Kingston CCG. Kingston Medical Services - Service Specification. KMS SP1: Audiology

Transcription

1 Kingston CCG Kingston Medical Services - Service Specification KMS SP1: Audiology The aim is to provide greater access to audiology screening in general practice and to reduce the number of avoidable referrals to secondary care. Contents 1. Background 2. Service Commencement and Mobilisation 3. Service Termination 4. Service Requirements 5. Data Collection 6. Monitoring Requirements 7. Payment and Validation 8. Review 1 Background The Audiology KPI is an existing Kingston PMS KPI for some PMS Practices in Kingston. Kingston CCG has been undertaking a review of all existing PMS KPIs as part of the PMS review and roll out of the Kingston Medical Services local contract KPIs and concluded that this service should be retained and extended across all practices in the borough. The audiology KMS Service aims to increase the provision of services in primary care. This service provides basic screening audiograms to be carried out in the surgery. Screening audiograms would be performed with very short lead times for patients in the comfort of the surgery. It is particularly the value added element of the service, with analysis of the audiogram onsite that patients appreciate. The number of referrals to audiology and to ENT for hearing issues. This methodology is not appropriate for young children or for particular groups such as people with significant learning difficulties who will continue to require access to specialised audiology and tympanometry services. The Local KPI Task & Finish Group consider that primary care audiometry could reduce referrals to audiology by screening appropriate patients who think they have hearing loss but actually they do not or it is only mild. The WHO thresholds for hearing loss are: Normal hearing Mild hearing loss Moderate hearing loss up to 25dB 26 to 40 db 41 to 60 db

2 Severe hearing loss Profound hearing loss 61 to 80 db over 81 db For further info the website is useful. Primary Care audiometry could also indicate that the patient needs to go to ENT urgently because there is asymmetrical hearing loss or there are other criteria. 2. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April Where the Service is not already in place, there will be a period of service mobilisation between [DATE] and [DATE] to achieve the aims in During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 4. Service Requirements The practice is required to have the appropriate audiology equipment such as an Amplivox 116 screening audiometer to screen patients whose complaint is possible hearing loss. The appropriately trained clinician will take a history and examine the patient looking for any wax or obstruction in the ear canal, discharge or infection.

3 An appropriately trained clinician can perform the audiometry in a suitably quiet, preferably soundproofed room. The report is given to the GP who requested it for interpretation and management. Where an onward referral to secondary care is required this should be processed via the E-referral system wherever available services exist in the system. 5. Data Collection 5.1. The Commissioner will provide the Practice with a suitable template for the submission of the information specified in paragraph 6.0 below The Practice shall submit the completed template on a quarterly basis. 6. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.1 Number of patients presenting with a problem requiring audiology in the relevant quarter, 6.2 Number of screening audiograms carried out in the relevant quarter, 6.3 Average waiting time for receiving practice screening audiogram (from date of referral to date of audiogram) during the relevant quarter, 6.4 Number of relevant referrals to audiology in preceding year, 6.5 Number of referrals to audiology in relevant quarter, 6.6 Number of referrals to ENT following a practice screening audiogram during relevant quarter. Learning from the information gathered about non-attendance and examples of good practice will be shared by the Commissioner across Kingston practices and with Public Health. 7. Payment and Validation 8. Review a. The Commissioner will make a payment of 0.50 per weighted patient per annum in respect of this service. b. Any annual uplift to the price is at the complete discretion of the Commissioner. c. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme.

4 The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date].

5 Kingston CCG Kingston Medical Services - Service Specification KMS SS[Number]: GP Forward View High Impact Actions Kingston Clinical Commissioning Group (KCCG) aims to support practices deliver the ten high impact actions set out in the GP Forward View. To support this KCCG has established a local KPI that allows Kingston practices to identify and focus on (in agreement with KCCG) the key areas that would yield the maximum impact for the practice. This KPI requires that xxx practice identifies the improvement areas to be made, in the GPFV framework that will contribute to the delivery of the KCCG primary care strategy. Contents 1. Background 2. Service Commencement and Mobilisation 3. Service Termination 4. Service Requirements 5. Data Collection 6. Monitoring Requirements 7. Payment and Validation 8. Review 1. Background The Five year forward view was published by NHS England in October General Practice was found to be under stress and the GP Forward View was published by NHS England in April It was recognised that general practice needed support on investment, workforce, workload and infrastructure. Various initiatives were launched to increase funding and support for general practice. GPFV quoted a study undertaken in 2015 to identify the chief areas where reducing bureaucracy and reshaping demand could help practices in England. The results of the study are available at Description Time to Care was released on the basis of the study. It points to the fact that there is much GP practices can do themselves to help address their workload pressures. A Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 5 of 52

6 growing number of practices are already making use of these, but it is clear that many are not. Ten areas were identified where action can be taken to release capacity in GP practices. In each area, there are several specific changes which could be implemented to make a difference. In addition to helping the practice serve its patients better through releasing staff time, many of these innovations offer a direct improvement for the patient. The first nine actions are the what of releasing capacity the changes practices could make. The tenth is about the how. The ten High Impact areas are referred to in the following graphic and table. A major engagement process identified examples of practice implementation of each of these areas. Links to all the areas are contained in Annex A. Ten high impact actions to release capacity in general practice 2. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE] During the period of mobilisation the contractor is expected to take the necessary steps to ensure that:- Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 6 of 52

7 There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 4. Service Requirements Development stage Practices will select areas of interest from the 10 High Impact changes. If practices have implemented any of the changes already they can use the resource to improve services further. Where there is a stainability and Transformation Partnerships (STP) work stream this high impact area will not be available for selection by the practice. For each area identified the practice will produce a development plan according to the agreed plan in Annex 2 [this has yet to be developed]. 1) Describes the rationale for selecting the area or areas 2) Describes the service development that they are intending to introduce with the proposed impact it will have on the practice. 3) Describes how the implementation will be monitored During this period the practice will liaise with the CCG for support and to ensure that the development is appropriate. The CCG will discuss and agree the detail with the practice and offer advice on improving the definition and implementation of the service offered. Where an onward referral to secondary care is required for a patient this should be processed via the E-referral system wherever available services exist in the system Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 7 of 52

8 Implementation stage Where extra staff or infrastructure is required, the practice will have [3 months] to recruit or train staff or agree access to staff from other providers. Once implemented, the practice will proved the CCG with a regular report on deliver and/or progress and will agree to share its results with other practices. 5. Data Collection 5.1. The Practice will agree appropriate data with the CCG to monitor the service with as minimal interference with practice working as possible. Where possible, existing data should be used. Where a service flag Read Code is used, the practice will identify this, 5.2. Where more than one practice is delivering the same service, practices should work together to achieve consistency of reporting. 6. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.1. The Practice will develop an appropriate report to be agreed with the CCG to monitor the service during the development phase The Practice shall submit a regular quarterly report and an annual summary report thereafter and discuss with the CCG its progress. 7. Payment and Validation a. The Commissioner will make a total payment of 2.00 per weighted patient per annum in respect of this service. b. Any annual uplift to the price is at the complete discretion of the Commissioner. c. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. 8. Review The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 8 of 52

