our own generic ‘care workers’ that are qualified to do all of the above.
NEW CARE PATHWAYSThrough the development of the team, we identified that there were clear gaps in the way care was delivered, so we needed new pathways. There were services being performed in hospitals that could have been done in a patient’s home or a nursing home, so we started looking for clinical methods that allowed us to move some treatment out of hospitals. For example, if nursing home staff were trained to administer subcutaneous fluids and IV antibiotics, it was possible to hugely decrease the amount of people who had to go into hospital for such routine procedures. The development of these pathways is still incomplete at this stage; though we are hopeful they can be delivered soon.
FRAGMENTED CAREThe fragmented nature of care provision is often what lands vulnerable people in hospital in the first place. For example, a social worker might visit a patient, decide the individual doesn’t look well and call an ambulance. This is done without the healthcare record and so is based purely on a personal reaction. However, it is quite possible the regular healthcare provider is aware of this patient’s circumstances and had agreed a treatment plan that did not require hospitalisation. Once the patient is in hospital, they have to go through the whole discharge procedure before they can leave, which is why we place such priority on enabling better communication between health and social care practitioners.
Further, when people go into hospital and stay there, they decompensate. While the acute issue they were admitted for might have been treated, they’re actually less independent than when they went into hospital. As many practitioners will know, for a patient over the age of 85, ten days in hospital equates to ten years of muscle wastage. So if we can address the acute issues whilst not compromising their independence we can avoid the patient becoming more reliant on the system and the services, which bring pressures to bear that we know the public health and care system can’t sustain.
Not only is it a financial saving, but it’s also fantastic that we’ve facilitated getting someone out of hospital. Once other organisations saw the benefit of what we were trying to achieve, they jumped on board. We have a lot of people who are putting their time into this voluntarily; their organisations are seconding them for half a session or a day a week – not for any financial gain, but purely for delivering better care and setting up a model for the future that is sustainable.
WHAT DO YOU THINK?We would like to hear from you. Send your comments and questions to: [email protected]
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15PRACTICE MATTERS | VOLUME 4 ISSUE 3 | NOVEMBER 2016 | medicalprotection.org
SCALING UP YOUR WORKSCALING DOWN YOUR RISKClinical Risk Education Manager Diane Baylis explains how our risk education team can support GP federations and other organisations working at scale
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he risks in primary care are not always related to clinical practice, but can be due to deficiencies in systems, communication, equipment or training. Managing these
risks is of paramount importance, not just for individual general practices, but also for larger groups of practices, such as federations, in order to reduce harm to patients and staff, and to improve the quality of care provided.
For many years Medical Protection has offered a range of risk education for single practices. From workshops for the practice team on topics such as medical records or dealing with adverse outcomes, to consultancy tools and assessments that identify risks in areas such as infection control and repeat prescribing and provide advice on how to eliminate them.
Now, as general practice changes, and many organisations ‘scale up’ into GP federations and super-practices, we have similarly grown our education offering to provide risk management advice and support for the unique risks that these new, larger organisations face.
REPEAT PRESCRIBING SUPPORT FOR NHS LAMBETH CCG
In 2015 we worked with NHS Lambeth Clinical Commissioning Group (CCG) to deliver repeat prescribing support visits to 48 GP practices in the locality. The practices that participated were provided with a report and an action plan of recommendations. In addition, an overall written report was sent to NHS Lambeth CCG Medicines Optimisation Team.
As a follow-up to this project, we were invited to deliver further support to practices, with the aim being to reduce the overall risk relating to repeat prescribing across the GP practices in the locality. This was facilitated between January and March 2016.
Those practices who had indicated completion of some of the recommendations detailed in their repeat prescribing reports in 2015 were offered a telephone support contact, while those practices who had not indicated any progress towards completing the recommendations of the initial report were offered a further practice visit.
The support visits involved a two-hour visit to the practice to discuss with the practice manager and/or lead GP:• the progress made following the initial
risk assessment in 2015
• any outstanding areas of risk
• identification of barriers to implementing the follow on action.
The aim of the project was to reduce the risk relating to repeat prescribing in GP practices across NHS Lambeth by 80%.
After the first visit in 2015 repeat prescribing risk across the practices was reduced by 19%. However, after the follow up visits in 2016 the reduction in repeat prescribing risk across NHS Lambeth grew to 87%.
At the end of the project a member of one of the practices said: “Having the second review and report was really helpful, as the recommendations were specific, clear and timely.” A member of another practice said: “The two visits are excellent exercises in clinical governance and preparation for CQC.”
