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NHS Canterbury and Coastal CCGExtraordinary Governing Body Meeting - Part 1

Office Meeting Room 2, Canterbury City Council Offices, Military Road, Canterbury, Kent, CT1 1YW

05 January 2017 09:00 - 05 January 2017 09:45

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AGENDA

# Description Owner Time

0 AgendaCCCCG Agenda - 05.01.17 - Extraordinary Part 1 v4.doc 5

1.17 Introductions and Apologies

2.17 Feedback and Pre-submitted questions

3.17 Quorum

4.17 Declarations of Interest04-17 - Declarations of Interest - updated November 2016.doc 7

5.17 Shared Care and Enhanced Prescribing Scheme Specification

05-17 - FC - Shared Care and Enhanced Prescribin... 11

05-17 - Shared Care and Enhanced Prescribing Sch... 15

6.17 Local Enhanced Service to Support Adult ADHD Monitoring and Prescribing06-17 - FC - ADHD prescribing and monitoring v2.doc 33

06-17 - OBC - Local Enhanced Service ADHD Presc... 37

7.17 Any Other Business

8.17 Invitations fro questions from members of the public on the current agenda

9.17 Next Governing Body meetings

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INDEX

CCCCG Agenda - 05.01.17 - Extraordinary Part 1 v4.doc.............................................................5

04-17 - Declarations of Interest - updated November 2016.doc.....................................................7

05-17 - FC - Shared Care and Enhanced Prescribing Scheme Specification v3.d........................11

05-17 - Shared Care and Enhanced Prescribing Scheme Specification 13-12-16.........................15

06-17 - FC - ADHD prescribing and monitoring v2.doc..................................................................33

06-17 - OBC - Local Enhanced Service ADHD Prescribing Adults v.2.doc....................................37

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EXTRAORDINARY GOVERNING BODY MEETING – Part 1Thursday 5 January 2017

9.00am – 9.50amOffice Meeting Room 2, Canterbury City Council Building, Military Road,

Canterbury CT1 1YWAGENDA

Paper Lead Time01/17 Introduction and Apologies Verbal Chair 5 mins02/17 Feedback and Pre-submitted

questionsVerbal Chair 5 mins

03/17 Quorum Verbal Chair 1 mins04/17 Declarations of Interest Chair 1 mins

DECISION/APPROVAL05/17 Shared Care and Enhanced

Prescribing Scheme SpecificationBill Millar 20 mins

06/17 Local Enhanced Service to Support Adult Attention Deficit Hyperactivity Disorder (ADHD) Monitoring and Prescribing

Bill Millar 20 mins

07/17 ANY OTHER BUSINESS08/17 Invitations for questions from

members of the public on the current agenda

Verbal Chair 10 mins

NEXT GOVERNING BODY MEETINGS

09/17 Governing Body Meetings - All held at Thanington Neighbourhood Resource Centre, Thanington Road, Canterbury CT1 3XE:Thursday 2 February 2017 – 9.00am to 1.00pm Thursday 1 February 2018 – 9.00am to 1.00pm Thursday 6 April 2017 – 9.00am to 1.00pm Thursday 1 June 2017 – 9.00am to 1.00pm Thursday 3 August 2017 – 9.00am to 1.00pm Thursday 5 October 2017 – 9.00am to 1.00pm Thursday 7 December 2017 – 9.00am to 1.00pm Thursday 1 February 2018 – 9.00am to 1.00pm

10/17 CLOSURE OF PART 1

Page 1 of 1CCCCG Agenda - 05.01.17 - Extraordinary Part 1 v4.docOverall of 46

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Updated November 2016

Declarations of InterestNHS Canterbury and Coastal Clinical Commissioning Group (CCG) Governing Body 2016/2017

Name Position Declaration of InterestSarah Phillips Clinical Chair, Canterbury and

Coastal CCG (Faversham) Member of Invicta Health CIC Member of Limited Liability Practice (LLP) that part owns the

Pharmacy at Newton Place. Practice has signed up to the Vanguard Multispecialty Community

Providers.Jackie Bell Lay Member, Canterbury and

Coastal CCG Nil

Matthew Capper Director of Performance and Delivery,

Ashford CCG and Canterbury and Coastal CCG

Wife is Speech and Language Therapist for East Kent Hospitals University Foundation Trust

Governor of a Primary School in Canterbury, Kent

Alistair Challiner Secondary Care Clinician Consultant in Intensive Care and Anaesthesia, Maidstone and Tunbridge Wells NHS Trust.

Lead Anaesthetist for ECT, Priority House Maidstone, KMPT Practice rights at BMI Somerfield Hospital, Maidstone Practice rights at Nuffield Hospital, Tunbridge Wells Practice rights at Kent Institute of Medicine and Surgery (KIMS) Medical Advisor Tactical Medical Unit, Kent Police Fellow Royal College of Anaesthetists Fellow Faculty of Intensive Care Medicine Professional Advisor to Care Quality Commission (CQC)

Nick Dawe Chief Finance Officer Ashford CCG and Canterbury and

Coastal CCG

Spouse works for East Kent Hospitals University Foundation Trust (EKHUFT)

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Name Position Declaration of InterestSimon Dunn Clinical Member, Canterbury

and Coastal CCG (Herne Bay) Full time GP Partner, St Anne’s Group Practice, Herne Bay St Anne’s Group Practice is member of Invicta Health CIC. Member and shareholder of Herne Bay Ophthalmology Clinic and

Cataract Service providing outpatient ophthalmology clinics and cataract services from Beltinge and Reculver Surgery.

Spouse is Primary Care quality Manager for West Kent CCG GP Appraiser contracted to NHS Kent and Medway GP Training Programme Director employed by Health Education

England Member of Individual Funding Request Panel and Provide clinical

advice to the Triage service for South East Commissioning Support Unit

Chris Healy Clinical Member, Canterbury and Coastal CCG (Ash/Sandwich)

Practice has signed up to the Vanguard Multispecialty Community Providers.

Dan Horton-Szar Clinical Member, Canterbury and Coastal CCG (Northgate)

Practice has signed up to the Vanguard Multispecialty Community Providers.

Anthony May Head of Corporate Governance, Ashford CCG and Canterbury

and Coastal CCG

Nil

Bill Millar Chief Operating Officer, Ashford CCG and Canterbury and

Coastal CCG

Wife works at Pilgrims Hospice. Wife works for One Healthcare Ashford



Name Position Declaration of InterestDaniel Moore Clinical Member, Canterbury

and Coastal CCG (Faversham Senior Partner of Faversham Medical Practice providing General

Medical Services as well as Enhanced Services and Minor Injury Unit Services.

The practice provides Intermediate care to Kiln Court Residential home.

Senior Partner of Alcroft Medical Services LLP providing medical Services

Employed by Kent Community Healthcare Foundation Trust as a Clinical Assistant.

Employed by Health Education England as a GP trainer. Employed by NHS England as a GP Appraiser. Shareholder of Invicta Health CIC, Canterbury. Practice has signed up to the Vanguard Multispecialty Community Providers (MCP). Advising Trojan Telecom exploring the development use of Elskan

cardiac monitoring devices for the NHS.