9 The Ten High Impact Actions at a glance Action Description Benefits for practice Benefits for patients 1 Active signposting Provide patients with a first point of contact which directs them to the most appropriate source of help. Web and appbased portals can provide self-help and self-management resources as well as signposting to the most appropriate professional. Receptionists acting as care navigators can ensure the patient are booked with the right person first time. Frees GP time. Makes more appropriate use of each team member's skills. Reduces internal referrals. 2 New consultation types Introduce new communication methods for some consultations, such as phone and . Where clinically appropriate, these can improve continuity and convenience for the patient, and reduce clinical time per contact. 3 Reduce DNAs Maximise the use of appointment slots and improve continuity by reducing DNAs. Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message, and making it quick for patients to cancel or rearrange an appointment. 4 Develop the team Consider broadening the workforce, to reduce demand for GP time and connect the patient more directly with the most appropriate professional. This may include training a senior nurse to provide a minor illness service, employing a community pharmacist or providing direct access to physiotherapy, counselling or welfare rights advice. Shorter appointments (e.g. phone consultation average 50% shorter, 66% dealt with entirely on phone). More opportunities to support selfcare with e-consultations, text message follow-ups and group consultations. Free GP time. Easier to avoid queues developing, through more accurate matching of capacity with demand. Frees GP time. Makes more appropriate use of each team member's skills. Reduces internal referrals. Improved job satisfaction for administrative staff undertaking enhanced roles. Improves appointment availability. Reduces low-value consultations and onward referrals. Shorter wait to get to see the most appropriate person. Greater convenience, often no longer requiring time off work/caring duties. Improves availability of appointments. More opportunities to build knowledge, skills and confidence for self-care. Improves appointment availability. Improves appointment availability. Reduces low-value consultations and onward referrals. Shorter wait to get to see the most appropriate person. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 9 of 52

10 Action Description Benefits for practice Benefits for patients 5 Productive work flows Introduce new ways of working which enable staff to work smarter, not just harder. These can reduce wasted time, reduce queues, ensure more problems are dealt with first time and that uncomplicated follow-ups are less reliant on GPs consultations. Frees time for staff throughout the practice. Reduces errors and rework. Improves appointment availability and patient experience. Improves appointment availability and customer service. 6 Personal productivity Staff is the most valuable resource in the NHS. We have a duty to nurture them as well as providing resources and training to ensure they are able to work in the most efficient way possible. This may include improving the environment, reducing waste in routine processes, streamlining information systems and enhancing skills such as reading and typing speed. 7 Partnership working For a number of years, practices have been exploring the benefits of working and collaborating at greater scale. This offers benefits in terms of improved organisational resilience and efficiency, and is essential for implementing many recent innovations in access and enhanced long-term conditions care. Increasing the scale of operations beyond the traditional small practice team requires considerable planning and leadership, as well as attention to the need to maintain the personal aspects of care which are the bedrock of effective primary care for many patients. 8 Use social prescribing Refer or signpost patients to services which increase wellbeing and independence. These are non-medical activities, advice, advocacy and support, and are often provided by voluntary and community sector organisations or local authorities. Examples include leisure and social community activities, befriending, carer respite, dementia support, housing, debt management and benefits advice, one to one specialist advocacy and support, employment support and sensory impairment services. Frees clinicians to do more in each consultation, with fewer distractions and frustrations. Improves staff wellbeing and job satisfaction. Frees GP time, makes best use of the specific expertise of staff in the practice. Creates economies of scale and opportunities for new services and organisational models. Frees GP time, makes best use of their specific medical expertise. Improved quality of consultations, with more achieved. Reduced absence of staff. Access to expanded range of services wrapped around the patient in the community. Reduces delays introduced by referrals to different providers. Improved quality of life. Improved ability to live an independent life. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 10 of 52

11 Action Description Benefits for practice Benefits for patients 9 Support self-care and Improved ability to live an management independent life. Take every opportunity to support people to play a greater role in their own health and care. This begins before the consultation, with methods of signposting patients to sources of information, advice and support in the community. Common examples include patient information websites, community pharmacies and patient support groups. For people with long-term conditions, this involves working in partnership to understand patients' mental and social needs as well as physical. Many patients will benefit from training in managing their condition, as well as connections to care and support services in the community. 10 Build QI expertise Develop a specialist team of facilitators to support service redesign and continuous quality improvement. Such a team will enable faster and more sustainable progress to be made on the other nine high impact changes. The team could be based in a CCG or federation. They should ideally include clinicians and managers, and have skills in leading change, using recognised improvement tools such as Lean, PDSA and SPC, and coaching GP practice teams. All of these will help practices to work smarter rather than harder, and to more rapidly introduce new ways of working. Frees GP time, makes best use of their specific medical expertise. Improved ability to achieve rapid, safe and sustainable improvements to any aspect of care. Increased staff morale and sense of control. Assurance of continuous improvement in patient safety, efficiency and quality of care. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 11 of 52

12 1. Active Signposting Provide patients with a first point of contact which directs them to the most appropriate source of help. Web and app-based portals can provide self-help and self-management resources as well as signposting to the most appropriate professional. Receptionists acting as care navigators can ensure the patient is booked with the right person first time. Introduction to 1 Active Signposting by Robert Varnam Fact sheet - 1 Active signposting by Robert Varnam Training for active signposting - what to look for? by Robert Varnam FAQs on active signposting by Robert Varnam Examples Reception care navigation: West Wakefield reception care navigation by Robert Varnam Online portal: Street Lane Practice patient online service by Robert Varnam 2. New Consultation Types Introduce new communication methods for some consultations, such as phone and . Where clinically appropriate, these can improve continuity and convenience for the patient, and reduce clinical time per contact. Introduction to 2 New consultation types by Robert Varnam Fact sheet - 2 New consultation types by Robert Varnam Online consultations - general information by Robert Varnam Examples Online consultations - general information by Robert Varnam Online Health Centre Cornwall by Patricia Dolor Increasing patient access with telephone surgeries by Frances Sheridan Online consultations at Unity Health, York by Robert Varnam Group consultations - first experience by Robert Varnam Text consultations for people with longterm conditions by Robert Varnam Group consultations: Group consultations for diabetes in Slough by Robert Varnam E-consultations: Online pre-consultation questionnaires, Haughton Thornley Medical Centres by Robert Varnam E-consultations: Online consultations at Docklands Medical Centre by Robert Varnam E-consultations: Online consultations, Rydal practice, N London by Robert Varnam Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 12 of 52

13 3. Reduce DNAs Maximise the use of appointment slots and improve continuity by reducing DNAs. Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message, and making it quick for patients to cancel or rearrange an appointment. Fact sheet - 3 Reduce DNAs by Robert Varnam Introduction to 3 Reduce DNAs by Robert Varnam 4. Develop the team Broaden the workforce, to reduce demand for GP time and connect the patient more directly with the most appropriate professional. This may include training a senior nurse to provide a minor illness service, employing a community pharmacist or providing direct access to physiotherapy, counselling or welfare rights advice. Introduction to 4 Develop the team by Robert Varnam Physician associates - an introduction by Robert Varnam The changing role of practice managers by Robert Varnam Practice pharmacists - what do they do? by Robert Varnam Physician associates in general practice - webinar by Robert Varnam Examples Direct access therapists: Physio First, West Wakefield by Robert Varnam Medical assistants: Clinical 'buddies', AT Medics, London by Robert Varnam Broadening the workforce - using direct access to physiotherapy as an alternative to seeing a GP by Jayne Beasley Paramedics: Practice based paramedics, S Kent Coast by Robert Varnam Practice pharmacists - guidance and specimen documents from Primary Care Pharmacy Association by Robert Varnam Medical assistants: Clerical staff processing letters, Wincanton Health Centre by Robert Varnam Medical assistants: Medical assistants processing letters, Brighton and Hove GP Access Fund by Robert Varnam 5. Productive work flows Introduce new ways of working which enable staff to work smarter, not just harder. These can reduce wasted time, reduce queues, ensure more problems are dealt with first time and that uncomplicated follow-ups are less reliant on GPs consultations. Fact sheet - 5 Productive work flows by Robert Varnam Introduction to 5 Productive work flows by Robert Varnam Examples Developing a practice reception team by Yesret Bi Improving medicines reconciliation in a GP practice by Frances Sheridan Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 13 of 52

