MEETING OF THE GOVERNING BODY

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1 MEETING OF THE GOVERNING BODY Agenda Item: 9 Date: 5 February 2014 Subject: Report of: Summary: Enhanced Services Chief Operating Officer Following national guidance all former local enhanced services that BCCG have responsibility for were rolled over on the existing agreements for 2013/14 pending re-procurement. During this period CCG s were asked to review all existing enhanced services and decide what services they wished to commission from April The attached papers set out the former Enhanced Services that have undergone the above process, the recommended procurement option, the variation from procurement advice where relevant and the rationale for this. RECOMMENDATION(S): The Governing Body are asked to review the attached paper and approve the recommendations by the respective Locality for the service detailed. CORPORATE IMPLICATIONS: BCCG Priorities: These services support the delivery of Bedfordshire Plan for Patients in providing accessible high quality services based on local need. IMPACT ASSESSMENTS Equalities/Human Rights: There are direct impacts on the other seven protected characteristics as set out in Equality Act However the services have a significant proportion of patients aged 65 years and over and the schemes are aimed at ensuring these patients are not disadvantaged in receiving accessible care. Services will potentially contribute to reducing health inequalities as evidence suggests that people with multiple long-term conditions tend to get poorer treatment than others. The Homeless service proposal targets patients often excluded from accessing services and contributes directly to reducing health inequalities.

2 NHS Constitution: The Homeless service directly supports the right to access NHS services. Financial: Funding stream for these services already existed and therefore no extra costs are being incurred by the organisation. The full business cases detail cost effective services which have been assured by the Clinical Investment Assurance Group chaired by the Director of Finance. In addition to this process, business cases were approved at the BCCG Executive Meeting on 16 th January Legal: No direct impact applicable to this paper Risk Management: Risks resulting from potential service cessation have been assessed including patient experience, access and reputational damage. Sustainability: No direct impact applicable to this paper Procurement: The tender routes, which the business case, the Executive team and this paper recommends are not in a number of cases consistent with procurement advice and the paper sets out the rationale for this. Conflict of Interest: CCG GP officers have been excluded from the decision making at Executive and the Governing Body. GPs from neighbouring CCGs have been invited to the Governing body to provide non-conflicted clinical input to the decisions. Executive Summary In October 2013 the Governing Body approved the process for approving how the former Local Enhanced Services would be commissioned from 2014/15 and for robustly managing the potential conflicts of interest associated with this. National Guidance Guidance from NHS England on the legal framework for procuring new services was published in April 2013 (Primary medical care functions delegated to clinical commissioning groups). Key points from that Guidance were: CCGs may commission any services that meet the needs of their population, including primary care services beyond the scope of the GP contract.

3 CCGs should follow guidance on managing conflicts of interest which includes when GP practices may be potential providers of services. Enhanced Services must use the NHS Standard Contract; they are not technically local enhanced services (i.e. services commissioned as adjuncts to the GP contract). Where there are a number of potential providers, CCGs need to decide whether to undertake a competitive procurement or to allow a range of providers by using the Any Qualified Provider (AQP) route. CCGs can award contracts without a competitive process if they are satisfied that there is only one provider capable of providing those services. Services for which there are no other possible providers, for instance because they require list-based primary medical care, CCGs will be able to commission services through single tender from GP practices. CCGs must consider each commissioning decision on the facts and justify/record their decisions accordingly. The process for determining the procurement route is;