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FIND OUT MORETo find out more about how we can provide a bespoke risk education service for your organisation contact us now:
Email: [email protected]: +44 (0)113 241 0359
WHAT WE OFFER Below is a list of just some of the services our education team can provide:
Risk assessments Our risk assessments assist practices to identify potential risks and provide recommendations in how to mitigate these risks. The assessments are delivered by expert facilitators and are suitable for the whole practice.
• Clinical Risk Self Assessment (CRSA) for General Practices
• Infection Control Risk Assessment
• Repeat Prescribing Risk Assessment
In-practice workshops Our workshops are facilitated at your practice and designed to support the whole primary care team. They aim to help you to mitigate potential areas of organisational and operational risk.
• Medical Records for General Practitioners
• Medical Records for Nurses in Primary Care
• Practical Guide to Risk Management in Primary Care
• Managing Conflict and Aggression in General Practice
• Infection Control
• Prescription for Risk – A prescribing workshop for nurses
• Your Repeat Prescribing Journey
• Medication Errors and Safer Prescribing
• Learning from Events (new in Autumn 2016)
• Consent and the Mental Capacity Act (available from December 2016)
Online assessments Our online assessments help you to identify where your practice system is performing well and areas for improvement. These take approximately 15 minutes to complete and are suitable for all members of the practice team.
• Infection Control 360
• Safety Culture 360
• Test Results 360
We can bespoke any of our workshops or risk assessments to the specific needs of a practice, CCG, federation or group.
17PRACTICE MATTERS | VOLUME 4 ISSUE 3 | NOVEMBER 2016 | medicalprotection.org
ow have emerging trends in primary care affected Medical Protection members?
What we’ve seen over the last 12 to 18 months is sustained growth in the number of practices “working at scale”. Because of funding for new care models in England, as well as similar initiatives in Wales, Northern Ireland and Scotland, we’ve seen practices coming together to cope with change and develop innovative new ways of caring for patients. This has led to a rise in the number of federations, super-practices and partnerships and multi-speciality community providers. For example, over the last year we’ve been working with a practice in the Midlands with around 50 GPs and another in the Yorkshire area that has grown to 40 GPs, as well as GP federations with more than 100 GPs.
GPs are being challenged to think about how to extend access to primary care and how to reorganise services in the community for the benefit of patients. They are adapting at speed and trying to lead the way, and that has caused us to think differently as an organisation.
How are you addressing these needs?
We’ve had to start rethinking our model of service delivery so that we no longer focus only on individual members, but also look at how we can provide more for organisations and large groups of members. I think this is one of the most significant changes to impact Medical Protection in its 124-year history.
For more than ten years we’ve offered Practice Xtra, a group scheme that caters very well for the needs of members working in a GP practice.
However, when we’re approached by a super-practice or federation we recognise that we need to treat them on an individual basis – creating a federation product, or “Federation Xtra” is not the right answer. We believe that we need to provide more bespoke solutions for these organisations, which take into account the whole team, often working across multiple sites, as well as the additional risk management and customer service support they need.
The idea of protection as well as defence is very important to us, and that starts with preventing potential problems from occurring. We particularly want to work with organisations that have a long-term strategy to develop their services, and who are committed to working in partnership with us, as this allows us to fully integrate our risk management approach.
What are the membership benefits available to organisations working at scale?
Firstly there are the positives we bring to any membership arrangement. This includes the right to request assistance if something goes wrong, and quality advice and risk management support to help doctors with everything, from the biggest to the smallest challenges they face every day.
At the same time, we recognise that organisations of a certain size need more support to understand how indemnity arrangements work in increasingly complex structures. Some of the changes we’ve made to our group scheme recently, such as extending membership to pharmacists working in a practice and allowing healthcare assistants to move between different sites, are about being flexible for members who are working in different ways.
Ultimately the biggest benefits are based around our brand promise of being ‘more than defence’. Our investment in
risk management education is a core competency of Medical Protection that extends to large groups and networks, and it adds up to more peace of mind when our members know they’re doing everything they can to avoid a claim.
Can larger scale membership arrangements help GPs save money on professional protection?
Larger groups of GPs may be able to qualify for a broader commercial arrangement, one which incorporates a discount and a risk management package. This still has to be realistically priced but remain fair to other members, as everyone contributes to the same fund for the same assistance should they ever need to request it.