14 Efficient processes - correspondence management, AT Medics by Robert Varnam Document management - rapid results by Robert Varnam Improving pathways by Yesret Bi Efficient processes - document management, Here (Brighton and Hove) by Robert Varnam Productive environment: Reoganised rooms, Sheffield by Robert Varnam Efficient processes: Improving repeat prescribing, W Cheshire by Robert Varnam Efficient processes: Script collection register, Bristol by Robert Varnam Efficient processes: Proactive medication reviews, The Robert Darbishire Practice by Robert Varnam 6. Personal productivity Support staff to develop their personal resilience, as well as specific skills to allow them to work in the most efficient way possible. This may include improving the environment, reducing waste in routine processes, streamlining information systems and enhancing skills such as reading and typing speed. Introduction to Personal productivity by Robert Varnam Topic Sheet - resilience by Robert Varnam Topic Sheet - touch typing and speed reading by Robert Varnam Topic Sheet - computer confidence by Robert Varnam 7. Partnership working Create partnershps and collaborations with other practices and other providers in the local health and social care system. This offers benefits in terms of improved organisational resilience and efficiency, and is essential for implementing many recent innovations in access and enhanced long term conditions care. Introduction to 7 Partnership working by Robert Varnam Fact sheet - 7 Partnership working by Robert Varnam Top tips for large-scale general practice by Anonymous Examples Improving access at scale, South Birmingham by Anonymous The productive federation, Haxby Group by Robert Varnam The productive federation, One Care by Robert Varnam Community pharmacy: Morecambe minor ailments service (GP Access Fund) by Robert Varnam Community pharmacy: GP records in community pharmacies, Brighton & Hove by Robert Varnam Community pharmacy: Extended pharmacy services in Devon by Robert Varnam The productive federation: South Cheshire & Vale Royal GPAF by Robert Varnam Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 14 of 52

15 8. Use social prescribing Use referral and signposting to non-medical services in the community which increase wellbeing and independence. Examples include leisure and social community activities, befriending, carer respite, dementia support, housing, debt management and benefits advice, one to one specialist advocacy and support, employment support and sensory impairment services. Introduction to 8 Use social prescribing by Robert Varnam Fact sheet - 8 Social prescribing by Robert Varnam Introduction to 8 Use social prescribing by Robert Varnam Fact sheet - 8 Social prescribing by Robert Varnam Videos introducing social prescribing by Robert Varnam Examples New Funding Opportunity for Social Prescribing by Anonymous Explaining social prescribing to patients by Robert Varnam Social prescribing at St Austell Healthcare - reducing demand and improving wellbeing by Anonymous Social prescribing at Thornton Medical Centre, Leeds by Robert Varnam Academic review of impact evidence for social prescribing by Robert Varnam External service: Rotherham social prescribing service by Robert Varnam External service: Ways to Wellness in Newcastle Gateshead CCG by Robert Varnam Practice based navigators: Primary Care Navigators for dementia, Oxford Terrace and Rawling Road Medical Group, Gateshead by Robert Varnam Practice based navigators: Practice Health Champions, Robin Lane Medical Centre, Leeds by Robert Varnam Practice based navigators: Cornwall Pathfinders project by Robert Varnam Practice based navigators: Shropshire community and care coordinators by Robert Varnam 9. Support self care and management Take every opportunity to support people to play a greater role in their own health and care. This begins before the consultation, with methods of signposting patients to sources of information, advice and support in the community. Common examples include patient information websites, community pharmacies and patient support groups. For people with longterm conditions, this involves working in partnership to understand patients' mental and social needs as well as physical. Many patients will benefit from training in managing their condition, as well as connections to care and support services in the community Re: Patient attitudes towards self care by Robert Varnam Text messaging for simple telehealth by Robert Varnam Self care - elearning from the RCGP by Robert Varnam Top tips for practices - from the Self Care Forum by Robert Varnam Examples Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 15 of 52

16 Longterm conditions: Roll-out of telehealth to long term conditions patients across Somerset by Robert Varnam Topic Sheet - patient online by Robert Varnam Prevention: Practice health champions, Oxford Terrace and Rawling Road Medical Group, Gateshead by Robert Varnam Introduction to 9 Support self care and management by Robert Varnam 10. Build QI expertise Develop a specialist team of facilitators to support service redesign and continuous quality improvement. Such a team will enable faster and more sustainable progress to be made on the other nine high impact changes. The team could be based in a CCG or federation. They should ideally include clinicians and managers, and have skills in leading change, using recognised improvement tools such as Lean, PDSA and SPC, and coaching GP practice teams. Introduction to 10 Build QI expertise by Robert Varnam What could QI offer my practice? by Robert Varnam Fact sheet - 10 Build QI expertise by Robert Varnam Examples Building capability for quality improvement across a GP federation by jenny drew Turnaround of a general practice in London by Yesret Bi The General Practice Improvement Leaders programme by Robert Varnam The RCGP quality improvement toolkit by Robert Varnam Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 16 of 52

17 Kingston CCG Kingston Medical Services - Service Specification KMS SS2: Mental Health & Early Intervention The aim is to increase the capacity of primary care to manage Mental Health need and improve outcomes for the local population Contents 9. Background 10. Service Commencement and Mobilisation 11. Service Termination 12. Service Requirements 13. Data Collection 14. Monitoring Requirements 15. Payment and Validation 16. Review 2 Background The Mental Health & Early Intervention KPI is an existing Kingston PMS KPI. Kingston CCG has been undertaking a review of all existing PMS KPIs as part of the PMS review and roll out of the Kingston Medical Services local contract KPIs. The Mental Health & Early Intervention PMS KPI has been reviewed as part of this process and is recommended for commissioning across Kingston practices. This means that this KPI has been revised and improved and offered to all Kingston practices. The aim is to provide enhanced support for adults with mental health (MH) issues in general practice and to reduce the number of avoidable referrals to secondary care. Kingston General Practice has not been in a position to offer this service to its population borough wide before. Kingston CCG will therefore want to learn from and adapt the Mental Health & Early Intervention service as needed. This will be done in collaboration with Kingston Practices providing the service. The four outcomes in this service focus on the following priority areas: 1. MH awareness training for GPs and their staff 2. Physical health checks on people with a Serious Mental Illness (SMI) 3. Perinatal MH 4. Dementia diagnosis Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 17 of 52

18 9. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE] During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1 This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below. 3.2 Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 11. Service Requirements 4.1. All GPs and their staff receive Mental Health awareness training The aim is for all appropriate members of the practice team have the knowledge and expertise to identify and manage patients with MH problems. All staff are to receive awareness training during the first year of this service and on a rolling 2-year programme thereafter and all new staff to receive training. Examples of appropriate training are included in Appendix 1 of this service. 4.2 Practices to achieve 90% of their patients on the QoF SMI register to have a NICE compliant physical health checks (PHCs) in the preceding year Practices, with support from the CCG, will be required to demonstrate they are working towards: Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 18 of 52

