schedule 2 – the services - sefton local medical committeeseftonlmc.co.uk/download/committee/lmc...

Local Quality Contract for General Practice

South Sefton

Year 2

2015/2016

Service Specifications

Version 1.4

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ContentsIntroduction 4Changes 2015/16 5Schedule 2 Service SpecificationIndicator 1 Primary Care Access 6Indicator 2 Frail Elderly 11Indicator 3 Identification and Care Planning EOL 24Indicator 4 Phlebotomy 29Indicator 5 Shared Care 32Indicator 6 Drug Administration 38Indicator 7 Data Review 42Indicator 8 ABPI 45Finance 49Reporting Schedule 50Sign up Sheet 51

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2014 – 17 Local Quality Contract

Introduction

National contract changes have confirmed that after 1st April 2014, Local Enhanced Services (LES) will cease. Funds and resources associated with these schemes will devolve back to Clinical Commissioning Groups (CCGs). NHS England has charged CCGs with responsibility for using these resources to improve quality in primary care, value for money, and improve outcomes for patients.

This investment will be above the core GP contract commissioned by NHS England.

Individual practice contracts with NHS England to provide services are presumed to continue.

Our CCG will commission these services using an NHS standard contract which will be operational from 1st August 2014. This will be a co-commissioned contract with the Local Authority.

South Sefton CCG Governing Body is committed to investment in primary care transformation through its approval of a Primary Care Quality Strategy covering three years, with an aspiration to continue for a further two years.

The Local Quality Contract will need to fulfil the NHS Outcome Framework domains objectives as well as following Darzi principles on quality improvement. Outcomes for the contract will encompass fairness, value for money, and be based on clinical evidence.

The opportunity for individual practices to invest in primary care and provide financial stability for the 2014 - 2017 are in line with national drivers ‘Improving General Practice – A Call to Action NHS England’, as well as fulfilling our CCGs strategic objectives.

Principles:

All areas are optional with practices signing in at year beginning for proposed activity areas

Practices have options to sign in at year beginning for each of years 1 - 3 Annual review of all indicators There is no CQUIN element applied to this contract 75% of payments will be paid monthly for indicators 1, 2 & 3, the remaining 25% will

be paid based on practice submissions / achievement A panel will assess practice achievement based on practice submissions Indicators xxxx will be paid quarterly based on production of an invoice

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Changes 2015/16

Indicator Continued Discontinued New Schemes2015/16

Access part 1 Continue – increase to a minimum of 13 appointments per 1000 patients daily Monday to Friday.

Access part 2 Continue – decrease time commitment to 15 minutes per 1000 patients outside core hours.

Practices to participate in the extended hours DES

A+E x

Exception Coding x

Community HealthMMR

X

Community HealthSmear

X

Community Health MDT Meetings

Continue as part of the frail elderly scheme

Phlebotomy Continue

Shared Care Continue – amendments in year 2015/16

Drug Administration

Continue. Remove the need for patient questionnaires – amendments in year 2015/16

Data Validation Continue with changes - Data Review

ABPI Continue

Practice improvement

X

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Goal

Frail Elderly x

Identification and Care Planning EOL

x

SCHEDULE 2 – THE SERVICES

A. Service Specifications

Service Specification No. 1

Service Primary Care Access

Commissioner Lead Jan Leonard

Provider Lead Practice Senior Partner

Period

Date of Review Annual

1. Population Needs

1.1 National/local context and evidence base

This Service Specification encourages practices to understand the impact that good patient access has on the whole healthcare system.

Stakeholder engagement has identified from our partners (Healthwatch) that access for patients is a priority. Innovative access arrangements may have local value.

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely x

Domain 2 Enhancing quality of life for people with long-term conditions

x

Domain 3 Helping people to recover from episodes of ill- x6

health or following injury

Domain 4 Ensuring people have a positive experience of care

x

Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm

x

2.2 Local defined outcomes Everyone Counts Planning for Patients Response to patient representative needs for access to primary care outside

of core hours An increase in primary care capacity to support urgent care pressures Reduce health inequalities Support practices to achieve increased capacity and investment

3. Scope

3.1 Aims and objectives of service To ensure that patients with conditions that can be well managed in primary

care receive the treatment they need from General Practice. The practice can offer the choice of bookable appointments, and also have a

system to allow urgent or unplanned appointments to be available – ‘Never full practice’.

Practices are encouraged to offer a wide range of bookable appointments e.g. Vaccination clinics / smear clinics within the extended hours availability

Practitioners can develop a plan to work with neighbouring practices to ensure appropriate delivery (plan to be available to patients on practice website)

Access arrangements are updated on practice websites to reflect these requirements

3.2 Service description/care pathway

Improving Access:1 A named GP to be available for the practice 5 mornings and 5 afternoons

per week (core hours) within a reasonable distance of the practice (i.e. 30 minutes travelling time)

2 Patient bookable appointments to be available at the practice 5 afternoons and 5 mornings per week

3. The practice should remain open* to patients throughout the day, except when the practice has a practice training session and this is limited to 1 session per month

4. Baseline audit of WTE GPs working at the practice (partners and salaried GPs)

5. A minimum of 13 appointments per 1000 patients daily (Monday to Friday), this can include telephone appointments, extras booked on the

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day and prescribing nurse appointments6. Practice should provide evidence that reasonable measures are taken to

answer phone requests for appointments within one contact. Issues which challenge this achievement may form priorities for future resources.

7. Collaborative working plans between practices would be acceptable e.g. covering neighbouring practices. Where practices work together appointment capacity would be based on the combined practices list size.

Implementation ongoing.

* ‘Open’ would mean that the practice doors are open, and practice phone lines are open, (no recorded messages to ring another number). A ‘day’ would be contracted hours 8 – 6.30, unless anyone has a contract for core hours with NHS England that states a different opening time’.

Practice plans should be submitted by 31st July 2015 which demonstrates increased capacity and improved outcomes. The reduction in time commitment from year 1, and participation in the Extended Hours DES should also be reflected.

The plans should include:

Public and Patient engagement Sustainability Scale and Ambition Leadership and Commitment Links to local strategy Capacity for rapid implementation Robust plans for monitoring and evaluation

The plans should also demonstrate how the practice will deliver access with specific reference to:

Over 75s Unplanned Care Vulnerable Patients Complex Patients

The plans should also demonstrate the ratio of increased capacity linked to practice list size.