Larger groups also make it possible for us to provide extended risk management services to help members identify and take action against some of the issues which could lead to a claim in the future. And, where groups are large enough, we may also be able to ring-fence their risk and claims experience in order to better tailor a price to their needs, although this is an approach that can take some years to reach maturity.
What is the best way to approach Medical Protection for further information and advice?
We have many skilled service staff within Medical Protection, including our membership helpline, online support team and our account managers in the field. In the first instance, we would encourage any federation, super- practice or other organisation developing a new care model to get in touch with us through one of these means, and speak to us at the earliest opportunity.
Depending on the nature of the organisation, we will often try to arrange a visit to establish requirements in more detail.
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IN THE HOT SEATDr Rob Hendry, Medical Director at Medical Protection, explains how we are adapting to the changes affecting primary care
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WHAT’S NEW IN MEDICAL PROTECTION
MEMBERSHIP?
• SCHEDULED AND UNSCHEDULED CARE To reflect the reality of more GPs working extended hours but seeing registered patients and with full access to their medical records, we have redefined how we calculate prices for primary care sessions, replacing old core and out-of-hours classifications with scheduled and unscheduled care.
• NEW CATEGORIES OF MEMBERSHIP A growing number of practices and organisations are employing multi-disciplinary teams. To meet their needs, practices who are part of a Practice Xtra group scheme can now request membership for pharmacists, paramedics, physiotherapists, physician’s associates and primary care co-ordinators/navigators.
• STAFF SHARING POLICY Not all individuals in a practice need an individual membership arrangement (eg, healthcare assistants and phlebotomists) as they should be protected through their employers’ arrangements. But in the past this meant they could only work in their employing practice. It is now possible for healthcare assistants, dispensers and phlebotomists employed by a Practice Xtra Gold practice to be ‘lent’ to another Practice Xtra Gold practice. It is also possible for a Practice Xtra Gold practice to ‘borrow’ healthcare assistants, dispensers and phlebotomists from any other practice.
• CORPORATE MEMBERSHIP A growing number of providers are now choosing our corporate membership product - which affords protection to the organisation as a legal entity – alongside individual or practice group arrangements where necessary.
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The idea of protection as well as defence is very important
to us, and that starts with preventing potential problems
from occurring
FIND OUT MORETo find out more about the bespoke solutions Medical Protection can offer your group, visit:
medicalprotection.org/solutions
PRACTICE MATTERS | VOLUME 4 ISSUE 3 | NOVEMBER 2016 | medicalprotection.org 19
INDEMNITY WHEN WORKING AT SCALE
Dr Nick Clements, Head of Risk and Underwriting Policy, answers questions about how new care models and other changes in primary care can affect your medical indemnity
o GPs need to make separate indemnity arrangements for their federation, or are they protected by Medical Protection?
GP indemnity is usually provided through an individual membership arrangement with us.
If the nature and extent of your work remains unchanged, simply being a part of a GP federation should not impact on your membership. However, if being part of a GP federation requires you to undertake additional clinical work, such as working in unscheduled care or directly employing healthcare professionals in new roles within your practice, then you will need to contact us as it may affect your indemnity arrangements.
Regardless, it is a good idea to speak to us to ensure that you are adequately protected.
Does this change if the GP federation is set up as a limited company?
If a GP federation is set up as a limited company, and is responsible for providing additional or enhanced services, or is directly employing staff to treat or triage patients, then both individual staff members and the limited company or legal entity could be at risk of a claim or complaint. The federation must therefore ensure it has its own corporate protection in place.
We offer a corporate membership arrangement tailored to individual organisations. This can provide an organisation with the right to request assistance and indemnity in respect of the defence and/or settlement of civil law claims of clinical negligence made against the company.
Such claims might arise from the act or omission of the organisation, its employees or individual contractors for whom the organisation is responsible.
Who is responsible if something goes wrong when a consultant from a local hospital provides a service in primary care?
This will depend on the nature of the agreement with the consultant and the incident. Consultants, like GPs, have a legal obligation to
ensure they hold adequate and appropriate indemnity for all the work they undertake.
In some cases, a consultant working in general practice will still be employed by their NHS trust and will therefore benefit from the trust’s indemnity arrangement. However, if the consultant is employed by a GP practice, a GP federation, or is working on a locum basis, then additional indemnity arrangements would need to be made by the consultant with us.
Before accepting a consultant into your practice to work, you should look into the details of their arrangements to make sure they have appropriate protection in place. It is also important to keep a written confirmation of this position.