19 1. Increasing the percentage of SMI patient reviews as measured through QOF (Mental Health QOF indicators MH001 to MH010). The baseline will be practices prior year QOF achievement, a trajectory to achieve 90% is to be agreed with the CCG. 2. Undertaking NICE compliant PHCs within the practice. At least one clinician in the practice to attend training on implementing the Bradford PHC template within the practice (refer to Appendix 2 for further information about the template). The Bradford PHC template is readily available within the EMIS Library and instructions for accessing it are shown in Appendix Pregnant women and new mothers at their post-natal check: i. To routinely be offered information on self-referral to the Kingston icope Service including icope Online. ii. Presenting with mild to moderate depression and/or anxiety are referred, or given information on self-referral to the Kingston icope Service including icope Online. 4.4 Practices must engage with the CCG and make internal efforts to: i. Reach or remain at or above 66.7% of expected NHSE prevalence of patients diagnosed with dementia or; ii. Improve by 5% on the prevalence of patients diagnosed with dementia (compared to March 2017) (whichever is the lower) 12. Data Collection 5.1. The Commissioner will provide the Practice with a suitable template for the submission of the information specified in paragraph 6.0 below The Practice shall submit the completed template on a quarterly basis As far as possible, existing data will be used to monitor this service. 13. Monitoring Requirements Practices must submit the following information on a quarterly basis in accordance with paragraph 5.0 above: MH awareness training for GPs and their staff i. Number of clinical and non-clinical staff in receipt of training ii. Dates of training or intended training for new staff 5.1. Physical health checks on people with a Serious Mental Illness (SMI) Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 19 of 52

20 i. Increase percentage of patients checked as measured through QOF. Information will be obtained via QOF and compared to previous year performance to demonstrate improvements made. ii. Undertake NICE compliant PHCs within the practice. Evidence of attendance at the PHC training (planned for 24 th January 2018) will be obtained from attendance sheet circulated at the training Perinatal MH i. Numbers of pregnant women and new mothers attending a post-natal check during the quarter and number of those offered information on self-referral to Kingston icope ii. Numbers of pregnant women and new mothers presenting with mild to moderate depression and/or anxiety at their post-natal check during the quarter and number of those referred to icope or given information on selfreferral to the Kingston icope Service including icope Online Dementia diagnosis i. Practices must agree to engage with CCG personnel to improve dementia diagnosis, ii. Practices will be assessed against this indicator using April 2018 as a baseline, iii. KCCG will monitor practice achievement through centrally reported data. Learning from the information gathered about non-attendance and examples of good practice will be shared by the Commissioner across Kingston practices and with Public Health. 14. Payment and Validation d. The Commissioner will make a payment of 1.50 per weighted patient per annum in respect of this Service. e. Any annual uplift to the price is at the complete discretion of the Commissioner. f. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. 15. Review The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date] Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 20 of 52

21 Appendix 1 Training Courses 1. Adult Mental Health First Aid (MHFA) Courses organised by RBK Local Authority (contact linda.munslow@kingston.gov.uk to book) 2. MH based tutorials run at the bi-monthly Educational Event for GPs and Practice staff organised by Dr Phil Moore 3. Mental Health Awareness training via E-Learning: ELearning for Healthcare Website ( Registration on the courses is via the website Skills for Health Website - elearning-healthcare 4. Suicide Awareness Training organised by RBK Local Authority (Book via PHPS@Kingston.gov.uk) 5. In house training provided by the Primary Care MH Team, the Kingston icope Service or a GP that has undertaken the Diploma in Mental Health. Practices may arrange practice-based training from other organisations but should get agreement from the CCG beforehand that this will meet the KPI criteria. Any other relevant MH training options identified by the CCG will be notified to practices. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 21 of 52

22 Kingston CCG Kingston Medical Services - Service Specification KMS PS3: Paediatric Same Day Appointment The aim is to provide greater access to appointments and to reduce the number of avoidable attendances at A&E. Contents 17. Background 18. Service Commencement and Mobilisation 19. Service Termination 20. Service Requirements 21. Data Collection 22. Monitoring Requirements 23. Payment and Validation 24. Review 3 Background This KMS Service builds on learning from a previous paediatric pilot in Kingston that aimed to provide dedicated appointments slots for children to be seen by their own GP to enable more appropriate use of a GP rather than attending the A&E department. A Kingston audit of the pilot activity revealed that the majority of patients repeatedly using the A&E were from the more deprived parts of Kingston, and that many attendances were in the time 4-8pm. Up to 40% of these were prevented by providing children s clinic appointments. The aim of this KMS Service is to support delivery of the Paediatric QIPP which is part of the Urgent and Emergency Care QIPP. The aims are: 1) To reduce the attendance of children, young people and families at A&E for minor attendances (as coded by VB08Z, VB09Z and VB11Z). 2) By increasing their access to same day appointments in a children s clinic at their local practice. It is important to acknowledge that local GPs already respond promptly to presentations by younger children within their available opening hours. However, the highest attendances at A&E by children and young people do broadly correlate with when their GP surgery is closed or first thing in the morning and suggests this need for instant access to trusted health advice and medical care is currently being met through A&E. In order to reduce reliance on A&E and divert patients back to the appropriate setting of general practice, and meet the needs of children and young people presenting to A&E for minor presentations it is important that GPs provide dedicated appointments during peak times of demand (early morning and after when schools close and Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 22 of 52

23 parents return from work) to increase access and ensure parents chose these appointments over attending A&E. This KMS Service supports the early application of good clinical practice as well as proposing commissioning savings. 16. Service Commencement and Mobilisation 2.1 This Service shall commence on 1 st April There will be a period of service mobilisation between [Date] and [Date]. 2.2 During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1 This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below. 3.2 Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 18. Service Requirements A local pilot scheme indicated that dedicated appointments in the after school period for children aged under 11 years has the maximum benefit, resulting in a 40% reduction in A&E attendances. As a guide, we are recommending that: Up to 6,000 weighted list size: a minimum of 30 minutes per weekday day with at least 3 appointments a day 6-8,000 weighted list size: a minimum of 40 minutes per weekday with at least 4 appointments a day Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 23 of 52

24 8-10,000 weighted list size: a minimum of 50 minutes per weekday with at least 5 appointments a day Over 10,000 weighted list size: a minimum of 60 minutes per weekday with at least 6 appointments a day These appointments are to be designated children s clinic appointments, to be available after 4pm for children only, up to and including the age of 10 years old. Where these appointments are not filled by 3 pm they can be released for general use. The Contractor / Practice may work together with another / other practice(s) to deliver this service with the consent of the Commissioner. Where an onward referral to secondary care is required for a patient this should be processed via the E-referral system wherever available services exist in the system. 19. Data Collection 5.1 The Commissioner will provide the Practice with a suitable template suitable template for the submission of the information specified in paragraph 6.0 below. 5.2 The Practice shall submit the completed template on a quarterly basis subject to Where the Contractor is working with another practice / other practices in the delivery of this service in accordance with the Service Requirements above, the Commissioner and Contractor shall agree who responsible for submitting the data in accordance with 5.1 and 5.2 above and how the Monitoring Requirements specified in paragraph 6.0 below shall be reported to reflect the Contractors activity. 20. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.1 A declaration that the Practice / Contractor has met the requirements of this KMS services specification. 6.2 Practice must submit a quarterly report of the total number of appointments, the number taken up the number unfilled, and the number of DNAs 21. Payment and Validation g. The Commissioner will make a total payment of 1.00 per weighted patient per annum in respect of this Service. h. Any annual uplift to the price is at the complete discretion of the Commissioner. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 24 of 52