Ana Paula Nacif Lay Member PPECanterbury and Coastal CCG

Executive Coach with the NHS London Leadership Academy Consultant/trainer with Social Enterprise Kent and former

Consultant/trainer with Red Zebra Independent Coach and facilitator with Living Well CIC, which Is a

delivery partner for Turning Point Volunteer wellbeing coach with Porchlight

Simon Perks Accountable Officer Ashford CCG and Canterbury and

Coastal CCG

Director and trustee of Cantercare Ltd, registered charity no: 1023652;

Trustee, Pilgrims Hospice



Name Position Declaration of InterestJohn Ribchester Clinical Member, Canterbury

and Coastal CCG (Whitstable) GP partner Whitstable Medical practice and part owner Chestfield

medical centre and Estuary View medical centre. Provider of GP enhanced services. Provider of a range of community

outpatient, diagnostic, and day surgery services. Provider of a level 3 minor injury unit. Provider of community physical

therapy services. Honorary Director and Shareholder, Thorndene Ltd, Swingfield,

Dover, Kent. Appointed Member Downs Syndrome Association Shareholder of Invicta Health CIC, Canterbury. Member Kent postgraduate education centre, Canterbury, Kent. Member of the NHS Alliance Practice has signed up to the Vanguard Multispecialty Community

Providers (MCP). Chair and Clinical Lead of Encompass Multi-speciality Community

Provider (MCP)Jonathan Sexton Independent member for

Strategic Health Planning Fellow of Faculty of Public Health Honorary Lecturer in Public Health: Canterbury Christ Church

University Associate at the Centre for Research into Children and Families:

Canterbury Christ Church University Trustee Home-Start Canterbury and Coastal Independent Chair – Standards Committee, Thanet District Council


Report to: Canterbury and Coastal CCG Governing Body

Agenda Item: 05/17

Date of Meeting: 5 January 2017

Title of Report: Shared Care and Enhanced Prescribing Scheme Specification

Author: Sheila Brown - Head of Medicines Management

Governing Body Sponsor:

Bill Millar, Chief Operating Officer

Action Required:Approval

XDecision Discussion/

AssuranceInformation

Conflict of Interest:

This scheme funds payments to GP practices for undertaking activities to support ‘shared care’. All GP practice staff and GPs are potentially conflicted, as each practice will be able to deliver the service and receive payment for it. This paper describes how the conflicts will be managed.

Summary of Key Issues for discussion:

The current ‘Shared care and enhanced prescribing’ scheme ends on 31 March 2017.

The scheme funds support to enable all patients on medication which requires on-going monitoring (seen as additional to usual GP activity) to receive this service safely and effectively through their GP practice, thereby avoiding regular and frequent visits to hospital for ongoing assessment.

A revision to the scheme was recommended for approval at the 6 October 2016 meeting of the Governing Body, following review by the Health Reform Panel and Clinical Strategy and Investment Committee (CSIC). The Governing Body expressed concerns regarding the financial implications of the recommendation and requested that those specific elements were looked at again. Clinical representatives from each of the Town Teams were invited to meet to discuss concerns

The scheme has now been revised to reflect the concerns raised. The revised scheme has been reviewed by the Health Reform Panel, where a recommendation for approval was made. The final approval of the service specification has been passed to the Governing Body to enable the direct financial interests of the GP membership of CSIC to be managed appropriately, in line with the CCG’s governance processes

The review process included:

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Review of the current specification Consideration of a proposal to move to a more

equitable payment structure

The current financial model is based on activity data which was then converted to a list based payment. The following issues were identified with the model:

The payments are not equitable and there are significant differences in payment to practices ranging from £26 to £61 per patient per annum. Some of this may be due to different cohorts of patients but may be due to list size

It does not allow practices to ‘opt out’ of therapeutic areas which was strongly supported at CSIC

The conversion process is not transparent leading to reputational risk to the CCG and membership.

Moving to an activity based funding model provides a more logical, equitable arrangement which allows the impact of additional medicines to be evaluated and included where safe and cost effective.

Existing funding of £210k per annum is in place in Canterbury and Coastal CCG for the current scheme.The main benefits of the schemes are:

Patients receiving care closer to home. Avoid an increase in appointments at acute trusts Investment in primary care

It is proposed that the same scheme will be replicated in NHS Ashford CCG. Having a standard process for both CCGs has the advantage that it:

Offers an equitable approach for practices in both CCGs reduces the general administrative burden both for

practices and the CCG new medication can be considered and added to this

funding arrangement

Risks:

All practices are engaged with the current scheme. There is a risk that not all practices will engage with the revised scheme, as some will see a reduction in funding. However, the revised scheme ensures that the distribution of funding is equitable, as it is aligned to the work being done.

The risk of practices not engaging will be mitigated by developing a Local Enhanced Service that would enable neighbouring GP practices to undertake this aspect of care on behalf of those GP practices that do not wish to engage with the scheme.

If the scheme is not approved investment in primary care will be


reduced and there is a risk this will increase attendance in secondary care.

Recommendations:

It is recommended that the Governing Body approves the revised specification and payment structure from 1st April 2017.

As outlined above, the specification describes a more logical, equitable payment structure linking activity with funding. Financial modelling has indicated there will be no substantial change in the current £210k per annum investment into primary care as a result of this proposal.

Next Steps: If approved, the specification will be circulated to practices for consideration and sign up

Link to Previous Reports: Governing Body paper submitted October 2016

Strategic Objective Link:Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital

Resources: Support from CCGs Medicine Management team

Communications: Via Town team meetings and Consortium

Financial Approval Required:

Yes No

Impact Assessments: Yes No N/A

Finance: Included in text above

Equality: Yes

Quality: Yes

Publication:Restriction (define) No Restriction

Yes

Supporting Paper/Appendices:

Shared Care and Enhanced Prescribing Scheme Specification 13-12-16


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of 18NHS Ashford Clinical Commissioning Group and

NHS Canterbury and Coastal Clinical Commissioning Group

Version 2.5Ratified by Clinical Strategy and Investment

CommitteeDate of Approval TBCAuthor Sheila Brown

Head of Medicine ManagementResponsible Committee / Board

Canterbury and Coastal CCG Shared Care Review Group

Review Date August 2019Target Audience GPs, Practice Managers

Shared Care and Enhanced Prescribing

Service Specification

For Approval

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SHARED CARE AND ENHANCED PRESCRIBING SERVICE SPECIFICATION

Any change or variations to this service specification will only be made after they have been agreed by the Local Medical Committee and the CCG.

Service Shared Care and Enhanced Prescribing Service Commissioner Lead Canterbury & Coastal CCG

Provider Lead Primary Care GP PracticesPeriod 1st April 2017 to 1st April 2019

1. Purpose

IntroductionThe development of a specification for a Shared Care and Enhanced Prescribing scheme arose from a need to replace the system of Local Enhanced Services (LES) with a scheme within the remit of the CCG structure. This scheme was designed to provide a defined set of standard Primary Care services and allow patients within Canterbury & Coastal CCG and Ashford CCG (the CCGs) to access information on whether support for the main therapeutic areas covered by the specification is provided at their registered practice or on a locality level through the Community Hub Operational Centres (CHOCs) (or equivalent).

