1. Promoting Clinical Excellence The Launch of the Consultation
2016/17
The Launch of the Consultation

2. Chair, Primary Care Commissioning Committee
Trish Haines
Chair, Primary Care Commissioning Committee

3. Agenda Aims of session:
To review progress on Promoting Clinical Excellence (PCE) 2015/16
To share the proposed elements of PCE 2016/17
To offer an opportunity to influence and shape PCE 2016/17
Start
Finish
Duration
Subject
Lead
6.30
7.00
30 mins
Refreshments on arrival
7.10
10 mins
Welcome, purpose of the session and recap on 2015/16
Trish Haines
7.35
25 mins
Strategic Direction and Proposed PCE scheme 2016/17
Lynda Dando
7.50
15 mins
Proactive Care – 16/17
Dr Maggie Keeble
7:50
8:00
Prescribing – A New Approach
Jane Freeguard
8:20
20 mins
Finance
Caroline Salmon
8:30
Next steps
8:55
Questions & answers
9:00
5 mins
Close

4. Scheme components – 2015/16
Proactive care for older people living with Frailty – frailty diagnosed and placed on frailty register – proactive, co-ordinated, planned care
Excellence in LTC - Blood pressure measurement – better management of LTC, improved quality of like
Excellence in LTC - Hypertension management – reduced morbidity and mortality – stroke, heart and kidney failure
Excellence in LTC - Atrial Fibrillation (anti-coagulation) – fewer strokes
Best care – End of Life – on-going process for bespoke quality improvements in all 32 practices
Best care – COPD and Asthma – better advanced care planning
IQSP – improving quality and supporting practices
Audits and Study days – high quality sustainable general practice
E-referrals – increased usage
Coding – improving coding quality

5. Promoting Clinical Excellence Achievement to 31 January 2016
1, 689 patients have been identified as frail and had a Proactive Care Assessment and Plan developed, separate evaluation by The University of Warwick Medical School
The table below summarises emergency admissions based on an ‘average’ CCG practice for April to March

6. Prevalence i.e. Identification of Patients
SWCCG – disease registers 1 April to 31 January 2016
The above table shows the change in register size between April 2015 and January 2016 for selected areas for SWCCG.

7. What’s happened since 10 September Workshop
8 Point Plan, in 2016/17 we shall:
Promoting Clinical Excellence
Expand the local improvement scheme contract, building on the good progress made during 2015/16, ensuring primary care resources are protected wherever possible and PMS premium funding is appropriate reinvested in a way that supports primary care and improved outcomes for patients as well as preparing Practices for any new national contract in 2017.
 Priorities:
Highest
Lowest
Workforce Development
Prevention
Excellent Long Term Conditions-Diabetes, COPD & Asthma
Premises
Proactive Co-ordinated Care
QIPP & esp prescribing

8. Feedback from Primary Care Commissioning Committee Development session 14 Jan 2016
Element
Comments
Pre diabetes, COPD & Asthma
Supported
Care navigator role
Working together initiative
Supported (“a step in the right direction”)
Bespoke indicators for atypical
practice populations
Supported. Some requests for ‘atypical’
to be explicitly defined AF
Focus on pulse checking in practices
would enable more diagnosis
What’s missing
Public health – smoking, obesity, diet,
alcohol and lifestyle

9. Associate Director, Primary Care Quality & Development
Lynda Dando
Associate Director, Primary Care Quality & Development

10. Strategic Direction – The Four Pillars of Primary Care
What are the benefits?
Elderly
Young
More proactive care
Person-centred/
holistic
More time with clinician
Faster routine access
After school, evening & weekend appointments
GP’s
More time with patients/continuity
Greater job satisfaction
Better use of skills & expertise

11. Promoting Clinical Excellence 2016/17 Aims and Principles
Promoting Clinical Excellence-8 Point Plan
Expand the local improvement scheme contract, building on the good progress made during 2015/16, ensuring primary care resources are protected wherever possible and PMS premium funding is appropriate reinvested in a way that supports primary care and improved outcomes for patients as well as preparing Practices for any new national contract in 2017.
Improving health outcomes
A philosophy of continuous improvement, supported by an evidence-base
Participation is voluntary
Proactive prevention focus
New ways of working & delivery of services will be tested through pilots
Sustainable primary care – five year forward view
There can be no double funding
Some things will be mandated e.g. compliance with prescribing policy
1 year contracts – 1 April start……………

12. The Opportunities GMS Contract DES & LES QOF Offer 1: Individual PCE
Offer 2: Atypical Population PCE
Offer 3: Working Together PCE