What should practices or federations do if they employ healthcare professionals in new roles that have not traditionally existed at
the practice before, such as pharmacists, physician associates, paramedics, and physiotherapists?It is important that you ensure you have appropriate indemnity in place for all your staff. As an employer, you might be leaving yourself vulnerable if you employ healthcare professionals without adequate indemnity arrangements.
This means that before employing a new member of staff, always check that we can provide a membership arrangement for them, and what the cost of that arrangement will be.
Medical Protection provides membership for a number of new roles which are now becoming commonplace in general practice. If we are unable to provide a membership arrangement for a specific role, we will try and sign-post other options that may be available.
Will the introduction of seven-day GP services have an impact on the cost of indemnity?
While we cannot comment on subscription rates for other medical defence organisations, the move to seven-day GP services alone should not directly impact on subscription rates with us. We believe we have led the way on supporting extended opening by changing the way we calculate subscriptions.
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We now calculate a price based on the number of weekly sessions members undertake, according to whether the care is ‘scheduled’ (when a GP treats registered patients, via appointment, during the regular opening hours of the practice and with access to the patient’s full medical records) or ‘unscheduled’ (such as sessions undertaken at any time of day in walk-in/urgent care centres).
Initiatives like the Prime Minister’s Access Fund therefore should not have had an impact on the subscription rate members pay, as in most cases GPs undertaking extended opening hours will be providing ‘scheduled care’.
While there may be some indirect impacts on the cost of indemnity resulting from more sessions taking place in general practice rather than in secondary care settings, it is too early to say what the long term impact, if any, of seven-day GP services will be. We will continue to monitor this and update you regularly.
How do GPs work out who is responsible if something goes wrong when a group of practices provide a service that is run out of
one practice’s premises? GPs should always have adequate and appropriate protection for all their work and will be accountable for their patient interactions regardless of the setting.
However, where practices create ‘hubs’ and share staff to deliver services across the federation, it can be difficult to attribute responsibility. Ultimately, both the organisation and the healthcare professionals who are delivering the service may carry some responsibility.
We would generally advise against staff sharing, in favour of an approach where staff who are delivering a service are clearly contracted to a practice or GP federation.
This provides assurances that rigorous employment checks have taken place and that there is clear accountability for actions.
However, we understand that many initiatives are currently in the pilot stage, and that there is a reluctance to put in place cross-practice employment contracts.
To support these initiatives, we have extended our membership benefits for GP partner members who are part of our Practice Xtra Gold scheme. This provides them with the right to request assistance with issues arising from certain groups of healthcare professionals that are loaned to their practices to deliver hub working.
However, certain exclusions apply so it is important that members contact us to confirm their arrangements.
What should practices and federations bear in mind about indemnity if they are preparing to bid for new contracts or services?
We would always recommend that practices and federations contact us as a priority before tendering for new contracts.
One issue we often come across is that providers may not adequately account for protection costs when tendering and pitching for new contracts. We want to work with you to ensure that you are fully informed and have complete peace of mind.
Therefore, as part of the process, it is important you get in touch to make sure you can obtain protection for the new service you are wishing to deliver, and that you know and fully understand all of the costs involved so you can factor this into your tender.
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We would always recommend that practices and federations contact us as a priority
before tendering for new contracts
MANAGE YOUR MEMBERSHIPTo manage your membership, visit
medicalprotection.org and click on the ‘For Members’ link.
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A version of this article has also appeared in a supplement published by Haymarket Media Group Ltd.
For more information, visit haymarket.com
21PRACTICE MATTERS | VOLUME 4 ISSUE 3 | NOVEMBER 2016 | medicalprotection.org 21PRACTICE MATTERS | VOLUME 4 ISSUE 3 | NOVEMBER 2016 | medicalprotection.org
FROM THE CASE FILES
r F, a 45-year-old executive manager in a major sales company, saw his GP, Dr D, for a cold. Dr D noted from the records that Mr F had attended the Emergency
Department ED three times prior to this for minor ailments. His blood pressure that day was 150/90mmHg and his BMI was 36.
He gave Mr F lifestyle advice and asked him to have his blood pressure checked. Mr F said he would not be able to take further time off during work hours for the BP check and Dr D’s practice did not offer extended opening hours. However, the practice was part of a federation, so it was agreed that Mr F would attend one of the other federation practices for this, as they offered healthcare assistant extended hours. Dr D also arranged for the patient to have a cholesterol test at the local phlebotomy clinic, which was nearer to the patient’s office.
