PMS Premium Reinvestment Wyre Forest CCG 6 September 2016 PMS Premium Reinvestment lynda.dando@worcestershire.nhs.uk

To share feedback on discussions to-date Aim Of Today To share feedback on discussions to-date To provide further opportunity to influence and shape the local contract, “Promoting Clinical Excellence” To provide feedback and recommendation to the Primary Care Commissioning Committee

Co-commissioning primary care - why? Deliver the best outcomes for our population Support sustainable, high quality primary care – fund practices for new ways of working Implement “Place-based Commissioning” – i.e. one budget for all health services in one community Alignment of contracts and incentives = better, more integrated out-of-hospital care, QIPP Paving way for 5-year forward view and general practice forward view Use PMS premium to support our aims & PC Priorities

NHSE to approve proposals PMS Premium – The Rules CCGs to publish proposals for reinvesting PMS Premium in line with national principles & framework: Reflects joint strategic plans for primary care Secures services or outcomes that go beyond core contract Helps reduce health inequalities Equality of opportunity for GP practices Consult with LMC NHSE to approve proposals

Delegated Functions - Some of the Rules “Where the CCG wishes to develop and offer a locally designed contract, it must ensure that it has consulted with its LMC in relation to the proposal and that it can demonstrate that the scheme will: Improve outcomes Reduce inequalities Provide value for money …”and avoids making any double payments under any Primary Medical Services Contracts” NHS England role in approving CCG plans – end of July

LMC – agree principles, reward to reflect effort Current Position LMC – agree principles, reward to reflect effort PCCC – agree priorities, principles NHSE – concern re lack of service provision!

Timetable Wyre Forest Patient Group 6 Sept 2016 Proposal available on intranet 19 Sept – 7 Oct 2016 Frailty presentation by Dr Maggie Keeble available on intranet 19 Sept – 31 Oct 2016 Survey monkey 19 Sept – 7 Oct 2016 FAQs available on intranet 19 Sept – 31 Oct 2016 PC Commissioning Committee 12 Oct 2016 Contract Start Date 1 Nov 2016

Promoting Clinical Excellence Contract (Local Improvement Scheme) 2016/17 & 2017/18 A Proposal

What are the Wyre Forest Priorities? Proactive Care for Older People living with Frailty – proactive care and co-ordinated care, personalised planning Excellence in management of Long Term Conditions – high quality personalised care – e.g. Atrial Fibrillation Effective Use of Resources-Best Practice – Making quality referrals The Right Access – releasing capacity in general practice e.g. Care Navigation

Contracting Vehicles GMS Contract = funding per patient plus DESs, QOF & LESs Local Improvement Scheme Frail elderly Long Term Conditions – AF Avoidable appointments/Release capacity Best Practice Right Access Funding £26,455 (16/17) and £34,227 (17/18) per average practice (10,416 patients) . Participation is voluntary Can be held by individual or groups of practices working collectively A number of pre-requisites: Engagement (including information requests, completion of surveys e.g. workforce) Compliance with prescribing formulary IQSP participation (funded) Others TBA

Funding Available 17 month contract starting 1 November 2016

Funding Per Average Practice

Contract & Payment PMS Premium ring-fenced for re-investment in primary care services 17 Month Local Improvement Scheme, added to GMS Contract, 1 Nov 2016 - 31 March 2017. Phase 2 -1 April 2017 31 March 2018 All or nothing sign up – i.e. no cherry picking. Longer contract caveat – recycle funding to new indicator if ‘double funding’ arises in 2017/18 due to contract, ES or QOF change. Payment for achievement of tasks & Key Performance Indicators (sliding scale where appropriate) Some Payments prepaid in November (IQSP, Quality Referrals, Training) Some payments based on achievement in May 2017 (e.g. “QOF Plus”) Practices to complete Delivery Plan Payments adjusted for list size Clear Payment profile & schedule to be provided for all practices Performance dashboard No manual claims – automatic data extract from systems

Frailty Standards Older People living with Frailty Clinical Frailty Score Older People living with Frailty Unplanned admissions Register 2% MDTM review - DES Combined Proactive Care Plan (EMIS template) incorporating Advance Care Planning