Parallel working can be considered, and is encouraged Flexible working based on practice need should be considered e.g. splitting

sessions Access to prescribing clinician should be reasonable and balanced, e.g. may

be offered by neighbouring clinician or within 24 hours Responding to patient need could be reflected in the framework of the clinic

e.g. smear / vaccination clinic for working mothers A framework representing proportionality around the principle of 15 minutes

per 1000 patients (or multiples thereof) worked flexibility, with a minimum of 2 appointments per 30 minute session

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Where a practice currently opens until 8pm and on Saturdays, additional extended opening will be for agreement with the CCG

Practice can pool resources and produce a combined plan to deliver improvements

Principle of ‘high trust and light touch’ to form basis of access panel criteria Engagement between access panel and practice to ensure access plan

fulfils NHS principles on use of NHS resources around local and national strategies.

Practices may consider signing up to part 1 only. Participation in part 2 either partial or whole year would entail participation in part 1.

Resource allocation

Participation in part 1 is £x per head Participation in part 2 with immediate implementation £x per head

Practice annual report on increased access outcomes should be available for end of DATE. This will allow payment of the final 25% by the end of DATE.

Plans should be submitted by DATE, for immediate implementation.

Submissions will be clinically assessed practices will be contacted if further clarity is required.

Years 3 to be determined based on outcomes and in consultation with stakeholders following receipt of annual reports.

3.4 Any acceptance and exclusion criteria and thresholds

3.5 Interdependence with other services/providersOther GP practices in South Sefton CCGNHS England LATNorth West Commissioning Support Unit (CSU)Data Facilitators

4. Applicable Service Standards

4.1 Applicable national standards (eg NICE) National GP Contract National Patient Survey National Medical Director 7 day working Everyone Counts Planning for Patients

4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)

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RCGP

4.3 Applicable local standards

Primary Care Quality Strategy – Health Outcomes / Workforce Development Sefton Big Chat Events Healthwatch Priorities ECIS report Primary Care Foundation Review Public Health Report – Key Health Needs 2011 CSU information on practice complaints reporting on access

5. Applicable quality requirements and CQUIN goals

5.1 Applicable Quality Requirements

Practice to provide evidence of compliance to section 3.2, and outcomes by DATE.

6. Location of Provider Premises

The Provider’s Premises are located at:Address of GP Practice

7. Individual Service User Placement

Address of GP Practice

Payment Schedule

Practices will receive 75% of 12 months value paid in 12 equal monthly instalments starting DATE, based on practice sign up.

The remaining balance of 25% based on year end results will be paid by the end of DATE on receipt of the practice annual report on patient access by DATE.

Where the plan has not been fulfilled at year end, the CCG reserves the right to make a financial adjustment.

Year 3 to be determined at end of above schedule.

The working assumption is that this element of the LQC will not be applicable to ………

Payment is £xxx per patient

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B. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreementOptional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement


Service Frail / Elderly


Provider Lead Senior Partner

Period


1. Population Needs


The care of the elderly population has changed beyond all recognition in the last 100 years. We have moved from care in extended family settings to care provision as an industry. This has occurred due to a range of societal changes, with social mobility, and the break-up of traditional family units being key influences. However, a very significant change in demographics has played an even greater role. Over the last 50 years (1960-2010) the average life span in the UK has increased by around 10 years for a man and 8 years for a woman. These changes are projected to continue, as the table from the UK Office for National Statistics below shows.

2. Outcomes




x

Domain 3 Helping people to recover from episodes of ill-health x

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or following injury

Domain 4 Ensuring people have a positive experience of care x


x

2.2 Local defined outcomes

Develop a frailty register Advanced/community care planning Proactive reviews Reduction of avoidable hospital admissions

3. Scope

3.1 Aims and objectives of service

Identify patients over 70 years of age residing in their own homes with potentially modifiable frailty and include on a frailty register

Offer falls advice intervention All patients over 70 on 10 or more medications to have a pharmacist review

of medication and every patient on the frailty register Generate integrated community care plans (ICPP) using a new CCG

template for patients on the frailty register Increase in prevalence data Planned time for a facilitated away day for practice development to consider

how the practice can implement ongoing frail elderly requirements Practice development Practice education of frail elderly / palliative care


There are two cohorts of patients for this pathway

Cohort 1 of Patients for inclusion/Exclusion:

Practice to identify patients aged 70 and over who reside in their own homes Patients on the Gold Standard Framework should be excluded ensuring that

an integrated community care plan is in place via the ‘Identification and Care Planning in End of Life’ specification

Practices should consider creating a patient alert system for the identified cohort

See Care Home section for Cohort 2

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PRISMA 7

PRISMA – 7 (the screening tool of choice) Appendix 1, is a widely accepted tool, recommended in the British Geriatrics Society (BSG) Fit for Frailty guidance

The practice would need to supply the patient with relevant information on why the survey is being requested and how their information will be used.

A PRISMA 7 guide can be accessed at (include hyperlink), page 150 of the document provides some useful information regarding completing the questions

The practice to use own judgement in relation to any local services to improve the patients’ health and wellbeing, including advice on falls prevention

Patient consent to share information should be included as part of the data gathering exercise as this is required should they be eligible for inclusion on the frailty register, and for ICCP

The method of contact should be determined by the practice but where PRISMA 7 has previously been used in other areas the initial contact has been via a postal survey. Patient perception is key, and where possible patients should answer the questions directly

A practice letter should explain the aims of improving care and that there are no right or wrong answers. If the patient has recently had an injury or illness that has left them struggling a bit, they need to answer the questions based on their normal function. It should also be explained that they can opt out at any point

Other methods to consider could be:

Telephone contactOpportunistic attendance at the practiceVia community pharmacistCollaborative working with neighbouring practices (flu campaign etc)Collaboration with other agencies

Where other methods are used ie telephone, the practice should explain to the patient the need for patient consent, a practice data sharing crib sheet could be developed, and patient consent recorded

Practices are responsible for developing a strategy to implement PRISMA 7, including how to contact patients who do not respond

80% of patients offered PRISMA 7 to have a response fully recorded by DATE

Identification of Patients

Practice to collate PRISMA 7 completed responses, complete electronic template

Patient consent or dissent should be recorded / scanned Patients scoring 2 or less will not have any further intervention, as they

would not be identified as having frailty. Information should be read coded and passed to GP for information.

