Service with a smile: the financial and organisational minutiae of practice management

MyHealthcare is an integrated service in Birmingham made up of 23 GP surgeries covering more than 100,000 patients, which has enjoyed notable success since being established in July 2015. Under the system three GP hubs are used to provide ‘enhanced clinical services complimented by pharmacy and nursing support, health, wellbeing and lifestyle services’. Tim Martin speaks to lead partnership manager Ann Forletta about the financial and organisational minutiae of the service

Q. £2.4m GP access fund grant, matched by NHS funding, was provided to get the MyHealthcare service off the ground. Tell us a bit more about the original funding arrangements

A. The £2.4m funding was from the Prime Minister’s Challenge Fund. In 2014 David Cameron announced that there would be £50m made available for extended access projects which groups of GPs could apply for. At the time Birmingham South Central CCG submitted an application on behalf of a group of GPs, but it was unsuccessful. The following year the prime minister announced that there would be a second wave of funding – £100m was made available this time around. A group of GPs, led by an organisation called South Doc Services (SDS), which is our umbrella organisation, decided they would lead the bid. SDS is a GP co-operative based in South Birmingham that’s been around for almost 21 years and they asked me to step in and write the new bid. We began by contacting all the practices in South Central – the bid had to come from within one specific geographical location or CCG – you couldn’t cross boundaries, for example – and it had to be supported by the CCG. Twenty-three practices said that they would be interested after we made initial contact.

The timescale was really tight. I was contacted at the end of November and the bid had to be in for the middle of January. We put it together, submitted and were successful! It was a £2.4m grant for a 12-month pilot which, when broken down, equated to £20 per patient.

The CCG had to provide match funds; some of this arrived in the form of cash but the bigger contribution was from staff support. For example, we work closely with a part-time clinical system facilitator. She has been with us from the beginning and makes sure that all the practices are able to understand changes to their IT software and we’ve also had close engagement with the clinical commissioning team from the CCG.

Q. What organisational challenges are there to running a service of this size

A. One of the biggest assets we had was that we already had SDS based at West Heath Medical Centre – the main hub from which the new system is co-ordinated. SDS already had a HR department and it had management support, a finance manager and a governance manager. If you don’t already have these in place, you need to put them in as soon as possible.

Due to the fact that we were able to mobilise so quickly we were able to go live sooner than expected. The first hub actually went live in July 2015 – and by ‘live’ I mean GPs seeing patients face-to-face. We didn’t receive any funding from NHS England until the end of August. People like myself, our clinical programme director, Nirmal Vora, and GPs wouldn’t have been able to be paid but for the financial support of SDS.

From an infrastructure point of view we had to join up the clinical systems of all 23 practices. We created three MyHealthcare hubs – Fernley Medical Centre, Riverbrook Medical Centre and West Heath Medical Centre. Every practice can now see all the appointments in every hub. If a receptionist at a local health centre has a patient requiring an out-of-hours appointment, or who would like to be seen at the evening or weekend, once the receptionist has checked their own practice system they can then check the three hubs and see what’s available elsewhere; they can also offer the patient a telephone consultation with either a GP or a pharmacist. At this stage, we haven’t imposed any control over how much each practice uses the service. It’s something we have discussed, and the NHS are very clear that they want us to continue with the service, so we will obviously try to make adjustments in the best interests of the practices.

Other challenges include IT policy implementation – for example, putting in place an information sharing agreement and fair processing notices in every practice. Information sharing agreements, unless you are an IT expert, are quite challenging to write! Then you have the recruitment of staff in the hubs, clinical and admin staff, for example – they have to be trained on how to use the system. Then, obviously, there is liaising with whoever is paying for all this – in our case NHS England and the CCG. There’s the communication work involved too. So, if a patient is given an appointment in one of the hubs there’s a leaflet telling them where exactly the appointment will take place. Really, if you try to do this on your own, it’s a huge task; in our case SDS took it all on.

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At the practice level there is a need for buy-in and for surgeries to look positively on what we are trying to achieve. To operate the service properly the receptionist has to know how to use the system properly, has to be committed to searching for a suitable alternative when a patient can’t see his/her own GP and discuss with them which hub they would like to use.

Q. How are enhanced services co-ordinated

A. We have so many well-organised practices, and lots of GPs who are skilled in various areas, so we can offer a broad range of services. We have extended the range of services available in the hubs too. West Heath are piloting a ‘physio first’ service so patients have access to a physio much faster than they otherwise would – nothing like the two-to-three month wait you would have in other parts of Birmingham at the moment.

We´re also delivering complex wound services at our hubs. Usually, if a patient had a really bad ulcer, they would be treated by a district nurse in their home but now they can be offered an appointment at the hub and a district nurse can help out there and then. Some patients won´t be mobile enough to make a trip to the hub, of course, but for a lot of patients knowing that they have a 1pm appointment as opposed to sitting around all day works better. It´s also a far better use of time and resources for our district nurses; they can see 20 patients in a day compared to three or four home visits. We also have an ECG recording and interpreting service at the hubs and we have plans to set up a deep vein thrombosis (DVT) diagnostic service. In the past, if it was indicated that a patient had DVT, they would be referred to secondary care. The pathway has already been agreed with secondary care and we are just about to extend our services to include another 21 practices as part of the winter pressures initiative.

Q. What direction is given to practice managers in a joined-up service like MyHealthcare

A. In terms of workload, we aren´t taking anything from practice managers or indeed giving them anything extra to do. We manage the services with SDS, and monitor things closely, but practice managers continue to run their practices as before; the only difference for them is that they have more capacity to offer their patients.

Q. Can you tell me a little about key performance indicators of the service?

A. Secondary care data has recently been analysed. We weren´t running a full service until November 2015 but, despite that, doing a like-for-like comparison with the previous year, A&E attendance from our practices had gone down by 2.9%. Considering this was our first 12 months of activity, and we still had to do a lot of work with the practices, we consider that to be a significant improvement. It´s certainly something to be proud of given what is currently happening across the country in A&E departments.

Our funding has since shrunk considerably. We have just agreed with our CCG that we will roll out the service to the rest of the practices in our federation – another 21. They are committed to the service but there are CCG mergers going on in Birmingham, as there are across the rest of the country, so, until they have confirmation of their budget for next year, they can´t confirm when or if funding will continue, stop, or be reduced.

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