CYPM Workstream: GPC Early Years Contract Update Summary of Early Years Activities commissioned from primary care and aligned service activity

Context A maternity enhanced service was commissioned several years ago from individual practices by the PCT, and this recurrent funding transferred to the Vulnerable Children’s Contract, and then to the Early Years Contract, held by the CCG Additional non recurrent funding was awarded by the CCG as the ‘Vulnerable Children’s Contract’, that became the ‘Early Years Contract’, for a range of children’s components (UPP link meetings, identification and referral of young carers, offer of 16th Birthday health check, and new child registration checks) Within the current 7 year GP confederation contract, from April 2018, the maternity and children’s components were commissioned with combined recurrent (£260K) and (1 year only) non-recurrent (£272K) budgets In 2018 the CCG notified the GPC that there would be no non-recurrent funding available from April 2019 Early analysis of related pathways and discussions identified duplication in funding / delivery of the pregnancy presentation and 16 week appointments, and likely post natally. Our neighbouring CCGs do not invest in antenatal care delivery in primary care Question for CCF – what should be the clinical priorities of the contract ?

Current Early Years Contract Maternity components - currently an agreed part of the pathway for women who book at HUHT only LTC Targeted Preconception proactive identification of women 20-45 years who are invited to an appt Pregnancy Presentation 16 Week Pre Natal Check 20 minute enhanced appt to be offered 6 Week Post Natal Check Children’s Components New UPP patient action plans enhanced capacity for vulnerable children link meetings with HVs Review UPP patient action plan Carers Register identification of children with caring responsibilities and offer of referral New Patient Checks (5-17) to bring in line with core GMS adults offer, early identification of needs 16th Birthday Checks promotion of offer, to support empowerment of young people to access services and take responsibility for their health

Contract Activity and Spend 2017-18 Early Years 2017 -18 End of year Activity and Cost Summary ACTIVITY TOTAL CAPPED PATIENT NUMBER TOTAL 2017/18 ACTIVITY TOTAL 2017/18 % OVER / UNDER DELIVERED AGAINST CAP RATE TOTAL ANNUAL PAYMENT LTC Targeted Preconception 750 634 85% £40 £25,360 Pregnancy Presentation (65%) 2925 3726 127% £149,040 16 Week Pre Natal Check (70%) 3150 2521 80% £100,840 6 Week Post Natal Check (85%) 3825 3624 95% £144,960 New UPP patient action plans (GP) 300 356 119% £64 £22,784 Review UPP patient action plan (GP) 1000 462 46% £30 £13,860 Carers Register   n/a New Patient Checks (5-17) 1150 1317 115% £52,680 16th Birthday Checks Total Early Years Contract Value ( maternity & childrens activity) £521,200 Total full year activity costs (Q1 to 4) £509,524 Total 2017/18 Underspend £11,676

2017/18 Early Years 16w apt. Audit A recent maternity audit examined women who had received a pregnancy presentation appointment at the practice but did not attend a 16 week antenatal appointment.  375 women were audited across practices. Main findings of the 375 audited women: 77% (287) of women presented at 10 weeks or under 72% (262) of women attended Homerton for their antenatal care 18% (66) of women attended UCL for their antenatal care 7% (25) of women attended Whittington for their antenatal care 3% (16) of women attended 11 other hospitals for their antenatal care 55% (208) of women had their first scan result sent by the hospital to the GP 27% (100) of women had a 16 week check appointment booked with the GP, of these, 17% (65) attended 23% (85) of women were identified as having an obstetric or social risk 30% (111) of women for whom it was their first pregnancy   Practices noted the following: Some hospitals see the women at 16 weeks rather than the GP Patients under consultant care are told they do not need to see the GP Some women presented late and consequently saw the midwife at 16 weeks Attendance has decreased since the practice-based midwives have been withdrawn 60% (25) practices operated an active recall system 83% (35) practices followed up DNAs As a result of undertaking this audit: 48% (20) practices planned to make improvements to their recall and DNA procedures

National schedule of antenatal visits for low risk women This pathway is funded via the PbR tariff, and delivered as part of standardised maternity care by Trusts: Booking appt (75 minutes) 11-13 weeks +6 combined test 16 week appointment 20 week for anomaly scan also offered pertussis and seasonal flu 26 weeks antenatal check 28-38 recommended vaccination pertussis if not already given 30 week antenatal check 34 week antenatal check 36 week check for 1st babies only 38 week check to discuss onset of labour 40 week check for 1st baby only 41 week antenatal check – arrange OPA for induction of labour 41+ weeks (Dependent on risk factors identified, woman is referred on to obstetric care)

Current Health Visitor Pathway This is commissioned by the LA using an aligned budget as part of the CYPM workstream. 5 of these indicators are nationally mandated: Antenatal universal offer but engagement is targeted New baby universal One month baby check targeted 6-8 weeks universal held in either children’s centre or GP practice 3-4 months targeted 1 year (9-12 months) universal 2 – 2.5 years universal This is the key period where families may ‘drop out’ and partnership working needs to promote engagement with services Safeguarding is a key focus of the HV visits

Proposed Early Years (primary care) Indicators from April 2019 Maternity Look at LTC core contract re. inclusion of targeted pre-conception advice in annual review ? Impact on non-commissioned care delivered by practices for women with hypertension, hypothyroidism Retain pregnancy presentation (still encourage direct booking so activity may reduce) Decommission 16 week appointment (so consistently offered by Trust and supports continuity of carer) Retain 6 week post natal appointment Children UPP – maintain requirement for joint review and planning via monthly link meetings 16th Birthday check – decommission consider maintaining for those with special educational needs and disabilities ? New Patient Checks – decommission ? Clinical value Of most value for families newly moved to Hackney? Consider for an identified vulnerable cohort e.g new to UK? Identification of child carers – decommission from April 2019 but continue to promote use of this pathway and child carers should continue to be flagged GPC Consultation with practices in January, service spec to be submitted to January contracts committee

Update following discussions with the GP Confederation Feedback from the GP confederation re-iterated strong support for retaining the pregnancy presentation, some pre- conception work and the post natal check. They also fed back that GPs wanted to prioritise UPP and some child carer work. It was agreed that the 16 week check was a low priority for retention. An additional small ‘step down’ sum has been agreed to support the contract for one year, from April 2019 to include all of the ‘prioritised’ elements, while still delivering a sizeable reduction in the non-recurrent elements. We propose that the 19/20 contract continues to be activity based, and this activity is monitored closely, with a review at 6 months (in addition to regular quarterly monitoring). This will give us a clearer indication of the impact of the changes and the implementation of the continuity of carer agenda and promotion of self referral antenatally. Thoughts from the Clinical Commissioning Forum on this as a way forward?