25 22. Review i. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 25 of 52

26 Kingston CCG Kingston Medical Services - Service Specification KMS [Number]: Practice Defined Scheme The aim is for the practice to develop its own scheme to address the needs of a patient group or groups with significant needs that would benefit from enhanced support and services. Contents 25. Background 26. Service Commencement and Mobilisation 27. Service Termination 28. Service Requirements 29. Data Collection 30. Monitoring Requirements 31. Payment and Validation 32. Review 1. Background The practice will identify a patient group(s) for whom delivery of targeted services would be beneficial. Throughout the development of Kingston Medical Services it has become clear that a one size fits all approach does not take into account the often unique needs of an individual practice population or the specialised expertise of its workforce. It is also recognised that there is significant pressure on practices from increased attendances by patients that might have a negative effect on recruitment and retention of staff that might be ameliorated by support for managing patients with significant needs. The aim of this Service is to be non-prescriptive to encourage practices to identify the specific needs of their practice population. This might include some value added services that might already be in place. Practices will be expected to identify areas of significant need and arrange services to meet them. Details of services and outcomes are to be shared with CCG and with other practices to encourage evidence based innovation and wider adoption of good practice. Practices may choose to develop shared staff. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 26 of 52

27 Practice may wish to consult with Public Health colleagues and the primary care development team to identify groups and services. Where appropriate they might wish to discuss with other providers. Practices might wish to develop and pilot a new enhanced service for a particular group or groups or implement an existing scheme. 2. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE] During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 4. Service Requirements Development stage The practice will identify a particular group or groups and create a new service or services, define its extended services or implement an existing scheme from elsewhere. For each group identified the practice will produce a report that: Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 27 of 52

28 4) Describes the rationale for including the group 5) Describes the particular needs of the group 6) Describes the service development that meets the particular needs 7) Describes how the service will be monitored using appropriate data. During this period the practice will liaise with the CCG for support and to ensure that the development is appropriate. The CCG will discuss and agree the detail with the practice and offer advice on improving the definition and implementation of the service offered. Where an onward referral to secondary care is required this should be processed via the E-referral system wherever available services exist in the system. Implementation stage Where services are already in place, the practice will ensure monitoring is achieved. Where extra staff or infrastructure is required, the practice will have [3 months] to recruit or train staff or agree access to staff from other providers. Once implemented, the practice will proved the CCG with a regular report on deliver and/or progress and will agree to share its results with other practices. 5. Data Collection 5.1. The Practice will agree appropriate data with the CCG to monitor the service with as minimal interference with practice working as possible. Where possible, existing data should be used. Where a service flag Read Code is used, the practice will identify this Where more than one practice is delivering the same service, practices should work together to achieve consistency of reporting. 6. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.3. The Practice will develop an appropriate report to be agreed with the CCG to monitor the service during the development phase The Practice shall submit a regular quarterly report and an annual summary report thereafter and discuss with the CCG its progress. 7. Payment and Validation j. The Commissioner will make a total payment of 3.50 per weighted patient per annum in respect of this service. k. Any annual uplift to the price is at the complete discretion of the Commissioner. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 28 of 52

29 8. Review l. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 29 of 52

30 Appendix 1 - Examples of patient groups with extra needs Vulnerable groups Vulnerable groups would include: Refugees Asylum Seekers Travellers Non English Speakers People from Black & Minority Ethnic Groups People with limited or no literacy People with communication barriers caused by illness, eg stroke Homeless people (including those in temporary forms of accommodation) People who face Domestic Violence People who experience Hate Crime People with poor mental health Carers Migrants Lesbian Gay Bisexual Transgender people People with sensory impairment Examples of developments might include: 1. Training for staff on a range of issues covering the above groups. Practices to identify 3 main changes annually they can implement to improve outcomes for vulnerable groups. 2. Practices able to demonstrate flexibility of approach in registration of patients and treatment of patients to ensure disadvantaged groups are able to access services. 3. Increased referral of disadvantaged groups to support services, e.g. Education or Learning opportunities, Council services, Children s Centres, Employment Support, Housing support, Advice organisations, Mental Health organisations, and others in public and voluntary sectors. 4. Good practice in Interpreting and Translation, e.g. demonstrate that you have systems and processes that offer a patient a choice of being given an interpreter by surgery, instead of using family and friends, if that is what the patient wishes. 5. Produce a practice register of vulnerable patients, which is updated using READ codes. By producing a register the practice will identify those that are vulnerable, and can take appropriate measures to improve health outcomes for these patients. The register will also identify those practices that have a large percentage of vulnerable patients, which will subsequently reflect the issues and workload the practice will face to improve health outcomes for these larger percentages of vulnerable patients. This will require increased workload and cost to these practices, and this increased workload will be reflected in this PKPI. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 30 of 52

31 Hard to reach groups The housebound or in nursing homes Example: The practice might introduce an enhanced follow up or monitoring scheme for patients who are housebound. This might include for instance providing extra nurse visiting, GP follow up for patients who require regular visits from Rapid Response who have not been seen by a practice member for some time Example: The practice might provide a regular visit to the nursing home Example: The practice might work with others to employ a health visitor or practice nurse to make half yearly or annual visits to the housebound. They might work with community providers to achieve this. People in hostels such as the YMCA Example: The practice might offer enhanced visiting or a lead member of staff with Homeless people Example: the practice might agree to be named as the lead practice for homeless people and provide signposting services Groups with extra needs. For example: Over 50% of patents in BAME categories Where a practice has a significant above average percentage of patients identified as in the BAME groups, it might wish to demonstrate how it meets the needs of that population. Significant numbers of people with learning disabilities in community developments Where a practice has significant numbers of people in community developments with learning difficulties it might wish to identify a lead to ensure their needs are met and ensure higher than average meeting of targets in Asylum seekers and Refugees The practice might agree to become the local lead for asylum seekers and refugees and develop expertise and signposting skills for instance by working with refugee charity(ies) Areas with higher than the Kingston average of deprivation Practices covering the areas of higher deprivation might wish to target services at residents that might improve their health such as increased proactive CHD checks, encouragement to breastfeed and/or to attend antenatal services by providing extra services Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 31 of 52

32 Practices with significant numbers of patients with above average needs for example Multiple long term conditions An example of this might be the increased population with multiple long term conditions identified in Chessington An example of a service might be targeted extra LTC trained nursing students Vulnerable, in need or at risk Children Where a practice has high numbers of children in need or at risk, an example might be an enhanced role for a particular member of staff in ensuring that registers are kept up to date and that reports are completed comprehensively and in a timely fashion Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 32 of 52