4 Local Process It was agreed that localities are best placed to identify the needs of their patients, and the priority services to be commissioned with these available resources. However, the member practices within localities inevitably have a conflict of interest, as decisions about these budgets will have a direct impact on their income. It was therefore proposed that the following process was followed, enabling localities to prioritise the use of these resources, but with scrutiny and sign-off of these local decisions by the Governing Body (as per NHS England s guidance, Managing conflicts of interests: Guidance for clinical commissioning groups). 1. Business Cases for the successor schemes will be produced and taken to Commissioning Investment Assurance Group (CIAG) as per standard process. 2. The cases will include a recommended procurement route and this will include the advice from BCCG procurement advisors (Central and Eastern Commissioning Support Unit) 3. The Governing Body will approve, at a meeting in public, either the award of a contract following tender (if this is to a local GP practice or local GP provider company) or the use of single tender to a practice, with assurance of the reasons for this. As previously confirmed conflicted GPs on the Governing Body will absent themselves from this discussion and the CCG will seek additional representation from a neighbouring CCG to allow the decision to be made. To note, that representation is in the form of:- a. Dr Sahadev Swain, Luton CCG b. Dr Nicola Smith, Milton Keynes CCG For all practice based services this means that practices will be issued with a standard NHS contract containing a service specification for each service commissioned. This will allow the CCG to legally contract for these services post 1 st April 2014 but also allows notice to be served where a procurement exercise needs to be undertaken. The contract will be for three years so practices have certainty on the shared care, specialist nursing home, AF service and homeless services. A three year contract allows for review each year and has a 12 month notice period so the CCG is not at undue risk. The attached papers set out the Enhanced Services that have undergone the above process, the recommended procurement option, the variation from procurement advice where relevant and the rationale for this. The paper provides more detail for each case. Recommendations 1. Practice Based Phlebotomy Bedford, Ivel Valley, Leighton Buzzard and Chiltern Vale The Governing Body are asked to approve the Executive Team recommendation to a tender waiver whilst a full review and procurement of phlebotomy services takes place across

5 Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification. 2. Combined phlebotomy and Domiciliary Risk Assessment & Prevention Service - West Mid Beds Locality The Governing Body are asked to approve the Executive Team recommendation to a tender waiver whilst a full review and procurement of the phlebotomy element of the service takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification. 3. Domiciliary Phlebotomy Bedford Locality The Governing Body are asked to approve the Executive Team recommendation to a tender waiver whilst a full review and procurement of the phlebotomy element of the service takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification. (Note. This is not an enhanced service) 4. GP Shared Care Methotrexate and Sulphasalazine Service Bedford, Leighton Buzzard, Chiltern Vale and Ivel Valley The Governing Body are asked to approve the Executive Team recommendation to a tender waiver as the service has been assessed as patient list based which means that only the specific provider is able to undertake this service. 5. GP Acute Treatment Service Chiltern Vale and Ivel Valley Localities The Governing Body are asked to approve the Executive Team recommendation of competitive tender. 6. Enhanced medical Support to Specialist Nursing Home West Mid Beds Locality The Governing Body are asked to approve the Executive Team recommendation to a tender waiver as the service has been assessed as patient list based which means that only the specific provider is able to undertake this service. 7. Atrial Fibrillation Service Identification & Management Service West Mid Beds Locality The Governing Body are asked to approve the Executive Team recommendation to a tender waiver as the service has been assessed as patient list based which means that only the specific provider is able to undertake this service. 8. Homeless Service Bedford and Leighton Buzzard

6 The Governing Body are asked to approve the Executive Team recommendation to a tender waiver as the service has been assessed as patient list based which means that only the specific provider(s) is able to undertake this service. 9. Anticoagulation Service All Localities The Governing Body are asked to approve the Executive Team recommendation to a tender waiver whilst a full review and procurement of the anticoagulation service takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification.

7 Enhanced Services Review Bedfordshire CCG Item No. Scheme Locality Annual Spend Recommendation of Procurement Team Recommendation of Executive Team 1 Phlebotomy (practice based) Bedford, Chiltern Vale, Leighton Buzzard & Ivel Valley Bedford - 28,440 Ivel Valley - 80,000 Chiltern Vale - 21,591 Leighton Buzzard - 27,000 West Mid Beds - Within combined service below Competitive Tender or AQP Tender waiver, due to full procurement within 12 months (i.e. by February 2015) with an expectation that the procurement will commence by August 2014 (rollover of existing service provision until the tender is completed and new contract awarded) 2 Combined practice based Phlebotomy and Holistic Risk Assessment Service West Mid Beds 67,403 Competitive Tender or AQP (Option 3 as per business case) Tender waiver, due to full procurement within 12 months (i.e. by February 2015) with an expectation that the procurement will commence by August 2014 (for phlebotomy) (rollover of existing service provision until the tender is completed and new contract awarded)