13. Key Differences 15/16 & 16/17 What’s out Use of e-referrals
Improving coding quality

14. No Change End of Life IQSP Study Days Audits
Stroke prevention – on-going [Blood pressure, hypertension, atrial fibrillation]

15. Offer 1 – Working Individually

16. What’s new - Proposed Components
Proactive Care
Re-focus Avoiding Unplanned Admissions DES*
New care navigator role
Identification of pre-diabetes
Respiratory – Asthma and COPD
Indicators for Atypical populations
Best Practice – Accessible Information Standard
* NHSE role

17. Pre-diabetes
WHY?
Pre-diabetes prevalence is twice that of diabetes - about 32k pre-diabetics in South Worcestershire.
Average cost of a diabetes case is £3,233-£3,717 per year in the UK [Kanavos et al (2012) at the London School of Economics]
Saving from deferring 5% of cohort diabetes onset by one year is £5.6m.
Savings estimate is conservative % reductions in incidence of Type 2 diabetes, over three years, are quoted for adults at high risk who receive intensive behavioural interventions [Public Health England].

18. Identification of Pre-Diabetes
How? Three Requirements for Practices:
Develop & maintain register of people with pre diabetes
(risk assessment via health check for eligible groups, opportunistically, NICE simple risk identification tools - Diagnosis based upon HbA1c of mmol/mol)
Signposting to available lifestyle support services
(we’ve successfully bid to be part of National Diabetes Prevention Programme=additional lifestyle intervention provision)
Annual Recall
(HbA1c retest & on-going annual monitoring as long as the patient remained within pre diabetic range)

19. COPD and Asthma Asthma: COPD: Written care plan
Review post emergency admission
Inhaler technique:
an improvement of 5% for those with good technique (maintain if at 95%+)
zero patients with poor technique
COPD:
Depression screening undertaken

20. Accessible Information Standard
Review recommendations from Healthwatch reports x 3:
Amending registration or new patient forms so that they are more accessible and include a question or section about information and communication needs
Adding a statement prompting patients or service users to inform the service if they have any information or communication needs to letters and leaflets
Displaying posters and information in different formats encouraging patients and service users to inform the service if they have any information or communication needs
Checking to see if there is an induction loop system available (to support hearing aid users) and, if so, checking that it works and that staff know how to use it
Engaging with your patient group to seek their support for implementing the Standard – they may also have contacts into local voluntary groups with relevant expertise
Review existing policy and practice around use of and text message to communicate with patients; these can be quick, cheap and convenient ways of contacting lots of people who have hearing or visual loss.

21. Offer 2 – Atypical Population

22. Atypical Populations and Innovation Definition and Examples
Atypical Populations - “Where a practice has an atypical population for SWCCG and identifies a specific need outside of the core standards set out in the GMS and PCE local contracts 2016/17, they may apply for a bespoke indicator that will address this particular need.
Examples of atypical populations include-
unusually young populations;
those with particular service needs (e.g. homeless and  drug users);
populations with substantial deprivation (top 40% nationally – IMD and above) ;
university practices;
practices with large numbers of temporary residents;
those with a high proportion of non-English speakers.

23. Offer 3 – Working Together

24. New models of care & working collectively
Point 7: 8 Point Plan new models of care and working collectively
Ensure that the role of primary care remains integral to the new models of care CCG strategic work. We will continue to support Practices to work together to deliver services at scale and improve integration between primary and community care teams.
Precursor to new voluntary GP contact from April 2017 :
Practices may opt to work together to deliver at least one PCE component
Minimum combined list size is 30,000
Planning for 7-day access
Workforce planning
Quality & sustainability
Working with others
Option to work towards shadow budgets

25. PCE 2016/17 Contract Prerequisites
Compliance with the CCG Prescribing Policy
Delivery of Medicines Optimisation in collaboration with SW Healthcare
Participation in “Making Quality Referrals” Initiative
Delivery of the dementia and learning disability DES
Engagement with the CCG (including information requests and completion of surveys)
Complete  National Diabetes Audit

26. Study “Days” & Audits Up to 4 educational events: Up to 4 Audits:
Sepsis Update
Up to 4 Audits:
Safeguarding-coding of vulnerable adults & children

27. PCE 16-17 Proactive Care Component
Dr Maggie Keeble
Proactive Care Lead SWCCG

28. SWCCG, Clinical Lead for Proactive Care
Dr Maggie Keeble
SWCCG, Clinical Lead for
Proactive Care

29. 2015-16 PCE Frailty cohort 1% of the 2%
AUA DES 2%
Frailty Cohort 1%

30. Challenges 2 different cohorts 2 different templates
Different processes for recording and claiming
Different expectations for review
Confusion