The treatment of several diseases within the fields of medicine, particularly in rheumatology, is increasingly reliant on medications that, while clinically effective, need regular blood monitoring. This is due to the potentially serious side-effects that these medications can occasionally cause. It has been shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out in a well-organised way, close to the patient’s home.

The CCGs are committed to the successful delivery of high quality General Practice services, recognising that this is essential to a sustainable health care system for the future.

1.1 Aims 1.1.1 To enable patients on medication or with conditions which require on-going

monitoring (to manage associated clinical risks or treatment compliance), to receive this service safely and effectively from their GP practice.

1.1.2 To improve the health of patients, reduce inequalities and inconsistencies in service delivery and ensure the most cost effective use of resource.

1.2 Objectives1.2.1 The service is designed to be one in which:

i. Therapy is only started for recognised indications for specified lengths of time

ii. Patients are on a stable treatment regime before ‘shared care’ or ‘transfer of care’ is considered. A record must be made in the patient record for any medication under this agreement noting that shared care or transfer of




care is appropriateiii. The service to the patient is convenientiv. There is strong communication between the specialist team and primary

care practitionerv. The need for continuation of therapy is reviewed regularlyvi. Treatment is monitored and the patient is referred back when appropriatevii. The therapy is discontinued when appropriate

1.3 ProcessThe Provider will deliver an innovative and high quality service whereby:

i. The clinicians delivering the services will be qualified and keep their training up to date.

ii. Any equipment used will be regularly maintained in line with the manufacturers recommendations

iii. Any required reporting will be completed and documented within the patient’s medical record

iv. The patient will be seen in a timely fashion v. To ensure the quality of the services being provided, there may be random

quality visits of the provider which will be looking at the quality of the service and the points mentioned in section 3.4 of this document.

2 Scope

2.1 Service Description2.1.1 Medications included in are included on the basis of their licensed indication.

2.1.2 It is not a requirement of the scheme to prescribe all medications within each of the given levels. The scheme is the funding agreement to support prescribing in these areas but it is accepted that not all practices will wish to develop expertise in all areas and therefore may be unable to accept on-going prescribing for some medications. The development of shared care plans includes information on training (both initial and on-going) and support as part of the assessment to the impact in primary care.

2.1.3 Medicines will be: Those with agreed East Kent Shared care plans published on the CCGs Prescribing Recommendations intranet http://www.canterburycoastalccg.nhs.uk/about-us/prescribing-advice/

2.1.4 Those medications previously covered by the Near Patient Testing (DMARDs) National Enhanced Service (NES), which are Penicillamine, Auranofin Sulfasalazine, Methotrexate and Sodium Aurothiomalate, for their licensed indications

2.1.5 Other DMARDs or immunosuppressant medications requiring extra monitoring, including Azathioprine for its licensed indication

2.1.6 Oral antipsychotics suitable for shared care, for their licensed indications

2.1.7 Medications which require complex or additional monitoring in primary care , usually initiated in secondary care, which are not covered by a shared care


http://www.canterburycoastalccg.nhs.uk/about-us/prescribing-advice/



scheme and are designated as ‘transfer of care’

2.1.8 Proposed Shared care plans and Prescribing Recommendations (which provide the criteria where Transfer of Care can be considered) for medicines in both levels are reviewed on behalf of the East Kent CCGs through the East Kent Prescribing Group and reported to the CCGs Clinical Investment and Strategy Committee (CSIC). This review includes an assessment of the impact on primary care workload

2.1.9 Where monitoring is required, it is recommended that prescriptions are issued in line with monitoring requirements

2.1.10 A summary of the therapeutic areas the medicines are prescribed in is provided in section 6 and a full list of medications included in this scheme is detailed in Appendix 1 of this specification and a link to shared care documents or monitoring recommendations.

2.1.11 The process to determining funding is shown in Appendix 2

2.1.12 This specification does not cover use of any medicine which does not have a UK license

2.1.13 This specification does not cover use of ‘off licensed use of medications’ i.e. medicines used outside the terms of their UK license’

2.1.14 Prescribing of medications outside of these criteria would be through an individual agreement between a specialist and General Practitioner. Should General Practitioners choose to prescribe unlicensed medications under such an agreement, a link to the GMC guidelines for prescribing is provided: http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp

2.1.15 Participating practices will be expected to notify the CCG which of the following main therapeutic groups they will prescribe (to patients within the agreed criteria for shared care) to enable information to be provided to patients and specialist providers and the CCG to plan services. Antipsychotic (oral) Dementia Osteoporosis (Denosumab) Disease Modifying Anti-Rheumatic Drugs (DMARDs) (Rheumatology)

(excluding sodium aurothiomalate)

2.1.16 Please note this does not cover all the medications within the scheme. Confirmation in advance of prescribers intentions in advance for medications where patient numbers are expected to be extremely low practices is not required only the main therapeutic groups as specified above.

2.1.17 This information must be provided prior to entry into the scheme

2.1.18 Participating practices will be expected to maintain A register Continuing information for patients Individual management plan Professional links


http://www.gmc-uk.org/guidance/ethical_guidance/14316.asp



Record keeping Training

2.2 Accessibility / Acceptability2.2.2 The Provider will ensure that services meet patients’ clinical needs appropriately,

providing services over a range of times

2.2.3 The Provider shall ensure that its services and facilities are accessible to all patients registered with their practice

2.2.4 The Provider will ensure that: The service is delivered with dignity and respect, with due regard to both

individuality and confidentiality The service is appropriate for the requirements of a patient’s age, sex,

ethnic origin, religion or disability The service recognises the clinical needs of the patient and considers when

delivering the service The service is delivered from premises fit for purpose In each case the patient should be fully informed of the treatment options

and the treatment proposed in order to give informed consent, as detailed in section 3.8 of this document

2.2.5 The Provider must be registered with the Care Quality Commission (CQC)

2.3 Interdependencies2.3.1 The Providers obligations:

To maintain systems supporting smooth and efficient booking and rescheduling of patients

3. Service Model

3.1 Data Protection3.1.1 The Provider must protect personal data in accordance with the provisions and

principles of the Data Protection Act 1998 and in particular The Provider must ensure compliance with the commissioner’s security arrangements and ensure the reliability of its staff that has access to any personal data held by the practice. In addition, if The Provider is required to access or process personal data held by the commissioner, the contractor shall keep all such personal data secure at all times and shall only process such data in accordance with instructions received from the commissioner including compliance NHS: The Care Record Guarantee - Our Guarantee for NHS Care Records in England that can be found at:

http://www.connectingforhealth.nhs.uk/crdb/boardpapers/docs/crs_guarantee_2.pdf

3.2 Workforce:3.2.1 The Provider will make sure that its workforce is able to meet the needs of the

service and are trained in line with CQC registration, taking into account the National Safer Recruitment and Employment Process

3.2.2 The Provider must ensure that each clinical member of staff engaged in providing the service shall:i. adhere to their respective codes of professional conduct at all timesii. be competent, being properly and sufficiently trained and instructed with regard

to the task or tasks that the person has to perform.


http://www.connectingforhealth.nhs.uk/crdb/boardpapers/docs/crs_guarantee_2.pdf



iii. maintain patient safety and ensure appropriate infection control has been properly implemented

iv. Appropriately trained in the use of the equipment used.v. Engage with Clinical Supervision (nurses and Healthcare Assistants only)

3.2.3 The Provider will:

i. Be expected to assess the practical competency of both clinical and non-clinical staff

ii. Ensure that any identified breaches in professional conduct or performance are addressed and reported to the CCG.

iii. Inform the commissioner with regard to any investigation or disciplinary matter (including any allegations regarding any people who work with children or vulnerable adults) up to and including referral to the regulatory authority.

iv. Implement an appropriate annual appraisal process for all staff.