Patients scoring, 2 or less who are not on a disease register, and therefore not having annual reviews, should be considered for invite to a well woman/man clinic appointment.

The number of patients scoring 3 or above who have given consent would be included in the frailty register and offered a screening appointment either

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in the practice or where a patient is housebound in their place of residence Patients who have not given their consent should still be offered a screening

appointment

Screening/Assessment

The screening tool is SAFE (Screening Assessment for the Frail and Elderly) Appendix 2, a screening and intervention tool put together based on British Geriatrics Society (BGS) and NICE guidance.

SAFE can be undertaken by a Health Care Assistant, it is for the practice to identify who undertakes the assessment

The Edmonton score is calculated as part of SAFE The lower Edmonton scoring cohort (9 or below) would receive no further

input apart from referrals triggered by the assessment The higher Edmonton scoring cohort (10 and over) would be flagged to the

GP for further action, this could involve the GP actioning any identified need or further management in conjunction with community teams or hospital based geriatric service

A managed approach to the identification/screening element should be used

Frailty Register

There is a requirement that the frailty register is shared with other organisations including GTD,NWAS, community teams and secondary care

Lancashire Fire and Rescue Service could be working with NWAS in a co-responding pilot in the near future which could cover some patients registered within the CCG

Every patient on the frailty register will have an ICCP in place The practice need to inform partner organisations when a significant change

to the register takes place, including where a patient becomes eligible for GSF register etc.

Integrated Community Care Planning

The CCG ICCP at Appendix 3 to be adopted. This supersedes current community care plans used for Avoiding Unplanned Admission (AUA DES). Patients who already have a community care plan using a previous template should have the information transferred to the CCG ICCP following patient consent, and read code ICCP used

Practices also undertaking the AUA DES need to continue to use read codes used for CQRS identification

95% of patients who reside in their own homes who have been placed on the frailty register to have an ICCP in place by DATE

Pointers on how to write a good care plan at Appendix 4 Where a health professional other than the GP has generated the ICCP, the

plan must be signed off by the GP ICCP should be scanned into the patients electronic clinical records There is a requirement that the community care plan is a shared / integrated

document with GTD, NWAS, community teams and secondary care subject to patient consent

The patient will retain a copy of the care plan in the coloured envelope provided by the CCG

There will be a requirement for at least monthly multidisciplinary team 14

meetings.

Medication Reviews

Using the STOPP START Tool, all patients 70 and over on 10 or more medications, and every patient on the frailty register to have a pharmacist review of medication

By the end of the year DATE 80% of patients eligible for the STOP START review should be read coded with a medication review

Cohort 2 Care Home Patients

Anyone residing in a care home regardless of age (unless exempted) should be placed on the frailty register following patient consent

Principles of Best Interest decisions should be adopted No PRISMA 7 data collection is required for this cohort because there is an

assumption that they are frail It remains best practice for all care home patients to have a care plan in

place signed by a GP Where a care plan currently exists, and following patient consent this should

be transposed to the CCG ICCP and shared with relevant organisations

Facilitated Away Day for Practices

A mandatory practice away day with a facilitator. Clinical cover would need to be secured at the practice to implement. All members of the practice are to attend.

It is recognised that the local quality scheme may be a logistical challenge for some practices to deliver. This away day gives the opportunity to identify and explore alternative ways of working. Consideration should be given to resource pooling between individual practices, or even collaboration on a locality level.

Suggested topics could include:

Appropriate delegation of tasks away from clinical staff Development of protocols for common presentations Efficiencies i.e. patients on multiple disease registers being seen for all their

conditions in one appointment rather than the same questions being asked at multiple visits

Telephone triage Identification of concerns within the locality i.e. gaps in services, patient

unmet needs etc. Discussion of performance compared to other practices, sharing best

practice i.e. unplanned admission numbers etc. How best to care for patients over the age of 70 Staffing needed to deliver services

Gaps in services identified should be shared with CCG/peers and sharing success and good practice.

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Practice Development

Workforce planning/capture of data via Health Education North West Core skills e-learning mandatory training

Identification of patients at end of life is delivered via a separate specification/ funding stream within this Local Quality Contract, but is required as part of the frail elderly pathway.

Education session for GP’s (and allied professions) focusing on care of the Frail and Elderly, and Palliative Care issues/ Advanced Care Planning for this group of patients.

Working in partnership with colleagues in secondary care, an education programme for GPs and allied professions to be delivered. This will be a CCG organised event

The suggested session would include:

A presentations on:o management of Frail and Elderly patients o the local services available to the patient and the GPo falls preventiono medication reviews with an emphasis on interpretation of published

guidelines in this group of patientso The importance of data sharing in a timely fashion when patients

move practices i.e. on discharge to CH/NH.o Community Care Planning/Future Care Planningo support in the community and in NH/CHo a question and answer session

Scenarios to be worked through in small groups Presentation by local Palliative Care Consultant on:

o Identification of patients likely to be in the last 12 months of life and the benefits they are entitled to

o Advanced Care Planningo End of Life Alert Notification Form (NWAS)o DNACPR orderso Anticipatory Care Planningo Electronic Palliative Care Co-ordinating System (EPaCCS)o Question and answer session

Scenarios to be worked through in small groups Brief discussion on DOLS and how they affect our practice Time to share best practice and where significant improvements have been

made

75% of GPs from each practice will be required to attend.

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Development of pathways and protocols for the management of frailty syndromes

There are five recognised frailty syndromes:

Falls (collapse, legs give way, found on the floor) Immobility (sudden change in mobility, “off legs”, stuck on toilet) Delirium (acute confusion, worsening of pre-existing condition) Incontinence (new onset or worsening of existing condition) Susceptibility to side effects of medication (confusion with codeine,

hypotension with antidepressants)

Pathways in these areas will be developed by a clinical team in year 2.Practices will be asked to adopt the pathways and protocols to deliver care to patients with frailty in year 3.

Patients benefiting from this programme to be surveyed about the approach and value of interventions

There is no necessary link between frailty and impaired mental capacity, while some patients may not be able to comment on the programme others will. As a clear, but perhaps less easily measured aim is to improve the quality of life of the patient, a survey could seek views on the success of the programme in this regard.