33 Kingston CCG Kingston Medical Services - Service Specification KMS SS[NUMBER]: Referral Management Contents 33. Background 34. Service Commencement and Mobilisation 35. Service Termination 36. Service Requirements 37. Data Collection 38. Monitoring Requirements 39. Payment and Validation 40. Review 4 Background This KMS Service aims to provide a robust structure to support appropriate outpatient referrals. The service will: 1. Support practice referral processes. 2. Provide GPs with information and tools which support informed referral decision making. 3. Provide a standardised, sustainable approach utilising local knowledge and best practice. 4. Provide practices and GPs with dedicated time to understand their referral trends and challenges, which in turn will inform the CCG of where to offer support. 5. Provide robust reporting to measure success and demonstrate progress. 6. supporting practice referral processes. 7. Provide GPs with information and tools which support informed referral decision making. 23. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE] During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 33 of 52

34 of activity and full training on using the E-referral system support for this offered via the CG referral support team. All referrals to consultant lead acute services are processed via the NHS E- referral system. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 25. Service Requirements Kingston Practices will be commissioned to complete the following actions and tasks: 4.1 Internal practice referral review process this will allow practices the opportunity to review and streamline in house referral processes. Practices will receive support from a dedicated referral support team. 4.2 In-house management of e-referral process - As part of this practices should review their E-referral utilisation with a view to achieving 100% for referral to consultant lead acute services by October 2018 in line with the NHS standard contract. The commissioner will offer support tools such as DXS and Kinesis to aid with referral processes. 4.3 GP Lead and monthly tasks - Every practice should have a referral lead and ensure a paid session each month (3.5 hrs) is available for the GP to participate in a monthly referral management related task which will be guided by the commissioner. 4.4 Peer review - To build on the peer review process already in place by focussing content to provide in-depth information around specific, identified issues. 4.5 Work to achieve an agreed referral management target - Each practice will be given a target for 2018/19. This will be tracked through the year. A process will Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 34 of 52

35 be put in place for any practices not meeting their target to discuss issues/support achievement of their target 26. Data Collection 5.1. The Commissioner will provide the Practice with suitable templates for the submission of the information specified in paragraph 6.0 below The Practice shall submit the completed template monthly subject to The Practice shall submit the peer review template quarterly subject to Where the Contractor is working with another practice / other practices in the delivery of this service in accordance with the Service Requirements above, the Commissioner and Contractor shall agree who is responsible for submitting the data in accordance with 5.1 and 5.2 above and how the Monitoring Requirements specified in paragraph 6.0 below shall be reported to reflect the Contractors activity. 27. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.1. A declaration that the Practice / Contractor has met the requirements of this KMS services specification, 6.2. Completion of the monthly submission form provided by the commissioner. This form includes a review of the monthly SUS data, and the outcome of the monthly task, 6.3. Completion of the quarterly peer review, 6.4. Completion of an End of Scheme form provided by the commissioner. 28. Payment and Validation 29. Review m. The Commissioner will make a total payment of 3.50 per weighted patient per annum in respect of this service. n. Any annual uplift to the price is at the complete discretion of the Commissioner. o. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 35 of 52

36 The aim is to improve Contents Kingston CCG Kingston Medical Services - Service Specification KMS SS[NUMBER]: Risk Stratification 41. Background 42. Service Commencement and Mobilisation 43. Service Termination 44. Service Requirements 45. Data Collection 46. Monitoring Requirements 47. Payment and Validation 48. Review 5 Background This KPI aims to provide a structure for practices to identify patients with high unplanned use of services (2 or more unplanned admissions in the last 12 months) and patients with very complex needs. The KPI focus is to ensure there is a workable care plan in place that has been reviewed and kept up to date. This KPI is also a key link and enabler to the Kingston Co-ordinated Care (KCC) project. The service will: Continue to identify and support patients at high risk of emergency admission; Support the management of a clear and useable tailor made care plan for patients at high risk of admission and ensure that these are shared, where appropriate, with the KCC Multi-Disciplinary Team; Improve the patients experience and outcomes and ensure their needs where appropriate are supported by the MDT; Reduce A&E attendances (supports delivery of the Top 500 A&E Attendance LCS); Provide evidence that the use of the risk stratification tool in this way actively reduces unplanned emergency admissions and avoidable attendances at A&E; Provide sustainable investment; Improve local understanding of needs and requirements. 30. Service Commencement and Mobilisation 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 36 of 52

37 2.2. During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 32. Service Requirements Kingston Practices will be commissioned to complete the following actions and tasks: 4.1 To run the Risk Stratification search which identifies patients who have had two or more unplanned emergency admissions in the last 12 months. It should also be noted that as some patients did not agree to data sharing, these patients will not appear in the risk stratification search and practices should consider which of these patients would benefit from inclusion in the KPI and add them to their list of care plans to review; 4.2 The GP reviews any care plan in place (or if appropriate creates a care plan). 4.3 Care plan to be given to the patient in a yellow folder, so it s easy to locate when the patient is visited by (medical) professionals in their home. Practices will be asked to purchase these and will be reimbursed by the CCG. A specific code and description will be circulated prior to the start of the KPI; 4.4 At a mid-way point in the KPI, practices will run 2 further risk stratification searches to: o September 2018: Rerun the risk stratification search and review all new patients identified in this second search. Provide the number of new Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 37 of 52

38 patients identified and the number of patients that have left the list from the April 2018 to October searches. o December 2018: Run an EMIS search for the list of patients who were tagged with the EMIS code EMISNQHI19 at the start of the KPI. For those that have had an unplanned emergency admission since the care plan was reviewed/finalised, note down the reason for the admission. 4.5 Completing a feedback form at the end of the year summarising findings. This will include noting whether patients included in the KPI have changed RUB (Resource Utilisation Banding) as a result of fewer unplanned emergency admissions. Patients are categorised as low, medium, high and very high depending on their past 12 month s activity. The outcome of this KPI is that a working care plan will be in place, and that, where appropriate, through the KCC MDT process, the patient would be referred to other (appropriate) services and/or their care be co-ordinated as part of the KCC programme. Where an onward referral to secondary care is required for a patient this should be processed via the E-referral system wherever available services exist in the system. 33. Data Collection 5.1. The Commissioner will provide the Practice with suitable templates for the submission of the information specified in paragraph 6.0 below, 5.2. The Practice shall submit the completed template monthly subject to 5.4, 5.3. The Practice shall submit the peer review template quarterly subject to 5.4, 5.4. Where the Contractor is working with another practice / other practices in the delivery of this service in accordance with the Service Requirements above, the Commissioner and Contractor shall agree who is responsible for submitting the data in accordance with 5.1 and 5.2 above and how the Monitoring Requirements specified in paragraph 6.0 below shall be reported to reflect the Contractors activity. 34. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: 6.1. A declaration that the Practice / Contractor has met the requirements of this KMS services specification, 6.2. Completion of the additional searches in September 2018 and December 2018, Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 38 of 52

39 6.3. Completion of an End of Scheme form provided by the commissioner. 35. Payment and Validation 36. Review p. The Commissioner will make a total payment of 3.50 per weighted patient per annum in respect of this service. q. Any annual uplift to the price is at the complete discretion of the Commissioner. r. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 39 of 52