3.2.4 The Provider must determine that personnel providing the service through the contract have appropriate professional indemnity insurance to meet in full, claims made against them as individuals.

3.3 Performance3.3.1 The Provider will adhere to the specification as detailed in section 6 of this

document, and will be subject to random quality visits during the contract period

3.4 Quality Visits & Monitoring3.4.1 The provider may be subject to random quality visits (with 2 weeks’ notice to the

practice) to ensure the quality of the service being provided. These quality visits will focus on, but are not restricted to, the patients journey through the service, in particular around safety, privacy & respect, and patient experience. During a quality visit, the provider will be expected to provide any supporting information or documentation in an up to date format.

3.4.2 The provider may be expected to submit to the CCG when requested, and have ready for quality visits, evidence of any documents required for CQC compliance.

3.4.3 As part of the quality visits and monitoring process, the provider will report all Serious Incidents to the CCG and the quality team, and any action plan which results. This includes any allegations made against any people (the provider does not need to identify the person involved, but should inform the CCG so they are aware of any concerns) in the practice. These quality visits will include a spot check data validation of the information recorded on the practices clinical system

3.4.4 Total activity figures will be reported on an annual basis to the CCG

3.5 Training & Accreditation3.5.1 Healthcare professionals taking part in this service will be expected to meet the

standard of appraisal

3.6 Safe Prescribing3.6.1 The practice will be required to ensure that there is safe and effective prescribing and

medicines management processes when delivering the services to patients. It must ensure that all clinical staff who prescribe or supply medicines do so in accordance with relevant national and local guidance including, but not limited to, the following: Department of Health, NICE and similar national safe and good practice




guidance relating to prescribing Ensure compliance with the requirements of safety alerts (e.g. from the NHS

Commissioning Board Specials Health Authority , including alerts from the Central Alerting System, and acting on them within the required timescales

Good Prescribing Practice as set out in the British National Formulary (BNF) Good Practice in Prescribing and Managing Medicines and Devices published

by the General Medical Council To ensure that all the service’s prescribers are aware of prescribing advice

issued by the East Kent Prescribing Group and the Clinical Strategy and Investment Committee (CSIC) and that they take it into account when reaching prescribing decisions

Guidance from the Royal Pharmaceutical Society of Great Britain on the safe and secure handling of medicines

3.7 Facilities & Equipment3.7.1 The provider will be responsible for

The maintenance, upkeep and safety checks of all equipment required for this service, according to the manufacturer’s recommendations.

Equipment and consumables used to deliver services within this contract

3.7.2 Complying with standards set within current NICE guidelines, wherever they apply.

3.8 Consent3.8.1 Consent for treatment should be included in the shared care plan or Prescribing

recommendations from the requesting clinician3.8.2 In each case the patient should be fully informed of the treatment options and the

treatment proposed

3.9 Record Keeping3.9.1 Providers must ensure that details of the patient’s treatment are included in his or her

lifelong record.

3.10 Confidentiality3.10.1 Providers must ensure that they are in line with standards required for CQC

registration and comply to Information Governance (IG) regulations

4. Referral, Access and Acceptance Criteria

4.1 Days/Hours of operation 4.1.1 The Provider will normally be expected to provide access to services Monday to

Friday, between 8am and 6:30pm. The service should have the capacity to meet the demands according to patient need.

4.2 Inclusion Criteria4.2.1 Criteria for the medications to be included in the scheme are noted in section 2.1 of

this specification. The process to add amend or delete medicines to this specification is described in Appendix 4

4.3 Route of Request4.3.1 Shared care or transfer of care is by invitation only, requested from a secondary

care clinician through a prescribing or non-prescribing shared care plan or prescribing recommendation and accepted by a GP




For clarification, the different stages of development of documents to support Shared care/Transfer of care are detailed below:

Shared care Position in Process Document Classification (Prescribing)In development Prescribing Shared Care Plan

(Proposed)Agreed as a general principle Prescribing Shared Care PlanAgreed for the specific patient Prescribing Shared Care Agreement

Transfer of care Position in Process Document Classification

(Prescribing)In development Prescribing Recommendations

(Proposed)Agreed as a general principle Prescribing Recommendations

ProposedAgreed for the specific patient Prescribing Recommendations

4.3.2 When care has been initiated in a tertiary centre, wherever possible patients should be referred back to the referring secondary care clinician before any request for shared care is made.

4.4 Patient Booking and Choice:4.4.1 Patient Booking and Patient Choice will comply with national guidance on Access

Booking and Choice

5. Continual Service Improvement

5.1 Clinical Outcomes Reporting:5.2.1. Providers and the CCG will work collaboratively to define patient outcomes to

improve the quality and effectiveness of care and the patient experience.




6. Service Detail

6.1 Medications included in the service6.1.1 Medications included in this scheme will be those as noted in section 2.1 of this

specification. Medications are designated as suitable for shared care (ShC) or Transferred Care (TC), where complex or additional monitoring is required

but not necessarily as part of a shared care agreement

The medications are in the following therapeutic groups

IndicationLevel Number of

chemical substances

DMARD (Rheumatology) 1 9

Antipsychotic (oral) 1 7

Dementia 1 4

Epilepsy 1 3

Parkinson’s 1 2

Cystic Fibrosis (CF) # 1 4

Osteoporosis 1 1

Amylotropic lateral sclerosis 1 1

DMARD (Dermatology) 1 1

Constitutional Delay of Growth & Puberty (CDGP) 1 1

Growth Hormone 1 1

Immunosuppressant once stable following heart/lung transplant # 1 2

#Responsibility for prescribing for patients newly initiated with these medications remains with NHS England and any request for GPs to prescribe should be returned to the requesting clinician. These medication are included in this scheme only to support care for patients who are currently

being prescribed, are stable and care cannot easily be repatriated to specialist care

Full list of the medications, links to shared care or monitoring arrangements are in Appendix 1 with funding levels in Appendix 3

Some medications on this list are licensed for indications that are purely managed in primary care, as well as for indications suitable for management under shared care.

Any clinical exceptions to individual shared care agreements must be reported to the CCG.

This list will be reviewed every year by the Shared Care and Enhanced Prescribing review group, or in light of significant changes in local or national guidance. Suggestions for medications to be included as part of the review process should be made to the CCG’s Medicine Management teams.

Revised specification will be circulated to practices with the option to opt out after a three month notice period.