A survey will be compiled seeking to ascertain patient opinions.

3.3 Population covered

All registered patients aged 70 and over/ and care home patients regardless of age


Refer to section 3.2

3.5 Interdependence with other services/providers

Local Voluntary OrganisationsSecondary CareiMerseysideNorth West Ambulance ServiceCommunity Nursing TeamVirtual Ward/CHIPMedicines ManagementWoodlands HospiceCare/Nursing Homes

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4.1 Applicable national standards

NICE

4.2 Applicable standards set out in Guidance and/or issued by a competent body

(eg Royal Colleges)

BGS Fit for Frailty 1 and 2Safe Compassionate Care for Frail Older PeopleTransforming Primary Care PolicyCommissioning for PreventionEveryone Counts


Primary Care Quality Strategy


5.2 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

Quarterly information will be requested on practice progress to understand the impact of implementation

Annual information on:

Cohort 1

Number of patients who reside in own home as per spec identified

Cohort 2

Number of care home patients as per spec identified

PRISMA 7

Number of PRISMA 7 surveys offered Number of PRISMA 7 responses completed (80% target of identified cohort)

Identification of Patients

Number of patients from PRISMA 7 responses scored 3 or above offered

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screening

Screening

Number of patients offered screening who have had an assessment completed

Number with an Edmonton Score of 10 or higher

Frailty Register / Medication Review

Cohort 1

Number of patients from completed PRISMA 7 who have given consent for inclusion on frailty register/ICCP

Cohort 2

Number of care home patients who have given their consent for inclusion on frailty register/ICCP

Total number of patients (cohort 1 and 2) on the frailty register Confirmation that the frailty register is shared with partner organisations and

is updated as per spec

ICCP

Number of patients on the frailty register with ICCP (95% target) Confirmation that the ICCP is shared with partner organisations

Medication Reviews

Number of patients eligible for a medication review as per spec Number who have had a medication review (80% target)

Facilitated Practice Away Day

Confirmation of a facilitated practice away day with outcomes as per spec

Education Session

Confirmation of 75% attendance at education session

5.3 Applicable CQUIN goals (See Schedule 4 Part [E])

N/A


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The Provider’s Premises are located at:

GP Practice


GP PracticeRead Codes (to be requested):

1) On Fragility Register2) PRISMA 7 Questionnaire sent/given to patient 3) PRISMA 7 Questionnaire completed (needs value recording)4) Declined to answer PRISMA 7 questionnaire5) Agreed consent to be on Fragility register and share data6) Agreed consent to share community care plan7) Dissent to go on Fragility Register or share care plan8) Fragility Screening Appointment offered9) SAFE assessment completed for Fragility (needs value recording)10) SAFE assessment declined

11) Integrated Community Care Plan in place??? Angie to get advice from clinician

12) Review of Integrated Community Care Plan??? As above

13) STOPP Start Tool completed (no current read code exist)

14) Medication Review done by Pharmacist “8BIC”

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Appendix 1

PRISMA 7 Questionnaire

The PRISMA 7 is a seven-item, self-completion questionnaire. It can therefore be used as a postal questionnaire, or for people who are too unwell to undertake the 4 metre walking speed test. One point is scored for each of the seven questions and a score of 3 points or more is considered to identify frailty.

The “PRISMA 7” Questions 1. Are you more than 85 years?

2. Male?

3. In general do you have any health problems that require you to limit your activities?

4. Do you need someone to help you on a regular basis?

5. In general do you have any health problems that require you to stay at home?

6. In case of need, can you count on someone close to you?

7. Do you regularly use a stick, walker or wheelchair to

A template is being devised that will populate patient details for postal use ie name, address, age/ sex. The template will calculate the PRISMA 7 score.

Wording for data sharing consent will also be included

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Appendix 2

SAFE

Assessment Value Trigger

BP measurement: Sitting and standing If no known hypertension: systolic >140 or diastolic >90 flag for GP review.

If known hypertension: less than 80 years of age if above 140/90 flag to GP. If over 80 years of age flag to GP if over 150/90.

If systolic falls by more than 20mmHg on standing flag to GP.

Pulse rate If irregular flag for GP review unless known AF

Pulse rhythm If <60 or >90 flag for GP review

Smoking status If smokes offer cessation advice

Audit C (alcohol) score If scores 8 or more offer referral to SATINs

Edmonton Frail Scale If scores more than 10 refer for further assessment.

If requires help with 2 or more activities of functional independence or if has no-one to meet their needs (Q3&4) signpost to social services.

If they sometimes forget to take their medicines (Q5) signpost to their pharmacy for consideration of blister packs.

If has a problem with continence (Q8) offer referral to continence service.

If Timed Up and Go test >20 secs consider referral to physiotherapy/ occupational therapy if appropriate (Q9).

FRAX

Omit if patient has had BMD in last 2 years or is already on treatment. Low risk – advice only. Intermediate or high risk – for BMD.

6 Step CIT Score <8 normal.

Score >8 offer referral to memory clinic.

MUST Medium risk – review with practice nurse in one week with diet sheet.

High risk – offer referral to dietician.

Bloods to be taken FBC, TFT, LFT, Cholesterol, Renal, B12, Folate, Ferritin, Vitamin D, HbA1c, Bone profile

Can you take care of your feet (nails etc)? If no, offer referral to podiatryDepression Screening:

During the last month have you been feeling down, depressed, or hopeless? Yes to either should prompt referral back to GP.During the last month have you been bothered by having little interest or pleasure in doing things? Yes to either should prompt referral back to GP.Falls screening:

Have you had a fall in the last 12 22

months?If yes, was it a simple trip i.e. not a collapse where you felt unwell beforehand?

If any suggestion it was a collapse refer to GP. If simple fall refer to falls service.

Advise regular dental care Advise regular optician care Do you have any hearing difficulties that are not already being treated? If yes, refer to audiology.Do you have a non-professional carer? Signpost to Sefton Carers for support.Readcode Next-of-Kin Readcode if housebound

STOPP START review Pass to pharmacist if on more than 10 medications

This template will be integrated with EMIS

Appendix 3 CCG ICCP and Appendix 4 Pointers on how to write a good ICCP to be included

Payment Schedule


The remaining balance of 25% based on year end results will be paid by the end of DATE on receipt of the practice annual report by DATE.