40 Kingston CCG Kingston Medical Services - Service Specification KMS SS[Number]: Respiratory KPI The aim is to focus capacity in primary care to support patients with asthma who struggle to manage their condition as well as those who have had an exacerbation, or who have had community acquired pneumonia, and patients who have high or inappropriate medication usage. Contents 49. Background 50. Service Commencement and Mobilisation 51. Service Termination 52. Service Requirements 53. Data Collection 54. Monitoring Requirements 55. Payment and Validation 56. Review 6 Background There are 24,230 patients identified as having persistent asthma, of those 7,396 have had an urgent care appointment. 30% of these patients who attend A&E for a respiratory complaint re-attend within 30 days. Increasing the ability of these patients to better manage their condition themselves could reduce exacerbation rates and urgent care activity. This is a small cohort of patients (adults and children) who are either not yet on optimal treatment, are non-compliant with more severe asthma, or who have difficult to manage asthma. The respiratory KPI aims to support these patients in developing better management of their condition through increasing the provision of services in primary care. The intention for all KPIs offered through the Kingston Medical Services is that all patients in Kingston should be able to access all services, regardless of whether the practice they are registered with provides that service or not. Kingston CCG will therefore be looking to develop a process for referring patients between practices or networks of practices for all local KPIs. Staff will be appropriately trained and have access to the relevant information. 37. Service Commencement and Mobilisation Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 40 of 52

41 2.1. This Service shall commence on 1 st April There will be a period of service mobilisation between [DATE] and [DATE] During the period of mobilisation the contractor is expected to take the necessary steps to ensure that: There are a sufficient number of suitably trained staff to enable service commencement on 1 st April Training should include the correct coding of activity. Any systems necessary for delivery of the service are in place for 1 st April Any systems necessary for data collection required by the Commissioner under this specification are in place for 1 st April Any necessary advanced communications with patients and other interested parties, should be undertaken ready for service commencement on 1 st April Service Termination 3.1. This Service shall terminate on [Date] unless an alternative date is mutually agreed between the Commissioner and the Contractor or unless the Commissioner serves notice that this Service shall terminate early in accordance with paragraph 3.2 below Whether this Service terminates on [Date] or on any other date the Commissioner must serve 6 months notice of Termination (unless an alternative period of notice is mutually agreed between the Contactor and the Commissioner). 39. Service Requirements This KPI covers 4 areas (areas 1 3 refer to both adults and children) with emphasis on the respiratory pathway for patients with asthma or lower respiratory tract infections. Patients with a dual diagnosis of asthma and COPD are excluded from this KPI and should be managed as per the COPD LCS. Ideally very few patients should have such a dual diagnosis Patients who have attended A&E or have had a hospital admission for Asthma or CAP: All patients, who have attended A&E with an exacerbation of Asthma or Community Acquired Pneumonia, should be reviewed within 72 hours of their discharge. Asthma patients who have had more than 2 courses of oral steroids in the previous year are to be referred to an asthma specialist within secondary care, active referrals have been shown to reduce A&E attendances Asthma annual reviews and medication usage Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 41 of 52

42 All patients on 1000mg beclomethasone equivalent per day should be given a steroid card (provided in the asthma prescribing guidelines), a letter is attached that can be given to patients with the card. All patients who have ordered 12 or more salbutamol or other reliever inhalers in the last 12 months should be called in for review of their asthma. This could be addressed at their annual review, but if they don t attend their annual review, they should receive further communications (letter, or SMS) inviting them for their review. Patients who don t attend their annual review should receive at least 3 communications (letter, or SMS) to attend during the year. At least one of these communications should be by post highlighting the dangers of poorly controlled asthma and include the information leaflet. 9OJ7 Asthma monitor verbal invite 9OJ4 Asthma monitor first letter 9OJ6 Asthma monitor third letter 9OJC Asthma monitoring invitation 9OJ8 Asthma monitor phone invite 9OJ5 Asthma monitor second letter 9OJB Asthma monitoring invite SMS 4.3. Standardised care plans Asthma UK Care Plan are to be the standard care plan used; using the KCR this will allow pharmacists to engage patients to review their inhaler technique. All patients able to understand how to use Peak Flow Meters, and all children able to use them under supervision, should receive a Peak Flow Meter (Standard EU) if they do not already have one. Their care plan should indicate their personal best Peak Flow and parameters of Peak Flow readings which they should use to determine how best to manage any deteriorations in their Asthma control Community Acquired Pneumonia (CAP): All patients who attend A&E and had a CRB65 score of 1 should have a follow up appointment (telephone or face to face) with a GP or Practice Nurse within 72 hours of discharge. If a CRB 65 score 1 is recorded but no diagnosis is recorded, the patient should still be offered an appointment (telephone of face to face). For the diagnosis of asthma, all persons aged 10 years or over need to have this verified via spirometry, those aged between 5 10 years will require a 2 week serial peak flow diary available at Patient UK. Where an onward referral to secondary care is required for a patient this should be processed via the E-referral system wherever available services exist in the system. 40. Data Collection 5.1. The Commissioner will provide the Practice with a suitable template for the submission of the information specified in paragraph 6.0 below The Practice shall submit the completed template on a quarterly basis. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 42 of 52

43 41. Monitoring Requirements Practices must submit the following information in accordance with paragraph 5.0 above: Description of outcome Percentage of patients who have attended A&E or have had a hospital admission for Asthma or Community Acquired Pneumonia have follow up contact by their practice to be made within 72 hours of their discharge. Data source Contractor s EMIS data and secondary care SUS data Reporting Frequency Quarterly Numerator No. of patients who have had a contact attempt made by the practice within 72 hours Denominator No. of patients who have attended A&E or had an admission with an asthma or community acquired pneumonia complaint Description of outcome Percentage of asthma patients who have had more than 2 courses of oral steroids in the previous year who have been referred to an asthma specialist within secondary care. Data source Contractor s EMIS data Reporting Frequency Quarterly Numerator No. of asthma patients who have had 2 courses of oral steroids and been referred to a secondary care specialist Denominator No. of asthma patients who have had 2 courses of oral steroids Description of outcome Percentage of patients on 1000mg beclomethasone equivalent per day given a steroid card Data source Contractor s EMIS data Reporting Frequency Quarterly Numerator No. of patients on 1000mg Denominator No. of patients on 1000mg Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 43 of 52

44 beclomethasone equivalent per day given a steroid card beclomethasone equivalent per day Description of outcome Percentage of patients who have ordered 12 or more salbutamol or other reliever inhalers in the last 12 months have been called in for review of their asthma. Data source Contractor s EMIS data Reporting Frequency Quarterly Numerator No. of patients who have ordered 12 or more salbutamol or other reliever inhalers in the last 12 months with 4 attempts of contact made. Denominator No. of patients who have ordered 12 or more salbutamol or other reliever inhalers in the last 12 months Description of outcome Percentage of patients who haven t attend their annual review should receive at least 3 communications Data source Contractor s EMIS data Reporting Frequency Quarterly Numerator No. of patients who haven t attended their annual review should have 3 attempts at communication made Denominator No. of patients who haven t attended their annual review 42. Payment and Validation s. The Commissioner will make a total payment of 1.50 per weighted patient per annum in respect of this Service. t. Any annual uplift to the price is at the complete discretion of the Commissioner. u. The Commissioner reserves the right to appropriately validate any submission made by the Contractor under this scheme. 43. Review Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 44 of 52

45 The Commissioner shall have undertaken a review of the need for this Service and advised the Contractor accordingly no later than [Date]. Kingston Medical Services - Service Specification Kingston KMS - [Number]: GPFV - Page 45 of 52