8 Enhanced Services Review Bedfordshire CCG Item No. Scheme Locality Annual Spend Recommendation of Procurement Team Recommendation of Executive Team 3 Domiciliary Phlebotomy Service (not LES) Bedford 69k (SEPT) Competitive Tender Tender waiver, due to full procurement within 12 months (i.e. by February 2015) with an expectation that the procurement will commence by August 2014 (rollover of existing service provision until the tender is completed and new contract awarded) 4 GP Shared Care Methotrexate and Sulphasalazine Service Bedford, Leighton Buzzard, Chiltern Vale and Ivel Valley Bedford - 48,720 Leighton Buzzard - 24,880 Chiltern Vale 27,120 Ivel Valley 41,720 Tender Waiver Tender waiver list based 5 GP Acute Treatment Service Chiltern Vale and Ivel Valley Chiltern Vale - 50,000 Ivel Valley - 75,050 Competitive Tender or AQP (Option 3 or 4 as per business case) Competitive Tender

9 Enhanced Services Review Bedfordshire CCG Item No. Scheme Locality Annual Spend Recommendation of Procurement Team Recommendation of Executive Team 6 Enhanced medical Support to Specialist Nursing Home West Mid Beds 2,542 Tender Waiver Tender waiver list based 7 Atrial Fibrillation Service Identification & Management Service West Mid Beds 18,500 Tender Waiver Tender waiver list based 8 Homeless Bedford & Leighton Buzzard 28,227 & 13,332 (both block contracts) Competitive Tender or AQP (not just limited to 2 GP practices) Tender waiver list based 9 Anticoagulation GP Enhanced Services: Bedford Chiltern Vale Ivel Valley Leighton Buzzard West Mid Beds Horizon Health Choices Warfarin Clinic Bedford Consumables Ivel Valley Consumables Bedford Hospital L&D Hospital 152,850 39, ,654 52,006 79, ,000 35,500 58, ,000 (Block) 105,000 (Block) plus 4,000 cost per case Competitive Tender or AQP TBC Tender waiver, due to full procurement within 12 months (i.e. by February 2015) with an expectation that the procurement will commence by August 2014 (rollover of existing service provision until the tender is completed and new contract awarded)

10 Meeting of the Governing Body Local Enhanced Services 2014/15 Service: Locality: Practice Based Phlebotomy Service Bedford, Chiltern Vale, Leighton Buzzard & Ivel Valley Localities Executive Summary Within BCCG we have a number of practices commissioned to deliver a practice based phlebotomy service via a local enhanced service agreement. Phlebotomy has previously been commissioned as an enhanced service it is not a requirement of general practice to absorb this work into business as usual and therefore a replacement service needs to be commissioned from April Failure to commission a new service has a potential for increased demand/volume attending the current service at the Acute Trusts which already regularly suffer from long waiting times. Rural patients will be inconvenienced and will incur longer journeys and expense from travel cost and car parking charges. To have a safe practice based phlebotomy service in for those current practices who wish to offer the service to their patients from April 2014 Improve access and convenience for patients Local provision is important within rural areas and is also particularly important for patients who do not have access to their own transport. This is a service that some patients need to use frequently and these patients are often the most vulnerable. To reduce pressure on hospital services. General Practice has existing premises that are locally accessible and CQC compliant. There would be no additional overhead costs in relation to this service so costs can be kept to a minimum. To create a framework for future growth in demand as a result of the QOF and NSF s. To incorporate within a service specification clear Key Performance Indictors. The recommendation of the Central and Eastern Commissioning Support Unit procurement team is a competitive tender. However in order to develop the specification and undertake a comprehensive CCG wide procurement process that delivers the intended benefits to patient 1