6.1.2. For the avoidance of misunderstanding, overall responsibility for the management of the patient under a shared care scheme falls under the specialist team. The specialist team will be expected to maintain a call and recall system for those patients under shared care.

6.1.3. Some medications listed are seen as ‘Transfer of care’ where responsibility for management is with the GP but secondary care clinicians have agreed to see patients promptly

6.1.4. It is the prescriber’s responsibility for the safe prescribing and on-going monitoring of the medication. Close collaboration with the appropriate specialist team, as set out in the ‘shared care’ or ‘specialist initiation’ supporting documents, is essential as well as clear instructions to patients regarding follow up.

6.1.5. Monitoring guidance for a number of the medications under this scheme is available through NICE’s Clinical Knowledge Summaries (CKS), available at http://cks.nice.org.uk

6.2 Criteria

Participating practices will be expected to maintain:

A register - Practices should be able to produce and maintain an up-to-date register of all patients whose prescribing is covered by this specification. Practices can use the read code 8BM5 to identify those patients under shared care management but this is not necessary to identify for payment.

Continuing information for patients – to ensure that all patients (and/or their carers and support staff where appropriate) are informed of how to access relevant information. It is assumed that appropriate education and advice on management and prevention of secondary complications of their condition has been provided by the specialist clinician, and is included in the written shared care agreement where necessary.

Individual management plan and clinical monitoring – GPs will adhere to the shared care agreement, which gives the reason for treatment, the planned duration, the monitoring timetable and, if appropriate, the therapeutic range to be obtained.

Professional links – to work together with other professionals when appropriate. Any health professionals involved in the care of patients under the shared care service should be appropriately trained

Record keeping – to maintain adequate records of the service provided, incorporating all known information relating to significant events

Training – each practice must ensure that all staff involved in providing any aspect of care under this scheme has the necessary training and skills to do so

7 Finance Details

7.1 Agreement PeriodThis agreement is for the period between and including 1st April 2017 and 31st March 2019


http://cks.nice.org.uk/



7.2 Allocated financeNotification of patient numbers within the financial year for each medication (adjusted as below) multiplied by the agreed tariff

Adjustment:Data should be downloaded from practice systems for all patients on the agreed medication for the agreed 12 month period) and the following adjustments made

Exclude entries for gels, patches of testosterone and eye/ear drops of any preparation Exclude patients where prescribing is being undertaken by another provider- these are

usually indicated by a prescription quantity of one or as a note within the directions e.g. supplied by acute trust (although denosumab will also be prescribed as a quantity of one and should be included where prescribed by the practice )

Exclude multiple entries for a patient due to multiple strengths issued Exclude multiple entries for medication in the same therapeutic group as monitoring

and review would be similar for all medication Payment is made per patient regardless of how long they have been prescribed the

medication in the 12 month period Support will be provided to practices to extract and format the data Information on which of the main therapeutic groups (specified in section 2.1.17)

practices will prescribe (for patients within the agreed criteria for shared care) must be provide to the CCG prior to signing up to this specification. This will enable information to be provided to patients and specialist providers and the CCG to plan services. Total payment per main therapeutic group will be reduced by one twelfth (1/12th)for each full month the information is not provided

Issuing one-off prescriptions for an item in any of the main therapeutic groups does not commit a practice to prescribing for all medications in this therapeutic group. It is accepted that one-off prescriptions may be required in exceptional circumstances. This activity however will not be funded

Payment for this service will be made on a quarterly basis using the following schedule:

Quarter Payment due Based on

Q1 30th June 20% of anticipated full year payment based on practice data

Q2 30th Sept 40% of anticipated full year paymentMINUS (payment made in Q1)

Q3 31st Dec 60% of anticipated full year paymentMINUS (payment made in Q1&Q2)

Q4 30th June*Actual full year payment based on practice dataMINUS (payment made in Q1,Q2 & Q3)

7.3 Claiming agreementThe provider will notify patient numbers at the beginning of the financial year as an estimate and payments at Q1, Q2 and Q3 will be made based on this estimate.




The data will be re-run in April for the actual data for the previous financial year and the final payment based on this. There may be a slight delay while data at year end is extracted and verified

Appendix 1- Full list of medications included in the scheme. December 2016 (Page 1 of 4)

BNF chapter

Indication Medication ShC/TC

Licensed For Link to Local/National Recommendations

4 Dementia Donepezil ShC Mild to moderate Alzheimer's EKPG Shared Care Guidelines

4 Dementia Galantamine ShC Mild to moderate Alzheimer's EKPG Shared Care Guidelines

4 Dementia Memantine ShC Moderate to severe Alzheimer's disease EKPG Shared Care Guidelines

4 Dementia Rivastigmine ShC Mild to moderate Alzheimer's, mild to moderate idiopathic Parkinson's

EKPG Shared Care Guidelines

4 Epilepsy Eslicarbazepine TC Epilepsy Eslicarbazepine Prescribing Guidelines - EKPG September 2014 (184KB)

4 Epilepsy Perampanel TC Epilepsy Perampanel prescribing information - EKPG June 2014 (174KB)

4 Epilepsy Zonisamide TC Epilepsy EKPG Zonisamide Prescribing Guidelines

4 Parkinson’s Apomorphine ShC Parkinson's CKS - Parkinson's Disease4 Parkinson’s Rotigotine ShC Early-stage Parkinson's CKS - Parkinson's Disease4 Antipsychotic

(oral)Amisulpride TC Schizophrenia CKS - Psychosis and

Schizophrenia 4 Antipsychotic

(oral)Aripiprazole TC Schizophrenia, moderate to severe mania,

prevention of mania recurrence in patients with bipolar disorder

CKS - Psychosis and Schizophrenia

4 Antipsychotic (oral)

Flupentixol TC Schizophrenia and other psychoses CKS - Psychosis and Schizophrenia


Haloperidol TC Adults: Schizophrenia and other psychoses, mania & hypomania restlessness and agitation in the elderly, Gilles de la Tourette syndrome and severe tics. Children: Childhood behavioural disorders, Gilles de la Tourette Syndrome



Olanzapine TC Schizophrenia, moderate to severe mania, prevention of mania recurrence in patients with bipolar disorder



Quetiapine TC Schizophrenia, moderate to severe manic episodes and major depressive episodes in bipolar disorder, prevention of mania recurrence in patients with bipolar disorder



Risperidone TC Schizophrenia, moderate to severe mania, short term treatment (6 weeks) of persistent aggression in patients with Alzheimer’s disease


4 Amylotropic lateral sclerosis

Riluzole ShC Amyotrophic lateral sclerosis (ALS) form of motor neurone disease (MND)



http://www.canterburycoastalccg.nhs.uk/EasysiteWeb/getresource.axd?AssetID=412017&type=full&servicetype=Attachment








http://www.canterburycoastalccg.nhs.uk/about-us/prescribing-advice/?assetdet7576137=407577&categoryesctl7925247=16951






http://www.canterburycoastalccg.nhs.uk/about-us/prescribing-advice/?categoryesctl7925247=16951

http://www.canterburycoastalccg.nhs.uk/about-us/prescribing-advice/?categoryesctl7925247=16951

http://cks.nice.org.uk/parkinsons-disease#!scenario:1

http://cks.nice.org.uk/parkinsons-disease#!scenario:1

http://cks.nice.org.uk/psychosis-and-schizophrenia#!scenario:2



















BNF chapter



5 Cystic Fibrosis (CF)#

Aztreonam (nebulised)