46 RECOMMENDED PRODUCTS GUIDANCE STEP REFER TO RESPIRATORY SPECIALIST SERVICE High-dose ICS can be started in primary care but patient must be referred for specialist review. KINGSTON JOINT GUIDELINES FOR THE MANAGEMENT OF ASTHMA IN ADULTS NOT controlled ALL PATIENTS SHOULD HAVE A WRITTEN ASTHMA ACTION PLAN STEP DOWN in STABLE patients Step 1 Mild asthma Salbutamol (Short-acting β 2 agonist, SABA) Review patients prescribed more than 12 SABA inhalers in 12- month period, Salbutamol 100 micrograms 1-2 puffs PRN: Salbutamol MDI (via Aerochamber Plus if needed) OR Easyhaler Salbutamol OR Salamol Easi- Breathe IF salbutamol not tolerated, consider giving Terbutaline: Bricanyl Turbohaler 1 puff PRN max QDS Consider Step Up if: SABA > twice weekly Night-time symptoms once a week Asthma attack in the last 2 years Step 2 Add regular inhaled corticosteroid (ICS) Appropriate starting dose 400 micrograms beclometasone dipropionate (BDP) or equivalent/day. CLENIL MODULITE MDI Beclometasone 100 micrograms 2 puffs BD via Volumatic spacer EASYHALER BECLOMETASONE 200 microgram 1 puff BD Step 3 Add long-acting β 2 agonist (LABA) to ICS as COMBINED inhaler Step 3 (a) GOOD RESPONSE TO LABA? Continue. Prescribe COMBINATION inhaler. FOSTAIR extra-fine Beclometasone/Formoterol 100/6 micrograms MDI (via Aerochamber Plus ) or Nexthaler 1 puff BD DUORESP SPIROMAX Budesonide/Formoterol 160/4.5 micrograms 1 puff BD Existing patients only: Seretide Evohaler Fluticasone/Salmeterol 50/25 micrograms MDI 2puffs BD or Seretide Accuhaler 100/50 micrograms 1 puff BD Step 3 (b) SOME RESPONSE TO LABA BUT INADEQUATE CONTROL? Continue LABA Increase ICS dose to 800 micrograms BDP or equivalent/day DUORESP SPIROMAX Budesonide/Formoterol 160/4.5 micrograms 2 puff BD OR 320/9 1 puff BD FOSTAIR extra-fine Beclometasone/Formoterol 200/6 micrograms MDI (via Aerochamber Plus ) or Nexthaler 1 puff BD Step 3 (c) NO RESPONSE to LABA? Stop LABA Increase ICS dose to 800 micrograms BDP or equivalent/day CLENIL MODULITE MDI Beclometasone 200 micrograms 2 puffs BD via Volumatic spacer EASYHALER BECLOMETASONE 200 micrograms 2 puffs BD ON RESPIRATORY SPECIALIST ADVICE ONLY QVAR Easi-breathe 100 micrograms 2 puffs BD Step 4 High-dose ICS ( 1000 micrograms daily*) with regular LABA Consider increasing ICS up to 2,000 micrograms BDP or equivalent/day. Consider trial of: Leukotriene receptor antagonist Montelukast 10mg OD Theophylline modified-release (Uniphyllin ) 200mg-400mg BD Tiotropium (Spiriva Respimat ) 2.5micrograms 2puffs OD Review and stop if inadequate response. Step 5 Add continuous or frequent use of oral steroids Continue High-Dose ICS 2000 micrograms BDP or equivalent daily. Add oral PREDNISOLONE at lowest possible daily dose. ENSURE ALL OTHER THERAPIES ARE OPTIMISED BEFORE STARTING ORAL PREDNISOLONE ALL PATIENTS AT STEP 4 and STEP 5 MUST BE REVIEWED BY A RESPIRATORY SPECIALIST (NRAD REPORT 2014) ALL PATIENTS ON HIGH-DOSE INHALED STEROIDS MUST BE GIVEN AN INHALED CORTICOSTEROID CARD, see page 2 ICS BDP MICROGRAMS EQUIVALENT/DAY: FOSTAIR extra-fine Beclometasone/Formoterol 200/6 MDI via Aerochamber Plus or NEXTHALER 1 puff BD DUORESP SPIROMAX Budesonide/Formoterol 320/9 micrograms 2 puff BD Existing patients only: Sirdupla MDI Fluticasone/Salmeterol MDI 125/25 micrograms 2 puffs BD or Seretide Accuhaler 250/50 micrograms 1 puff BD ICS BDP 2000 MICROGRAMS EQUIVALENT/DAY: FOSTAIR extra-fine Beclometasone/Formoterol 200/6 micrograms MDI via Aerochamber Plus or NEXTHALER 2 puffs BD FLUTIFORM Fluticasone/Formoterol 250/10 micrograms MDI (via Aerochamber Plus ) 2 puffs BD Existing patients only: Sirdupla MDI Fluticasone/Salmeterol 250/25 micrograms 2 puffs BD or Seretide Accuhaler 500/50 micrograms 1 puff BD SMOKING CESSATION: Treatment of tobacco dependence is an important clinical intervention in patients with asthma. Ask about smoking at every opportunity. Refer to NHS Kingston Stop Smoking Service Kick It Stop Smoking Service click for the website or call INHALER TECHNIQUE: Regularly ask patients to demonstrate inhaler technique. Use In-Check device to confirm correct inspiratory flow for inhaler device. Establish adherence BEFORE stepping up treatment. ASTHMA ACTION PLAN: All patients should have a written self-management plan and when indicated, an inhaled corticosteroid (ICS) card, see page 2. *Note: Sirdupla is an MDI generic equivalent for Seretide Evohaler. If appropriate, patients on Seretide Evohaler should be considered for a change to Sirdupla, with patient consultation and agreement.

47 RESPONSIBLE RESPIRATORY PRESCRIBING ADVICE All patients should have a written asthma management action plan: this should be reviewed and updated yearly or more frequently if needed. Available from Asthma UK, click here. (BTS guideline, NRAD report 2014). Prescribe LABA and ICS inhalers by brand to avoid confusion and ensure patients get the correct inhaler device. Regularly ask patients to demonstrate inhaler technique. Use In-Check device to confirm correct inspiratory flow for inhaler device. Inhaler devices should be changed only after consultation with patients to promote adherence and ensure inhaler technique is correct. Patients who are prescribed more than 12 SABA inhalers in 12 months must be invited for a review. (NRAD report 2014). Inhaled corticosteroid cards should be given to all patients using ICS 1000 micrograms beclometasone dipropionate or equivalent. Contact the Kingston Hospital Pharmacy Team or Kingston CCG Medicines Optimisation Team for advice on how to order, or order directly through here. STEPPING UP Check adherence to therapy Check inhaler technique Encourage smoking cessation where appropriate. STEPPING DOWN Consider when a patient has been stable for at least 3 months Review patients regularly with respect to: Severity of asthma Side effects of treatment Time on current dose Beneficial effect achieved Patients preference Maintain patient at lowest possible dose of ICS. For patients not already on the lowest appropriate ICS dose, reduction in ICS dose should be considered every 3 months, decreasing the dose by approximately 25-50% each time INHALER TECHNIQUE - TIPS FOR ALL INHALER TYPES Prepare inhaler as per patient leaflet guide Breathe out before use inhaler Ensure lips are sealed around inhaler Breathe in according to inhaler device see below Hold breathe for 5-10 seconds immediately after activating inhaler Breathe out through the nose Inhaler and spacer technique video guides available on Asthma UK Website INHALER TYPES Aerosols Breathe in Slow and Steady INHALER TYPES Dry powder Breathe in Quick and Deep MDI RESPIMAT EASI-BREATHE EASYHALER NEXTHALER SPIROMAX