Mr F did not attend the follow-up appointment for a blood pressure check. For some reason, Dr D was not informed of this by the other practice.
Six months later, Mr F attended his own practice again and was seen by a different doctor, Dr V. Looking at the notes, she saw that Mr F had attended evening and weekend appointments at other practices in the federation and received treatment for minor ailments six times since his last attendance at the practice. The result of his last blood test was not available but his cholesterol was significantly raised on the blood test taken six months ago. It appeared that no note had been sent to the patient to come in to discuss the result.
Once again, Mr F’s BP was raised, this time significantly higher than before, and Dr V was concerned. Dr V and Mr F discussed the best management option and Dr V decided to refer Mr F to cardiology based on this high reading, and started Mr F on an antihypertensive medication. She also offered a local patient education session on blood pressure, which Mr F declined. Mr F failed to attend the outpatient appointment.
Two months later, Mr F had an episode of indigestion. He again attended another practice in the federation for an evening appointment. When asked whether he was on any medication, Mr F said he was taking none. He was given antacids. However, he continued to have pain for three days on and off. He then suffered a cardiac arrest and unfortunately could not be resuscitated. The postmortem showed myocardial infarction.
A claim was made against all doctors involved, alleging that their failure to follow up and appropriately treat the risk factors for ischaemic heart disease, namely raised cholesterol and hypertension, had led to the patient sustaining a fatal cardiac arrest.
EXPERT OPINION
Medical Protection instructed a GP expert to examine the case. The expert noted that there had been repeated blood pressures recorded in his notes from various appointments at multiple practices in the federation, and readings had been steadily increasing. He opined that the failure to instigate a proper management plan and the inadequate follow up constituted a clear breach of the GPs’ duty of care. The case was deemed indefensible and was settled for a substantial sum reflecting Mr F’s age and the fact he was a high earner and had dependent children.
LEARNING POINTS• If GP federations share services, such as phlebotomy clinics and healthcare assistant (HCA) blood pressure checking, there should be clear communication between the services and processes in place to ensure that results are communicated and patients not lost to follow up.• Arranging follow-up for any appointments missed or medication started makes practice safer. In this particular case, the patient missed an outpatient appointment and a HCA appointment and was not followed up for either non-attendance to find out what happened. • When patients attend the ED multiple times for minor ailments, it may be worth addressing this in the consultation and explaining alternatives, such as the option to attend other practices within the federation, to avoid a lack of continuity of care.
• Any advice given to non-compliant patients should include the risks of failing to take medication or attend appointments, and should be documented.• With poorly compliant patients, or those who are difficult to track, it is important to take advantage of opportunistic follow-up, and perform routine checks, such as blood pressure.• Practices within federations should have robust policies in place regarding communication between healthcare providers and responsibilities for following up test results. The result should always be communicated back to the clinician requesting the test, and any DNAs should also be reported to the treating clinician.
This case demonstrates some of the risks practices face when working at scale, and the importance of ensuring effective systems and communication across practices
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The Medical Protection Society Limited (‘MPS’) is the world’s leading protection organisation for doctors, dentists and healthcare professionals. We protect and support the professional interests of more than 300,000 members around the world. Membership provides access to expert advice and support together with the right to request indemnity for complaints or claims arising from professional practice.
Our in-house experts assist with the wide range of legal and ethical problems that arise from professional practice. This can include clinical negligence claims, complaints, medical and dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and fatal accident inquiries.
Our philosophy is to support safe practice in medicine and dentistry by helping to avert problems in the first place. We do this by promoting risk management through our workshops, E-learning, clinical risk assessments, publications, conferences, lectures and presentations.
MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
The content of this publication is correct as of the date it was published.
Copyright © MPS 2016Review date February 2018 All rights reserved.Published by MPS, Victoria House, 2 Victoria Place, Leeds LS11 5AE 1926: 06/16
HANDBOOK
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4,000REASONSTO JOIN
Even beyond the discounts available for your GPs and nurses, the extra benefi ts of joining the Medical Protection group scheme could add up to £4,000.
Practice Xtra supports your team in meeting CQC and other national standards with valuable training and risk assessments.
Add in the unlimited business advice practice managers and partners can call on to help with running a busy practice, and it’s easy to see how the savings add up.
Taken together, Practice Xtra is an easier way to run your practice more safely, more e� ciently, for less. It also includes more personal support, with your own account manager to help you get more out of your membership.
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