31. Proactive Care Register 2%
PCE - 2% DES cohort – focus on Frailty but flexible – and consistent terminology – ‘Proactive Care’
Proactive Care Register 2%

32. DES requirements Identification Timely access phone numbers
Care assessment and Care planning
Appointment of Care Coordinator (clinical role)
72 hr reviews following discharge from hospital
Monthly review of the register
Monthly reviews of all unplanned admissions/AnE attendances
Yearly reviews if stable

33. Proactive Care Register
One cohort – predominantly frail – identified using Rockwood/eFI/common sense – at risk of unplanned admission
If not frail or not otherwise at high risk take off the register
One template –SWCCG PACT templates
One reporting process
Escalation planning (ECAP)
Consistent approach

34. Care Navigator Role Aim of introducing the role:
To improve access to integrated support and care for those patients identified as most likely to benefit from the Proactive Care Initiative
Better communication and co-ordination across all services providing care and support to the same cohort of patients to ensure reduced duplication and improve efficiency for all
To reduce the burden of work on GPs by co-ordinating review and follow-up and by directing the tasks currently undertaken by GPs that could be done by someone else

35. District Nurse Service
Intermediate Care
Hospital Out patients
Hospital AnE
Hospital Wards
Community Hospital
Care Home
Pharmacist
Community SW GP
OOH
Enhanced Care Team
District Nurse Service
Palliative Care CNS
Hospices
PACT team
OAMHT
Ambulance Service
Rapid Response SW

36. Onside Advocacy IMCA services Advice re POA Wills etc
Specialist Nurses eg PD Neurological Dx
Admiral Nurses
Support with visual aids OT
Physio
Equipment GP
Opticians
Age Uk
Housing association
Speech and Language Therapy OT
Strength and Balance Classes
Audiology Assessment
Domiciliary Care Agency

37. Referral to Carers Organisations Capacity Assessments
Care Line
Stair lifts Aids and Adaptations GP
Continence Products
Wheelchairs
Exemption from Council Tax
Blue Badges
Chiropody

38. Roles of Care Navigator 1
Roles of Care Navigator 1. ‘Go to person’ for patient and informal carer
Go to person for patients and carers looking for advice and support
Single direct phone line and a named individual
Signposting and advising
Increased awareness of local provision
Access to Framework for information re Social Care

39. 2. ‘Go to person’ for health and social care professionals and others
Central point of contact for organisations/other health care professionals to notify of involvement or changes or when seeking information at the interfaces of care
Notification of admissions discharges and transfers – hospital intermediate care ECT and care homes
Chased Discharge information if missing
Updates EMIS and liaises with relevant others eg PACT/CHNP/ Pharmacist/SW

40. 3. Admin support – Proactive Care Cohort
takes part in MDTM
keeps records updated
informs OOH/WMAS if on EOL register
make appropriate requests for routine bloods and referrals with GP consent e.g. for continence assessment and equipment
Organises review appointments

41. Care Navigator Working in GP practice
Ideally knows the system well already
Dedicated phone line for patients and other organisations
Able to attend monthly information and update sessions
Happy to network with other care navigators to share information and learning

42. Ideal Attributes:
Passion and commitment to improving the quality of care and improved patient outcomes
Excellent communication skills to navigate patients and those important to them through the various pathways
Enthusiasm and the ability to motivate others with a positive approach
A can do attitude
A solution focussed approach to problem solving

43. Care Navigator Project Manager/Leader
To communicate with all practices
To support the care navigators
To encourage role development
To organise workshops and training
To liaise with other health and care teams and organisations to increase awareness of role
To evaluate the role : usage impact outcomes and collating feedback

44. Head of Medicines Commissioning
Jane Freeguard
Head of Medicines Commissioning

45. Medicines Optimisation
Current complexity
QIPP
Medicines Optimisation service
Care Home pharmacy service
Anticoagulants
Direct acting drugs (high drug cost)
Warfarin (monitoring costs)
Result = confused practices/reduced return

46. 2016/17 Position
8 Point Plan priorities - delivery of QIPP and especially changing prescribing behaviour SWHC (on behalf of SW practices) gained access to national funding for Clinical Pharmacists in General Practice Prescribing costs continue to rise in line with the improved care delivered under PCE 2015/16

47. 2016/17 Proposal Within PCE, practices will be required to;
Follow a SW CCG prescribing policy
This will identify expectations around prescribing and provide guidance to clinicians on prescribing in certain situations
highlighting items that GPs should not prescribe e.g. non-NHS funded travel vaccines or unlicensed medicines
prescribing for occupational health purposes or following private consultations
Work with SWHC to demonstrate effective medicines use