Where the plan has not been fulfilled at year end, the CCG reserves the right to make a financial adjustment.

Year 3 to be determined at end of above schedule.

The working assumption is that this element of the LQC will not be applicable to……….

A premium will be paid for each patient registered aged 70 and over (difference between core contract value and xxxx)

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C. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreementOptional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement


Service Identification and Care Planning in End Of Life (EOL)

Commissioner Lead Moira McGuiness/Dr Debbie Harvey

Provider Lead Senior Partner

Period


1. Population Needs

1.3 There are approximately 1500 deaths per year in South Sefton. The majority (90%) are expected.It is important to identify this patient group in order to provide an opportunity for collaborative MDT care planning to ensure, as far as possible, that the patient ultimately dies in their preferred place of care.

2. Outcomes


Domain 1 Preventing people from dying prematurely


x

Domain 3 Helping people to recover from episodes of ill-health or following injury


x



Reduce health inequalities 24

Identify and help support patients to receive care where they choose in the final year of life and to die in their preferred place of care

Reduce unnecessary admissions to hospital

3. Scope


To ensure that GPs identify the majority of patients deemed to be in the last year of life (may be longer). This will include patients with terminal cancer, end stage long term condition e.g. COPD, dementia and frailty.

To ensure that every patient at the end of life (or their next of kin/IMCA if the individual lacks capacity) has the opportunity to discuss their preferences with regards to treatment options, where the latter is delivered and their preferred place of death. Discussions should also take place with regards to resuscitation and be clearly documented and shared.

To ensure that the GSF register includes all patients in the final year of life To ensure that all relevant services are given sufficient information via a

locally agreed care plan through the agreed sharing processes


Part one – Identification

GP practices identify patients deemed to be in the final year of life using the surprise question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days?’ All patients should have this opportunity and a minimum 0.3% of the practice population be included and a maximum of 1%

The identified patient cohort must include all registered patients aged 18 and over identified in the last 12/12 of life regardless of place of residence

Part two – the conversation

It is well recognised that conversations regarding the final year of life far outweigh the presence of documentation which encourages a tick box approach ( Documentation is however important to communicate a summary of these discussions -see below)

Critically these conversations should include the patient’s wishes with regards to their medical care, where they wish to be treated and where they wish to die. Importantly discussions also need to include resuscitation in keeping with current guidelines.

Practices need to read code that a discussion regarding care in the final year of life has been offered even if the patient does not wish to engage in subsequent care planning xxxxxxxxx Dr H exploring this RC xxxxxxxxxxx

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Part three – documentation

A locally agreed CCG Integrated Community Care Plan (ICCP) template (see Appendix 3 in Frail/Elderly specification) to be completed in all cases where patients (or agreed advocate) have agreed a care plan. This will help guide any professionals involved in the patient’s care and ensure that any future clinical decisions are made according to the patient’s wishes and preferences where possible.

In addition, a separate North West unified DNACPR form should be completed where appropriate Appendix?

Part four – sharing

It is vital that anyone who comes into contact with a patient in the final year of life is alerted to this fact along with any specific agreed planning

Completed templates should be shared with 1. The patient/carer i.e. there needs to be a ‘visible’ copy at the

patient’s address2. OOH provider via fax3. NWAS via ERISS 4. Patient consent to be on the GSF register and share ICCP should be

recorded

Part five – Register

Any patients who have an EOL care plan should be included on the practice GSF register


Patients in the final year of life regardless of residence e.g. care home, private home etc. registered with a South Sefton GP


Patients 18+ and registered with a South Sefton GP Practicedeemed to be in the final year of life (Min 0.3%, max 1% of registered population)

Patients should be given the opportunity to have the conversation with regards to their care preferences in the final year of life (NOK/IMCA etc if there is no capacity).

However, patients do not have to engage in a care planning process and may not participate. This choice is permitted and should be read coded.

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Care homes Community matrons Community geriatrician District nurses Specialist palliative care nurses NWAS OOH provider/s Airedale hub (for care home residents) Woodlands Hospice Secondary care This is not inclusive

4.1 Applicable national standards (eg NICE) More Care Less Pathway, A review of the Liverpool Care Pathway 2014

4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges)

Thinking Ahead - Advance Care Planning (ACP) Gold Standards Framework Your Life and Your Choices: Plan Ahead Macmillan GMC Treatment and care towards the end of life: good practice in decision

making House of Commons Health Committee – End of Life Care 2014/15


n/a


5.4 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

Quarterly information will be requested on practice progress to understand the impact of implementation

Annual report re the number of patients identified as being in last 12/12 of life

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Annual report re the number of conversations offered Annual report re the number of integrated community care plan

completed using agreed template Annual report re the number of shared care plans

5.5 Applicable CQUIN goals (See Schedule 4 Part [E])

n/a





Payment Schedule


The remaining balance of 25% based on year end results will be paid by the end of DATE on receipt of an annual report on by DATE.

The working assumption is that this element of the LQC will not be applicable to……….

Xxx per registered patient

Include DNAR / ACP Network paper

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Service Primary Care - Phlebotomy



Period


1. Population Needs

1.4 National/local context and evidence baseSince the introduction of the new GP contract in 2004, the demand for phlebotomy has risen significantly as GP practices have built up disease registers to meet the requirement of the QOF. This demand cannot be met by secondary care provision alone and is neither cost effective nor convenient for patients.

As phlebotomy is a service that does not require a patient to be registered with a GP, this specification will only be reviewed.

It is envisaged that phlebotomy will be provided via the AQP route

2. Outcomes


Domain 1 Preventing people from dying prematurely xDomain 2 Enhancing quality of life for people with long-term

conditionsx


x


x


x

2.2 Local defined outcomes Response to patient representative needs for access to primary care

29

phlebotomy An increase in primary care capacity to support long term conditions

management Reduce health inequalities Support practices to achieve increased capacity and investment

3. Scope

3.1 Aims and objectives of serviceTo support access to phlebotomy closer to home in GP practices, whilst complimenting current phlebotomy provision by the community services.