ShC Cystic fibrosis #Responsibility for prescribing for patients newly initiated with these medications remains with NHS England-see below


Colistimethate sulphate nebulised



Tobramycin nebulised



Dornase alfa ShC Cystic fibrosis (Prescribing for patients newly initiated now remains with NHSE and should not be prescribed in Primary care)

#Responsibility for prescribing for patients newly initiated with these medications remains with NHS England-see below

6 Osteoporosis Denosumab TC Osteoporosis in postmenopausal women at risk of fracture, bone loss associated with prostate cancer at risk of fracture


6 Constitutional Delay of Growth & Puberty (CDGP)

Testosterone(Sustanon)

ShC Testosterone replacement therapy for primary and secondary hypogonadism, supportive therapy for female-to-male gender reassignment


Area Prescribing Committee (prior to CCG) Shared Care Guidelines - Adults

6 Growth Hormone Somatropin ShC Growth Hormone Deficiency, growth disturbance, Prader-Willi syndrome

Area Prescribing Committee (prior to CCG) Shared Care Guidelines - Paediatrics

#Responsibility for prescribing for patients newly initiated with these medications remains with NHS England and any request for GPs to prescribe should be returned to the requesting clinician. These medications are included in this scheme only to support care for patients who are currently being prescribed, are stable and care cannot easily be repatriated to specialist care






http://www.kentandmedway.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=24727











BNF chapter



8 Immuno-suppressant once stable following heart/lung transplant #

Sirolimus ShC Prophylaxis of transplant rejection in adult liver allograft recipients Renal patients from EKHUFT should all be repatriated.

#Responsibility for prescribing for patients newly initiated with these medications remains with NHS England-see below

8 Immuno-suppressant once stable following heart/lung transplant #

Tacrolimus ShC Prophylaxis of transplant rejection in adult kidney or liver allograft recipients, moderate to severe atopic eczema

##Responsibility for prescribing for patients newly initiated with these medications remains with NHS England-see below

10 DMARD (Rheumatology)-no blood tests required

Hydroxy-chloroquine

ShC Rheumatoid arthritis, Discoid and Systemic Lupus Erythematosus (DLE & SLE), dermatological conditions aggravated by sunlight, Paeds: JIA, DLE & SLE

EKPG Guidelines

10 DMARD (Rheumatology)

Sulfasalazine ShC Ulcerative colitis, Crohn's disease, rheumatoid arthritis (2nd line)

EKPG Guidelines


Azathioprine ShC Organ transplant, immunosuppression, severe/moderate rheumatoid arthritis (2nd line), polyarticular Juvenile Idiopathic Arthritis (JIA), axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, psoriasis, severe or moderately severe UC or Crohn’s disease, dermatological conditions aggravated by sunlight

EKPG Guidelines


Ciclosporin, ShC Organ transplant, bone marrow transplant, Endogenous uveitis, nephrotic syndrome, Rheumatoid arthritis, psoriasis, atopic dermatitis

EKPG Guidelines


Leflunomide ShC Rheumatoid arthritis, Psoriatic arthritis EKPG Guidelines


Methotrexate (oral)

ShC Adults: Severe, active, classical or definite rheumatoid arthritis (2nd line), severe uncontrolled psoriasis (2nd line), acute neoplastic conditions

EKPG Guidelines


Mycophenolate mofetil

ShC Organ transplant, Ulcerative Colitis, Crohn’s Disease

EKPG Guidelines


Penicillamine ShC Severe active rheumatoid arthritis, including juvenile forms, Wilson's disease, cysinuria, lead poisoning, chronic active hepatitis

EKPG Guidelines

10 DMARD (Rheumatology)-Gold

Sodium Aurothiomalate

ShC Active progressive rheumatoid arthritis and progressive juvenile chronic arthritis, especially if polyarticular or seropositive

CKS - Gold Monitoring Requirements (included as on previous DMARD DES)

#Responsibility for prescribing for patients newly initiated with these medications remains with NHS England and any request for GPs to prescribe should be returned to the requesting clinician. These medications are included in this scheme only to support care for patients who are currently being prescribed, are stable and care cannot easily be repatriated to specialist care










http://cks.nice.org.uk/dmards#!scenario:5






BNF chapter


Licensed For Link to Local/National Recommendations Included for current patients as on previous East Kent recommendation.Requests to GPs to prescribe for new patient from EKHUFT should be referred back to secondary care until the revised shared care has been approved

5 DMARD (Dermatology)

Dapsone-Treatment of dermatitis herpetiformis and other dermatoses

ShC Dermatitis herpetiformis

Previous recommendationFBC, Reticulocyte, LFT all 3 monthly




Appendix 2-Process for determining funding

Points allocatedImpact on workload in Primary Care - points allocated

0 (None) 1 (Low) 2 (Medium) 3 (High)

Frequency of prescribing in primary care N/A Common Unusual Very unusual

Frequency of tests required in primary care once stable

(Maximum frequency for a stable patient)

None Annually>monthly

< annuallyMonthly

Specialist Support available N/A Local responsive support Limited

Complexity of patient and medication N/A Routinely seen in

primary care Complex

Points Payment per annum*

0-4 £18

5 to 6 £28

7 to 9 £39

DMARDs * £50

Denosumab** £66

*DMARDS- based on 6 review of test results per annum + £5 administration **Denosumab- based on previous fee in Ashford

Funding for new groups of medication being considered for including in the scheme will be determined following financial review of the impact on workload in practices

*Data should be downloaded from practice systems for all patients on the agreed medication for the agreed 12 month period) and the following adjustments made to calculate patient numbers

Exclude entries for gels, patches of testosterone and eye/ear drops of any preparation Exclude patients where prescribing is being undertaken by another provider- these are

usually indicated by a prescription quantity of one or as a note within the directions (although denosumab will also be prescribed as a quantity of one and should be included where prescribed by the practice )

Exclude multiple entries for a patient due to multiple strengths issued Exclude multiple entries for medication in the same therapeutic group as monitoring and

review would be similar for all medication Payment is made per patient regardless of how long they have been prescribed the

medication in the 12 month period A protocol will be provide to practices to download the data




Appendix 3-Funding levels

Indication FundingDementia £18Epilepsy £18Parkinson’s £28Antipsychotic (oral) £28Amylotropic lateral sclerosis £28Cystic Fibrosis (CF)# £39Osteoporosis £66Constitutional Delay of Growth & Puberty (CDGP) £28Growth Hormone £39Immuno-suppressant once stable following heart/lung transplant # £39DMARD (Rheumatology) £50DMARD (Rheumatology)-Gold £50DMARD (Dermatology) £66

#Responsibility for prescribing for patients newly initiated with medications in these therapeutic groups remains with NHS England and any request for GPs to prescribe should be returned to the requesting clinician. These medication are included in this scheme only to support care for patients who are currently being prescribed, are stable and care cannot easily be repatriated to specialist care