48. SWHC agreement
SWHC will work with practices to deliver effective medicines use, including;
Managing prescribing spend
Medication review (including proactive care patients)
Medicines Optimisation
Anticoagulant monitoring
Measures will be simplified to include financial monitoring medicines assurance only
This will give practices the option to directly employ staff or access support from SWHC to deliver these services in primary care

49. Primary Care Commissioning Lead
Caroline Salmon
Primary Care Commissioning Lead

50. Primary Care Funding – National Context
Received CCG 2016/17 allocation and distance from target
Primary Care is 22.8% over our fair share target
£44,819k versus £36,974k target = £7,845k
Levelling process - differential growth across CCGs – SWCCG will receive less
In effect, we will receive below inflation uplifts because of our overfunding in Primary Care
CCG already invests 10% of allocation in Primary Care
GPC view move towards 11% - SWCCG already close

51. Supporting Primary Care
The CCG has funded additional expenditure on primary care outside PC allocation:

52. Reinvestment of PMS Premium - Rules
PC Commissioning Committee has agreed PMS Premium ring-fenced
Can’t use PMS for core GMS provision
Can’t double fund
PMS can be used for wider primary care - not just GP practices
Proposed use of PMS has to be agreed by NHS England

53. GP Practice Funding Variation £ per Weighted Patient 2015/16
National Funding 2015/16 £76.51
Target National Funding 2020/21 £78.33

54. Source of PCE Funding
8 Point Plan, in 2016/17 we shall:
Promoting Clinical Excellence
Expand the local improvement scheme contract, building on the good progress made during 2015/16, ensuring primary care resources are protected wherever possible and PMS premium funding is appropriately reinvested in a way that supports primary care and improved outcomes for patients as well as preparing Practices for any new national contract in 2017.
(Borrowing to be repaid from following year’s PMS premium)

55. Funding

56. Funding – Average Practice

57. Pre-Diabetes Example Develop and maintain a register
Signpost to available lifestyle support services
Annual recall
Pre-diabetes prevalence is twice that of diabetes. Pre-diabetes is defined as non diabetic patients within a Hba1c range of Typically practices will already have some patients like this coded in EMIS.
To qualify for a band C payment the practice needs to identify as many pre-diabetic patients as they have diabetic patients coded in QOF. This will amount to about half of all pre-diabetic patients on their practice lists.
To qualify for a band B payment the practice needs to identify pre-diabetic patients equivalent to 120% of the number of diabetic patients coded in QOF. This will amount to about 60% of all pre-diabetic patients on their practice lists.
To qualify for a band A payment the practice needs to identify pre-diabetic patients equivalent to 140% of the number of diabetic patients coded in QOF. This will amount to about 70% of all pre-diabetic patients on their practice lists.
In the table above it is assumed that the practice already has 435 patients coded within the pre-diabetic range (typical of what is currently coded in EMIS). They need to find an additional 83 to get £1,264, an additional 187 to get £4,767 and an additional 290 patients to get £9,906.

58. Primary Care Funding Outside of PCE?
Point 7: 8 Point Plan – We will continue to support practices to work together to deliver services at scale and improve integration between primary and community care teams
Primary Care Funding Outside of PCE?
Currently scoping the CCG’s financial plan and hope to be able to establish some money to fund:
Prime Minister’s Challenge Fund
Funding to continue and expand proven initiatives
Primary Care Development Funding
Funding for pump-priming to support practices wishing to work collectively e.g. legal advice, development of plan, including backfill costs
via devolvement of locality monies
Minimum 3 locality wide meetings per year
A business case will need to be developed

59. Enhanced Services Update and Proposals for 2016/17
Point 4: 8 Point Plan – Local Enhanced Services
“Maintain a programme of Local Enhanced Services that are closely aligned to the Promoting Clinical Excellence local improvement scheme. We will continue to review the effectiveness of these schemes and continue to reduce the bureaucracy associated with administering them.”

60. Questions & Answers

61. Next Steps 11 Feb to 11 Mar Consultation period (4 weeks) 15 March
PCCAG considers practice feedback & agrees recommendations
17 March
PCC Committee consider recommendations & agree PCE 2016/18 contracts
w/c 21 March
Offer made to practices with templates, read codes, delivery plan(s)
31 March
Signed PCE 2016/17 Contracts returned
19 April
Development Day
Plans submitted:
30 April
Single working
Atypical population bids
31 May
Working together (draft submission)
30 June
Working together (finalised)