3.2 Service description/care pathway Practices must state whether an appointment is required Practices offering an appointment system should be able to offer an

appointment within 48 hours ( 2 working days) Clinicians delivering the service must comply with the practice Health and

Safety policy, Sharps Policy, Infection Control, National Guidance on Clinical Waste and assessed as competent to undertake the task

Blood samples should be forwarded to either Aintree Hospital or Southport DGH

Practices will indicate if willing to perform phlebotomy for neighbouring practices

Read codes:

Routine blood test – Haematology test performed 4212


Patients registered at the practice aged 16 and over who require routine blood tests.


Patients undergoing phlebotomy for NHS Health checks or any other that are funded as part of another agreement.

3.5 Interdependence with other services/providers Liverpool Community Health NHS Trust NHS Local Acute Trusts/ICO CCG Public Health


4.1 Applicable national standards (e.g. NICE)

QOF Long Term Conditions30



Primary Care Quality Strategy – Clinical Standards/health OutcomesHealth watch (previously Sefton LINK)


1.1 Applicable Quality Requirements Practice quarterly report/invoice to include:

Number of bloods taken per 1000 patients performed at the practice Total number of bloods

Practice satisfaction survey (20 random samples) annually



Insert GP practice premises address


Practices will be paid cost per case (i.e. per venepuncture) £xxx on production of quarterly invoice


31



Service Primary Care Prescribing – Shared Care

Commissioner Lead Suzanne Lynch


Period


1. Population Needs

1.1 Shared Care protocols allow a GP to prescribe certain drugs, under the supervision of a named consultant; to patients, that are normally prescribed by and in secondary care. By enabling GPs to prescribe the following drugs (see appendices) patients avoid attending unnecessary hospital appointments.1.2 Drugs can only be prescribed to patients on the practice list

2. Outcomes



conditionsx


x


x


x

2.2 Local defined outcomes Response to national drivers for care closer to home An increase in primary care capacity to support provision of shared

care in below clinical areas Reduce health inequalities Support practices to achieve increased capacity and investment

3. Scope


32

Shared care is intended to enable practices to:

Be confident in agreeing to accept the legal responsibility for prescribing and the clinical responsibility for undertaking shared care as per agreed clinical protocols (where available) for drugs listed in Appendix 1. It is important to note that practices are only expected to prescribe/monitor those drugs that they feel clinically competent to do so

Be able to be paid for the prescribing, monitoring and supervision of patients being cared for in accordance with an approved shared care agreement.

Be able to provide a robust quality service that is convenient to the patient whilst remaining clinically safe.

3.2 Service description/care pathway / inclusions

Background

When prescribing responsibility for a drug for an individual patient is transferred from specialist to General Practitioner (GP), the GP should have both confidence and competence in prescribing the drug. Therefore for drugs a GP would not normally be familiar with, it is essential the transfer of prescribing and potentially some aspects of the drug monitoring should not take place without the sharing of information with the individual GP, and recorded agreement to this transfer of care. The concept of “shared care” of drugs that GPs would not routinely initiate and therefore would not normally be familiar with is encompassed in Dept. of Health EL(91)127 “Responsibility for Prescribing between Hospitals and GPs”.


A number of drugs have been identified in Appendix 1 as suitable for prescribing in primary care within an agreed shared care protocol. The list of drugs in Appendix 1 will be updated when required. A shared care protocol for the drug or group of drugs developed at pan Mersey level and subject to approval by the CCG Medicines Operation Group defines the specialists’ and the GPs’ responsibilities for use of the drug in an individual patient.

Prescribing by a General Practitioner of an Appendix 1 list drug should normally be carried out in accordance with the shared-care clinical protocol for that drug. However on occasions, specialists and GPs may agree to work outside of the shared-care protocol for that drug if circumstances make this appropriate.

It is recognized that some drugs such as the disease-modifying ant rheumatic drugs (DMARDs) require more intense monitoring and this has been addressed through the different levels of payment.

Any drug removed from level 2 or 3 in Appendix 1 during a routine review of this drugs list, will still attract payments for the quarterly period in which removal takes place. Drugs added to the list will only attract payments commencing in that quarter in which they were added.

Any drugs added or removed from level 1 in Appendix 1 during a routine review

33

of this drugs list will not attract any change to the fixed fee per annum based on total practice list size for prescribing all other shared care drugs unless the net effect of any additions and removals increases or decreases the total number of patients in the CCG as a whole receiving drugs listed in level 1 by 10% or more, as estimated from most recent quarter prescribing data using defined daily doses. In this case the fixed fee will be increased or decreased by the same percentage from the quarter in which the review occurs.

The patient must currently be monitored and supervised by the practice for the drugs listed in Appendix 1 during the relevant time period for which payment is claimed for level 2 and 3 payment.

This service specification will fund the acceptance of clinical responsibility associated with prescribing and monitoring drugs on the list at Appendix 1 as per the shared care clinical protocols. This list will be updated at intervals. A shared care protocol developed at a pan Mersey level and subject to approval by the CCG Medicines Operational Group defines the specialists’ and the GPs’ responsibilities for use of the drug in an individual patient.

The practice will develop and maintain an up-to-date register that will include details of all patients being prescribed Appendix 1 payment level 2 and 3 drugs by the practice.

The practice must have in place an effective and robust system for call and recall of patients it is monitoring. The practice must be confident that if monitoring is taking place in another setting that appropriate arrangements are in place for call and recall. This must include a robust system for the management of non-attendees as per the shared care protocols.

The practice must ensure that each patient has been provided with relevant patient information. Patients need to be able to access appropriate information in an ongoing manner and must be advised how to do so. The patient must be advised:

on the risks and benefits of their medication patient understanding and consent must be confirmed the need for monitoring and the schedule explained Written information provided including a patient-held record card and, pre-

treatment patient information leaflet (for DMARDs and lithium).

It is primarily the responsibility of the referring specialist to provide this to the patient but practices have a duty to confirm that they have done so and if not, provide it themselves. Practices should report instances of specialist services’ failure to provide this information to the CCG Lead for Medicines Management.