Appendix 4-Process to add, delete amend list of medication

The CCG’s planning process will identify areas where moving prescribing of medication into primary care has advantages for patient care

Shared care documents /prescribing recommendations will be considered through East Kent Prescribing Group and the CCGs Prescribing Committee along with an assessment of the impact in primary care

A Task and Finish group for review of the Shared Care and Enhanced Prescribing Service Specification will be arranged:

annually for review of the scheme and consider proposals to the impact scores of medicines

to run concurrently with the consideration of the above prescribing documents

Comments on the workload impact in primary care will be collated at the task and finish group but the financial impact determined by the CCGs finance team with Local Medical Committee input

The financial arrangement will be agreed through the CCG’s Health Reform Panel (HRP) and then through Clinical Strategy and investment Committee (CSIC)


Report to: Canterbury and Coastal CCG Governing Body

Agenda Item: 06/17

Date of Meeting: 5 January 2017

Title of Report: Local Enhanced Service to Support Adult Attention Deficit Hyperactivity Disorder (ADHD) Monitoring and Prescribing

Author: Lisa Barclay - Head of Commissioning Delivery

Governing Body Sponsor: Bill Millar - Chief Operating Officer

Action Required:Approval

XDecision Discussion/

AssuranceInformation

Conflict of Interest:

This scheme funds payments to GP practices for undertaking activities to support the ongoing monitoring and prescribing of Attention deficit hyperactivity disorder(ADHD) medication for stable adult patients. All GP practice staff and GPs are potentially conflicted, as each practice will be able to deliver the service and receive payment for it. This paper describes how the conflicts will be managed.

Summary of Key Issues for discussion:

Currently there is no commissioned service for the ongoing monitoring and prescribing of ADHD medication for stable adult patients, following the retirement of Dr Chopra.The majority of GP practices within the CCG area are currently prescribing on a time bounded “goodwill” interim basis, with guidance from specialist provider South London and Maudsley NHS Foundation Trust (SLaM). One GP practice within the locality has felt unable to provide the service and as a result patients have had to register with a GP practice that has been willing to support the changes.The attached paper recommends the Governing Body supports the offer of a local enhanced service to GP practices to enable choice as to whether GP practices undertake this service on behalf of their own and other nominated practices.The outline business case attached has been supported by the Health Reform Panel who have considered the financial impact and value for money implications. Due to the direct financial interest of the GP members of the Clinical, Strategy and Investment Committee, the business case cannot be approved by the committee; approval has therefore been escalated to the Governing Body.

Page 1 of 306-17 - FC - ADHD prescribing and monitoring v2.docOverall of 46

Risks:If the recommendation is not supported the CCG will have no provision, interim or otherwise. To mitigate the risk, the business case has been worked up with engagement from the local practices.

Recommendations:It is recommended that the Governing Body support the offer of local enhanced service to GPs at a cost of £150 per patient per year, paid in quarterly instalments, in line with monitoring review requirements. (Option 2 in the attached outline business case).

Next Steps:

All GP Practices within the CCG to be contacted to confirm sign up.

Service specification to be confirmed.

Communication to patients advising of alternative service provision.

Transfer of patients’ notes from previous provider to the new provider.

Link to Previous Reports: Report to October 2016 Governing Body

Strategic Objective Link:

Improving the health related quality of life of people with one or more long-term condition, including mental health conditions.Increasing the number of people having a positive experience of care outside of hospital, in general practice and in the community.

Resources: As described within the business case

Communications: Previously discussed at Consortium, Health Reform Panel, Clinical Strategy and Investment Committee

Financial Approval Required:

Yes

Impact Assessments: Yes No N/A

Finance: Yes

Equality: Yes

Quality: Yes

Publication:Restriction (define) No Restriction

X


Benefit to Patient:Provision of care closer to homeContinuity of care and consideration of wider health conditions if delivered by GP provider

Supporting Paper/Appendices:

Outline business case for Local Enhanced Service


Overall of 46

1NHS Ashford Clinical Commissioning GroupNHS Canterbury and Coastal Clinical Commissioning Group

Outline Business Case

Meeting: Health Reform Delivery Group

Date of Meeting: 21 December 2016

Agenda item:

Project Name: Local Enhanced Service Prescribing for Adult ADHD medication

Reporting Officer:Simon Lundy MH LeadLisa Barclay

Decision:

Supported Not Supported

Comment:

Page 1 of 1006-17 - OBC - Local Enhanced Service ADHD Prescribing Adults v.2.docOverall of 46


Version Control

Update history is as follows, include changes as consequence of input from each contributor (e.g. finance, information, clinical lead):

Version Created by Main Changesv1.0 L Barclay



BEFORE COMPLETEION MAKE SURE YOU HAVE CONSIDERED THE DECISION TREEPLEASE USE BULLET POINTS WHERE POSSIBLE TO REMAIN WITHIN THE WORD

COUNT

1.1 What is the objective and how will the objective impact on patients care?Brief summary of the proposed service/pathway/project/pilot to be commissioned and why. Please include a brief statement in here with regard to patient benefit (to be expanded on in section 5 below)

Maximum 100 Words

To provide a local service for the monitoring and prescribing of ADHD medication for adults.

The previous primary care service ceased on 30 September 2016, following the retirement of the GP historically commissioned to deliver this service. The CCG has a statutory obligation to commission a service, with an opportunity to deliver care closer to home in line with local care vision.

1.2 Describe what the business case is proposing.Describe the new pathway/service/project/pilot and its key features. Provide evidence that proposed change will be effective

Maximum 100 Words

The case is proposing to offer the member practices a local enhanced service to deliver monitoring and prescribing of ADHD medication to adults who are deemed stable for care transfer, following diagnosis or further input from the specialist provider (SLAM).

Currently there is no formal commissioned service and a number of general practices have agreed to prescribe for their patients on an interim basis. One practice has confirmed that they are not happy to prescribe for their registered patients and as a result these patients are having to register with a practice that has agreed to give interim support, outside of their home locality.

It is proposed that practices will be able to choose to give support to their own patients, as well as patients who are registered with a practice that do not wish to offer this service, on a locality basis.

The enhanced service will be required to Prescribe for stable patients every two months, in line with specialist provider

guidance, with record keeping to support invoicing Review patients quarterly, with clear guidance on observations recorded, with at least

one of these reviews being an annual review with a GP (in line with specialist provider guidance).



2. How does the case meet the strategic priorities of the CCG?Describe the new pathway/service/project/pilot and how its key features will meet the CCG Strategic Objectives.

Maximum 50 Words per outcome, where applicable

Strategic Outcome Commentary1. Securing additional years of

life for the people of England with treatable mental and physical health conditions.

Requirement to commission service for patients with enduring mental health need.

2. Improving the health related quality of life of the 15 million+ people with one or more long-term condition, including mental health conditions.

A service offered by local GPs with access to wider patient records will support a more holistic approach to care.