Frailty Standards Assess current 2% DES register for Frailty using recommended tool (Rockwood Frailty Scale) – payment of £150 per patient (same as SW) for all appropriate frail patients assessed and plan developed (cap at 2% of practice population). 2016/17 Identify Clinical Lead Score and code severity accordingly Attend Study Day & cascade knowledge internally 2017/18 Continue to score & code severity Use of EMIS template for comprehensive Proactive Care Assessment and Plan for those patients coded as severely frail (up to 50% of the total DES register). In-depth medication review with pharmacist or using STOPP-START tool. Clinical lead attend Study Days x 2 & cascade learning internally

Payment Element for Frailty 2016/17 payments based upon 3 components:- £12,500 per average practice (£60 per patient on DES register) identified and coded as being frail £1,400 per practice for a lead GP and practice education 2017/18 payment:- £18,764 per average practice (£90 per patient on DES register) for comprehensive assessment INCLUDING medication review If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently We need a whole new model of care based around a Proactive Patient Centred approach

Payment Element for Frailty If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently We need a whole new model of care based around a Proactive Patient Centred approach

Long Term Conditions QOF PLUS

Scheme to reduce the incidence of stroke Atrial Fibrillation Scheme to reduce the incidence of stroke Increase detection via Improving Quality Supporting Practices Increase percentage with AF receiving OAC

Atrial Fibrillation (AF007) – Current Achievement Definition: In those patients with atrial fibrillation with a record of a CHAD2DSC-VASc score of 2 or more the percentage of patients who are treated with anticoagulation drug therapy An incentive payment is payable if a practice achieves anti-coagulation rates. The payment is adjusted for list size. Rates are after exception reporting. Outliers are identified as exceeding mean plus one standard deviation. WF has slightly lower anti-coagulation rates than SW.

Anti-Coagulation – Exception Reporting But WF has lower exception reporting rates and less variation between practices.

AF Proposal Set same targets for WF as for SW. Exception reporting outlier to be based on 2016/17 mean + 1 SD This works out as

Right Access Releasing Capacity

Implement Avoidable Appointments Audit (£691) Share Results Releasing Capacity Implement Avoidable Appointments Audit (£691) Share Results Preparation for 2017 Identify Key Areas of Focus There is funding available in 2017/18 which can be used to support the findings of the avoidable appointments audit e.g. introduce Care Navigator role.

Effective Use of Resources Making Quality Referrals - Best Practice

Making Quality Referrals Funded time to do skills register, top tips, utilize advice and guidance and time to review referral before it leaves the building. - £7,636 Review method (desktop, face-to-face etc.) decided by practice. Practices identify a lead for 2-3 specialities - £250 Practices use inter-practice referrals, e-referrals, advice and guidance. Agreed training - £1,000 16/17 no coding to ‘Referral for further care’ - £750 (If non-compliance occurs the practice will be invited to re-code the relevant items. Once this has been done satisfactorily full payment will be made). Decision later re 17/18 If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently We need a whole new model of care based around a Proactive Patient Centred approach

Tools – PCE Dashboard

Is contract spanning two financial years better for practices? Questions Is contract spanning two financial years better for practices? Longer contract caveat – recycle funding to new indicator if ‘double funding’ arises in 2017/18 due to changes in priorities, GMS contract, Enhanced Services, QOF Multiple Contracts – only frailty & IQSP spanning two years?

What Outcomes do we expect to see as a result of re-investment? Proactive, co-ordinated and high quality care for older adults with severe frailty Better advanced care planning Better management of long term conditions – improved quality of life Reduced morbidity and mortality – Stroke Reduction in inappropriate hospital admissions Fewer exacerbations leading to acute emergency admissions Re-investment of funds in general practice to support sustainability, improve standards of care More accurate coding of referrals Release of capacity within general practice

Timetable Wyre Forest Patient Group 6 Sept 2016 Proposal available on intranet 19 Sept – 7 Oct 2016 Frailty presentation by Dr Maggie Keeble available on intranet 19 Sept – 31 Oct 2016 Survey monkey 19 Sept – 7 Oct 2016 FAQs available on intranet 19 Sept – 31 Oct 2016 PC Commissioning Committee 12 Oct 2016 Contract Start Date 1 Nov 2016