3.3 Population coveredThe registered practice population


34

o There must be a shared care protocol developed at a pan Mersey level and subject to approval by the CCG Medicines Operational Group.

o The contractor will currently hold a contract with NHS England to provide essential general/personal medical services.

o The patient must be registered with the practice


NHS England The Local Medical Committee The Area Prescribing Committee The CCG Acute Trusts/ICO/consultants





Primary Care Quality Strategy

See section G for evidence and individual local scheme



All healthcare professionals involved in the provision of care to patients in respect of the drugs listed in this agreement should have the relevant skills and be able to satisfy key competencies. Staff should as a minimum:

Know the clinical indications for treatment and whether the indication is licensed or unlicensed.

Be aware of the cautions and contraindications of the drug being used. Be aware of the dose range and schedule for the drug and the circumstances

that might cause dose variation. Be aware of any significant drug interactions. Be aware of the monitoring schedule needed to ensure safe drug use. Be aware of the signs of potential toxicity and the actions to be taken if it is

identified. Be aware of any issues around the administration of injectable drugs and the

subsequent appropriate method of disposal of sharps or medicinal residue. Where specialists do not carry out their responsibilities or monitoring required by

the shared care protocol, practices should return care and prescribing back to the specialist.

35

Clinicians must report any adverse events of treatment to the specialist and inform them of any relevant change in the patients’ circumstance.

There are currently shared care agreements resulting in level 3 payments for treatment of rheumatoid conditions. Level 3 payments will also apply when a practice has agreed to treat and monitor patients prescribed DMARDs for other indications which would otherwise be undertaken in secondary care and the practice is satisfied with clinical direction on transfer of care. This recognises the extra workload undertaken at practice level for patients other than rheumatoid patients.




Practices will be paid on production of a quarterly invoice

Shared Care Appendix 1Specified Drugs and Payment levels

36

Level Payment Drug Indication

Level 1 £500 fixed annual fee, based on average list size of 5,000

All shared-care (amber) drugs (except those listed in Level 2 and 3 below) regionally agreed by North West Medicines Management Alliance Guidelines on Prescribing Responsibilities for Red and Amber Medicines (RAG list) updated from time to time, as ratified by NHS Sefton Medicines Management Committee

As per locally agreed shared

care protocols

Level 2 £60 per patient per annum

Bicalutamide As per locally agreed shared

care protocols

Flutamide

Cyproterone

Level 3 £150 per patient per annum

Azathioprine As per locally agreed shared

care protocols

Leflunomide

Methotrexate

Penicillamine

Sodium Aurothiomalate

Sulfasalazine

Cyclosporin

MycophenolateLithium As per locally agreed shared

care protocols

Low molecular weight heparin As per locally agreed shared care protocols

The PDF shared care documents are currently being updated and can be accessed at:

http://nww.southportandformbyccg.nhs.uk/patient-care/Medicines/Interface_Issues.aspx

37






Service Drug Administration

Commissioner Lead Susanne Lynch


Period

Date of Review Annual Review

1. Population Needs


Safe appropriate and convenient care for the patient resulting in a decrease in secondary care outpatient activity

2. Outcomes




x


x


x


x


38

Response to national drivers for care closer to home

An increase in primary care capacity to support provision of shared care in below clinical areas

Reduce health inequalities

Support practices to achieve increased capacity and investment

3. Scope


Suitable patients requiring Goserelin injections for stable prostate cancer have their injections delivered in a primary care setting. Patients receiving Goserelin will still have a periodic review at the consultant clinic, where all monitoring will take place. Patients who appear unwell or who experience worsening or new symptoms should be referred back to secondary care immediately.

Suitable patients requiring Denosumab injections for stable osteoporosis have their injections delivered in a primary care setting. Patients receiving Denosumab will not require a periodic review at the consultant clinic. NICE (2010) expectations state denosumab will subsequently be delivered almost exclusively in primary care. A review in primary care is appropriate. It may be appropriate to refer a patient back to secondary care if patient’s condition deteriorates after a period of time or stop the medication with patient agreement.

The benefits to the patients are care closer to home where currently frequent attendances at outpatients departments are required


Any practice wishing to provide drug administration will provide the following information to the Commissioners :

• The name of the clinician carrying out each procedure

• Details of the training undertaken by a suitably qualified clinician – course, provider, dates

This information will be held on a register by the Commissioners


Goserelin

All male patients, registered with a CCG General Practitioner, who is aged 16 years and over, with stable prostate cancer (as determined by their Consultant but denoted by: anti androgen therapy completed, Goserelin first dose delivered, PSA dropped, stable renal profile, symptoms managed) who require administration of

39

Goserelin injections – having received their first injection of Goserelin therapy in a secondary care setting.

NB. More than one injection in secondary care may be required until the patient is stable.

Denosumab

Postmenopausal patients at increased risk of fractures and initiated on Denosumab by a Consultant. Patients would have undergone an assessment for indication of use, Denosumab first dose delivered and a stable calcium and renal profile in a secondary care setting before having subsequent injections in primary care



Consultants in local NHS Acute Trusts



4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges)


Local protocol

Primary Care Quality Strategy – Clinical Services/Health Outcomes.



Practice quarterly report/invoice to include:

The number of procedures carried out

The number of patients who have full monitoring information recorded,

40

(compliance rate 90%)



Insert GP practice address.


Practices will be paid cost per injection £xxxx on production of quarterly invoice for Goserelin, and £xxx per injection for Denosumab on production of a quarterly invoice.

41



Service Specification No.7

Service Data Review

Commissioner LeadJan Leonard

Provider LeadPractice Senior Partner

Period

Date of ReviewAnnual

1. Population Needs

1.1

2. Outcomes




x


x


x


x


Identify and review patient episodes of care in locality defined specialities Reduce and challenge financial implications of inaccurate patient activity data within

secondary care Effective use of resources

42

3. Scope


Provide additional investment to support practices to clinically peer review activity and expenditure in secondary care. Also to supply intelligence for future commissioning of community services to support the strategic direction of providing care closer to home.


Each locality to discuss and determine outcomes of local/ QIPP priorities Patients will be identified via practice clinical systems Cancer Register /Significant Event Analysis and (identify other areas) include

details

Due to the comprehensive analysis required, each participating practice will check a minimum of 1% of their practice list size.

Example: A practice with 5000 registered patients – 1% of the population = 50 patients.

The practice undertakes an internal clinical peer review, using the template below. The output / report of the review to be made available to the locality for external clinical peer review. The internal report should detail a review of the patients episode of care, including how different management could have prevented the non-elective episode.