3. Reducing the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital.

n/a

4. Increasing the proportion of older people living independently at home following discharge from hospital.

n/a

5. Increasing the number of people with mental and physical health conditions having a positive experience of hospital care.

n/a

6. Increasing the number of people with mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community.

Feedback from patients following the closure of the previous service has been a request to have monitoring and prescribing closer to home.

7. Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care.

n/a

8. Ensuring a sustainable financial future and good governance

Prior to the retirement of previous service provider, quality issues for record keeping and monitoring of patients within this service had been raised. A clear specification for an enhanced service with patient based activity payments would provide a more robust framework.

9. Effective stakeholder engagement, public engagement and partnership



working

3. Outline the source of funding identified for the business case.Does the business case rely on external funding or sponsorship, does it rely on funding being taken from another area? What are the proposed cost savings?

Maximum 100 Words

Previous service historically commissioned on a block contract, with no performance data submitted to demonstrate demand or activity delivered.

No uplift in budget since commencement of service in 2008. Funding was split between CCGs with no consideration of population size or

prevalence. Ashford Budget £7489 Canterbury Budget £7709 Budget will need to be increased as per finance proposals in section 7. Assumptions

made on nos of patients notes collected from previous provider and information from specialist service regarding nos of new patients annually. n.b. it needs to be noted that not all patient notes collected are actively receiving medication. Assumptions have been made at 60% based on information available.

4. Describe the main benefits associated with the business caseWhat outcomes will be achieved, who do these apply to, and what is the quantitative and/or qualitative evidence which supports this. This should include patient care, quality, operation, accessibility, pathway benefits.

Maximum 100 Words

A local enhanced service will allow a holistic approach to care for this cohort of patients, who may have multi co-morbidities.

General Practice has access to the patient primary care record and history. Opportunity to implement a robust service with agreed specification and performance

management, to give assurance regarding quality and safety of service. Abilty to capture demand and commission appropriate level of service. A local enhanced service delivered by GP membership, appropriately trained, can be

supported internally to ensure regular educational updates.

5. Describe the options that need to be considered and appraise each option, indicating the reasons for choosing the preferred option.NB There should always be a “do nothing” option.

Maximum 250 Words

Option 1



Do nothingRisk – GPs are currently offering support an interim basis as goodwill. This will be withdrawn and patients will not receive medication for their long term mental health condition. This could lead to a deterioration in patient mental health and potentially impact on unscheduled care required.

Option 2Support the offer of local enhanced service to GPs at a cost of £150 per patient per year, paid in quarterly instalments, in line with monitoring review requirements.

Option 3Commission a single specialist provider to deliver the service. In discussion with a potential alternative provider cost indication was significantly in excess of proposed funding model above.Risk – no access to primary care data to allow holistic provision

6. What impact will the proposal have on prescribing?

Maximum 100 Words

Prescribing data has historically been charged to the CCG via the previous service. The only impact will be the likely increase in prescribing in line with diagnosis rates.

7. Activity and Finance Summary Full details of current and proposed costs. This also need to include CCG staffing requirement in delivering the project (e.g. Commissioner, Finance, Information, Clinical Lead)

Maximum 100 Words or summary table

Proposed cost model was worked up with GPs, Practice Managers, CCG finance, commissioning, quality, prescribing and LMC representatives.

Hourly rates were discussed and based on those currently used for GP and Nurse engagement in other CCG business.

Total cost per annum = £150 to include:

One initial/annual GP reviewBi-monthly GP check of monitoring – review after year 1 **Three quarterly patient reviews with a Practice NurseTime for administration has been included

** The GPs felt that they needed additional time to review patient notes prior to renewing the prescription whilst they familiarised themselves with this new drug and co-hort of patients.



Summary of activity and cost projections using proposed model

2016-17 - Q4 projections

Patient notes collected

Quarterly cost

Total

Ashford 63 37.5 £2,362.50£3,725.00 Balance of Dr Chopra clinic-£1,362.50 Q4 saving

Canterbury 180 37.5 £6,750.00£3,945.00 Balance of Dr Chopra clinic£2,805.00 Q4 cost pressure

If 60% of patients that had notes collected are receiving medication

Ashford 38 37.5 £1,425.00£3,725.00 Balance of Dr Chopra clinic-£2,300.00 Q4 Saving

Canterbury 108 37.5 £4,050.00£3,945.00 Balance of Dr Chopra clinic£105.00 Q4 cost pressure

2017-18 Full year projectionsPatient notes collected

Projected new patients per annum

Total Activity 17/18

Cost PA

Projected annual cost

Ashford 63 30 93 £150 £13,950£7,489 Less FY Budget£6,461 Cost pressure

Canterbury 180 75 255 £150 £38,250£7,709 Less FY Budget£30,541 Cost pressure



If 60% of patients that had notes collected are receiving medicationAshford 38 30 68 £150 £10,200

£7,489 Less FY Budget£2,711 Cost pressure

Canterbury 108 75 183 £150 £27,450£7,709 Less FY Budget£19,741 Cost pressure

8. When is it likely that the business case can be implemented - describe key timescales and provide a mini project planWhen is it likely that the business case can be implemented? Describe key timescales. Include contractual, procurement requirements.

Maximum 100 Words

The majority of practices are prescribing on an interim basis. Key timescales as follows;

Recommendation for enhanced service agreed at HRP and CSIC Dec 16 Agreement with practices and sign up January 2017 Communication to patients regarding service provision Jan/early Feb 17 Service delivery February 17

9. Delivery Plan including communication to relevant partiesKey actions that need to be undertaken to ensure delivery and expected implementation date dependent on options. This should include communications plan and any statutory requirements such as Public Consultation and ProcurementMaximum 200 Words

Meeting to agree proposed funding model with GP, Commissioning, Quality, Prescribing and LMC representatives – Nov 16

Gauge GP support – Nov/early Dec 16 OBC to HRP Dec 16 Implementation plan from Jan 17 Quarterly activity monitoring and review with prescribing/finance and providers Post implementation review March 18

10. What Performance Management and reporting arrangements have been identified?



Describe what has been put in place/ can be put in place to ensure finance, activity and other key business case assumptions are delivered.

Maximum 100 Words

Practices to submit quarterly activity level data for validation to support payment. Use of Eclipse by medical management team to support validation of invoices with

prescribing data. Quarterly meeting with Commissioing/medical management and quality to review

data

11. Post implementation reviewHow will the success, or otherwise, of the project be measure? What quantitative changes do you expect to achieve?

PIR would be a review of demand and activity versus cost of service.Indicator How this will be measured Anticipated Change

12. Impact on Wider Health EconomyIs there an anticipated impact elsewhere in the health economy – impact on GPs, public relationshipsMaximum 200 Words

If this case is not supported and patients are left without easily accessible route to obtain their medication, this will have an impact on their mental health and potentially other services, particularly unscheduled care.

13. Exit StrategyHow will you close this project down if it does not achieve the planned improvements?Maximum 200 Words

If an alternative improved provision is identified following PIR, exit plan will be required folloing a procurement process.



Please attached any annex documents here - at minimum this should include the following:

Quality Impact Assessment - appendix 1.

Equality Impact Assessment appendix 2

Privacy Impact Assessment – appendix 3

Financial Impact Assessment – include within case.


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