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Integrated working

14 October 2011

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Alison Rounce

Managing Partner
Church Walk Surgery, Nottingham

Alison is a non-clinical partner and has been with the Church Walk practice for more than 17 years. Her responsibilities include the overview of the strategic direction of the practice and include quality and contractual compliance. Alison is also the commissioning business manager for the practice-based commissioning (PBC) cluster of 12 practices, and interim locality lead for PBC provider services, managed through Church Walk Surgery on behalf of the practice cluster

I started work as a practice manager at Church Walk Surgery in Eastwood Nottinghamshire in May 1994. Prior to that I worked in personnel and recruitment at Nottinghamshire Family Health Services Authority (FHSA) – the predecessors to primary care trusts (PCTs). In 2007 I became Managing Partner of the surgery, with a full-equity share within the practice and responsibility for the practice budget.

My passion to support the development and delivery of sustained, high-quality health services on the frontline is what led me in recent times to take part in the Transforming Community Services (TCS) programme.(1)

In 2008, all of the 12 practices in our clinical commissioning group formed a single cluster provider company, called Nottingham West Healthcare. In June 2010, our PCT made the decision to put all the community provider services out to tender. This was a brave decision as this was not the case in many other areas of the country. By that time, my work within Nottingham West Healthcare had already given me some insight into how integrated community services and general practice can make all the difference to patient care.

The company provides a number of projects – see Box 1.


The partnership and the bidding process
My involvement started very early in the bidding process, as a result of a partnership formed in July 2010 with our local mental healthcare trust and Primary Care, named County Health Partnerships (CHP).

The main purpose of CHP is to bring clinical staff together across primary and community care to deliver common aims and lead the necessary changes to frontline services. This will allow primary care and community expertise to deliver local strategic objectives and to develop creative solutions to deliver better patient outcomes.

I was asked to represent primary care on the bidding team for CHP services, as one of a team of representatives including frontline clinicians, primary care management colleagues and senior representatives from Nottinghamshire Mental Healthcare Trust, including the chief executive.

My feelings were a mixture of sheer terror and excitement. This was a very new environment for me to be working in but, at the same time, I was very excited at the possibilities the future could bring in terms of our local services and also how, for the first time, primary care management could contribute to their development.

The bidding process involved a number of presentations to the PCT commissioners, followed by a series of questions about our services and our thoughts on their development. I had been asked to lead the presentation on walk-in centre services, one of which was in our locality. Preparation for this was very well structured and I received coaching on my presentation to develop my presenting skills. This was also a new personal experience for me, since practice managers do not generally receive one-to-one coaching.

Our pitch day was fairly nerve racking. I presented with three other colleagues, including a senior manager from the mental healthcare trust and an advanced nurse practitioner from one of our walk-in centres in the north of the county. We presented to around 10 commissioners for about 10 minutes with subsequent questions for a further 20 minutes.

The whole procurement process took about two months to finalise. In November 2010, our partnership was successful in receiving 87% of the community services contracts, including adult community services, children’s services and the walk-in centre and community hospitals.

The bidding process was a totally new experience, which has formed a strong bond between all of the CHP representatives. We have a strong vision of wanting to provide greater integration between community services and primary care. We were also excited that our new partnership could now integrate mental health services into the community.

Where are we now?
The bidding process finished in November 2010. From then until April 2011 we concentrated on the legal and safe transfer of services. The mental healthcare trust side of the partnership led on the transfer as it involved a great amount of governance and legal work, which they had existing expertise in. The new contract commenced on 1 April 2011.

To date, the work has focused on how we will commence working more closely with primary care. I had always felt that our role as practice managers in the partnership was crucial to the process, as we can provide clinicians with real experience of primary care management and align our objectives in a more co-ordinated way.

I am currently an Interim Locality Lead, together with one of my practice manager colleagues. We are currently in the process of recruiting clinical directors for our five localities, a highly important position for local leadership, and aligning our objectives in primary and community care.

One of the first things we did was look at quick wins across primary and community services to start the process of building trust, integration and shared objectives between primary care and community staff. Some of these quick wins included a revised referral form that was less of an administrative burden for GPs, shared objectives across
end-of-life care and better communication.

In terms of shared outcomes we are beginning to look at things in a different way. We are looking at a joint telehealth pilot – conducted between our community matrons, chronic obstructive pulmonary disease (COPD) nurses and GP practices – to review the benefits this equipment could have for some of our patients. As well as the technological innovation, this is a joint, integrated project of benefit to our patients and clinical teams.

The future is bright
The TCS project has opened up a world of opportunity for primary care and primary care managers. The CHP partnership cemented this and provides us with a platform to discuss and develop new ways of working in our localities. It also gives us the ability to start some of those conversations and commence work on joint projects without worrying about the political agenda, as we are all on the same team. It has opened new doors that, as primary care managers, I doubt we would have had available to us had this opportunity not arisen.

One of the lessons of all this is that community providers need to be more innovative to align health budgets. Having shared outcomes and working together as a health community with our three main partners (community health, primary care and secondary care) means we have been able to work together for the benefit of patients.

Starting with small projects to address areas that can cause frustration for primary and community staff is also a good idea. We started with dressings and came up with a new process that works across primary care for both district nurses and pharmacy. We are also jointly looking at how we can work with residential homes in a more co-ordinated way to prevent avoidable hospital admissions.

This is the only way we are going to get truly integrated care. More integration is needed between health managers and clinicians and this gives practice managers the opportunity to do so. We can work with our management colleagues in community care more closely on such things as palliative care, safeguarding children through health visitors and health promotion through our school nurses.

We need to build our networks with our clinical and managerial colleagues in the community to engage in new ways of working. My experience has been a positive one and I believe it can be for other practice managers too.