Each locality should nominate a report author(s) from the membership who will collate a locality report for each speciality. This should include an explanation of any variance and correcting measures/plan to improve patient care

Each locality report should be peer reviewed / shared for best practice with another locality

A 1/3 of the value of the scheme will be paid following completion of the steps above for each speciality

Each locality are expected to produce an annual report for the Governing Body by DATE.

Locality to agree the headings of the template/information to collectName of clinician :

NHS no

M/F

Age

Date of Attendance

Day of Week

Time of Attendance

Normal place of Residence

Referral Source

Last contact with Primary Care

Last contact with Secondary Care

Is there an alternative pathway available (specify)

Is the patient on a QOF register for the presenting speciality

Practice Name:43

Practice Code:Agreed Speciality:Date of Internal Clinical Peer Review:Attendees present:

Summary of discussions that have taken place at the meeting:

3.3 Population covered Patients registered who at South Sefton GP practices




4.1 Applicable national standards (e.g. NICE)N/A


N/A

4.3 Applicable local standardsPrimary Care Quality Strategy – Health Outcomes



Reports, evidence of group peer discussion.




A 1/3 of the value of the scheme will be paid following completion of the steps above for each speciality. Total value of the scheme is £xxxx per patient

44




Service Primary Care - ABPI



Period


1. Population Needs

1.2 National/local context and evidence baseIt has been estimated by Local Vascular Consultants that approximately 25% of referrals are for Peripheral Vascular Disease (PVD) which could be managed in primary care.

There are guidelines produced by national bodies (SIGN, MOM, and Target PAD) that have been adapted and agreed by local experts. Please see Peripheral Arterial Disease (PAD) Primary Care Algorithm Appendix.

2. Outcomes



conditionsx


x


x


x


Commissioning strategy to reduce secondary care referrals

45

3. Scope

3.1 Aims and objectives of serviceProvide ABPI tests in a community setting for patients who are experiencing symptoms of claudication without leg ulceration. The service will be provided from more than one location in order to improve access and patient choice.

3.2 Service description/care pathwayProvide ABPI tests in a community setting for patients who are experiencing symptoms of claudication without leg ulceration. The service will be provided from more than one GP practice in order to improve access and patient choice.

This service can be performed by Health Care Assistants or Practice Nurses who have received specific training and have successfully been deemed competent (proof required)

It is the responsibility of the practice to ensure that new staff attend training (proof required)

Consent for the procedure must be recorded within the patient’s medical record. Where practices offer this service to patients outside their practice records of summaries of attendance / consent must be kept.

A summary of the test recorded within the patient’s medical record, where practices offer this service to patients outside their practice a summary is sent back to the referring GP. (Referral/summary of test is available on CCG website)

Participating practices will provide appointments for ABPI tests The practice will be responsible for supplying relevant consumables Practices must provide a comfortable and safe environment for patients

attending community based ABPI Clinicians delivering the service must comply with practice Health and

Safety Policy, Infection Control Policy, National Guidance on Clinical Waste and assessed as competent to undertake the task.

Quarterly activity / breakdown of referrals to be forwarded to the CCG Annual patient satisfaction surveys must be undertaken by the participating

practice A list of practices with contact details will be displayed on the CCG

websiteCriteria for practices referring to the ABPI community service is on the CCG intranet

3.3 Population coveredThe Clinical Commissioning Group Population.


N/A


Vascular Consultants working in local NHS Trusts.CCG


46


N/A4.2 Applicable standards set out in Guidance and/or issued by a

competent body (e.g. Royal Colleges)


Primary care Quality Strategy – Clinical Services/Health Outcomes


5.7 Applicable Quality Requirements Quarterly report / invoice detailing:

Number of procedures carried out Whether the test was within or outside normal range Neighbouring practices who have referred to the service

Patient satisfaction survey (20 random samples) annually


The Provider’s Premises are located at:(insert Practice premises address)


Practices will be paid cost per case £xxxx on production of quarterly invoice

Insert PAD Algorithm

47

SCHEDULE 3 – PAYMENT

A Local Prices

Specification

Primary care Access £xxx per patient

Frail / Elderly

Identification and Care Planning in End of Life (EOL) £xxx per patientPhlebotomy £xxxx per venepuncture

Shared Care Level 1 £xxx fixed annual fee, based on average list size of 5,000

Level 2 £xx per patient per annum

Level 3 £xxx per patient per annum

Drug Administration £xxxx per injection GoserelinDenosumab £xxxx per injection

Data Review £xxxx per patient

ABPI £xxxx per test

List size figures will be based on information released each April.

49

Reporting Schedule – South Sefton

Specification Requirement Dates 2015/16 Requirement Date 2016

1 Primary Care Access

Action Plan DATE Annual Practice Report

DATE

2 Frail / Elderly Quarterly information as requested

Last working day of the financial quarter

Annual Practice Report

DATE

3 Identification and Care Planning in End of Life (EOL)

Quarterly information as requested


Annual Practice Report

DATE

4 Phlebotomy Quarterly Invoice


Patient satisfaction Report (20 random samples)

DATE

5 Shared Care Quarterly Invoice

Last working day of financial quarter

6 Drug Administration

Quarterly Invoice

Last working day of financial quarter

7 Data Review Agreement of 3 local/QIPP priorities for internal clinical peer review – report and clinical external review at locality meeting

8 ABPI Quarterly invoice


Quarters outlined above reflect financial quarters where invoices are required

50

SIGNATURE SHEET

Practices stating an intention to participate must complete and return this signature sheet by DATE.

A 3 year NHS Standard Contract was collated for the practice in 2014, a variation to the contract to reflect services provided in 2015/16, will form the contract between the practice and the CCG.

Practice Name:

N Code:

Practice intention to participateIndicator 1 Primary Care AccessIndicator 2 Frail Elderly

Indicator 3 Identification and Care Planning in End of LifeIndicator 4 PhlebotomyIndicator 5 Shared CareIndicator 6 Drug AdministrationIndicator 7 Data ReviewIndicator 8 ABPI

Public Health - LARC

Practice Signature ………………………………………………………………………..

Print Name………………………………………………………………………………….

Please return to [email protected]

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schedule 2 – the services - sefton local medical committeeseftonlmc.co.uk/download/committee/lmc...

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