11 sit is proposed to roll forward the current contracts and undertake the procurement during 2014/15. Recommendation The Governing Body are asked to confirm the Executive Team recommendation to continue with the current providers (General Practices) through a tender waiver whilst a full review and procurement of phlebotomy services takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification.. o o o o o o Service: Report of: Combined phlebotomy and Domiciliary Risk Assessment & Prevention Sservice - West Mid Beds Locality West Mid Beds Locality Executive Summary: As part of the decommissioning arrangements localities have reviewed services and West Mid Beds Locality has concluded that practice based and domiciliary phlebotomy are essential services to offer such a rural population as they enable patients to receive this care directly in their own homes or within their registered practice. The locality review also highlighted that the prospect presented by Practice nurses and health care assistants visiting patients in their own homes for phlebotomy purposes and long term condition reviews offers an excellent opportunity to make every contact count (MECC) by conducting a holistic risk assessment. Phlebotomy Service The six general practices in West Mid Beds are commissioned to deliver a practice based and domiciliary phlebotomy service via a local enhanced service agreement. Failure to commission a new service has a potential for increased demand /volume attending the current service at both the Bedford Hospital Trust and the Luton and Dunstable Hospital which already regularly suffer from long waiting times. Also rural patients will be inconvenienced and will incur longer journeys and expense from travel cost and car parking charges. To continue to have a safe practice-based phlebotomy service within the six practices in West Mid Beds from April 2014 Maintain access and convenience for patients. Local provision is important within rural areas and is also particularly important for vulnerable patients who do not have access to their own transport. This is a service that some patients need to use frequently and these patients are often the most vulnerable. 2

12 To continue to reduce pressure on both hospital services. General Practice has existing premises that are locally accessible and CQC compliant. There would be no additional overhead costs in relation to this service so costs can be kept to a minimal. To keep costs for the service low. It is generally recognised that this service is subsidised and provided below the real costs. TUPE regulations may apply if alternative provider is the preferred option the current workforce involved in delivering phlebotomy services within the locality costs the practices in excess of 115,000 (significantly less than the 67,000 they will be funded to continue to deliver this service). Additional Risk Assessment Element of Service The aim of the initiative is to enable practice staff to utilise a risk assessment whilst in each patient s own home (e.g. when already visiting to take a domiciliary blood test), with the aim of preventing avoidable problems such as urinary tract infections caused by poor hydration; poor medicines compliance or the development of pressure sores. Additionally in the West Mid Beds Health Needs Assessment (Coffie, 2013) the locality highlighted the need for the primary prevention of falls. The assessment will therefore also contain a section around hazards in the home, poor footwear and balance, mobility and gait difficulties. The objective of the project is a population management method to prevent avoidable admissions to hospital whilst aligning to the integration agenda by improving working relationships between practice nurses and HCAs, community nurses and third sector providers. The recommendation of the Central and Eastern Commissioning Support Unit procurement team is a competitive tender. However in order to develop the specification for phlebeotomy and undertake a comprehensive CCG wide procurement process that delivers the intended benefits to patient sit is proposed to roll forward the current contracts and undertake the procurement during 2014/15. Recommendation The Governing Body is asked to approve the procurement of the combined phlebotomy and domiciliary risk assessment service via a single tender to practices, with the phlebotomy element potentially subject to the CCG wide review and procurement of phlebotomy services no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification.. 3

13 o o o o o o Service: Locality: Domiciliary Phlebotomy Service Bedford Locality Bedford Locality Executive Summary This is not an enhanced service. Within Bedford Locality three practices currently delivering home visits through the phlebotomy enhanced service. The remainder, and majority, of the activity is currently provided through SEPT via a separate Domiciliary Phlebotomy contract (not an enhanced service). Bedford Locality Board made the decision in September 2013 to give notice on the current contract and re-procure an alternative provider from April Recommendation The Governing Body are asked to confirm the Executive Team recommendation to continue with an appropriate interim procurement route whilst a full review of phlebotomy services takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification. o o o o o o Service: Shared Care Methotrexate and Sulphasalazine Monitoring Service Bedford, Leighton Buzzard, Chiltern Vale and Ivel Valley Localities Locality: Ivel Valley, Bedford, Chiltern Vale and Leighton Buzzard Localities Executive Summary The Nationally Enhanced Service (NES) for near patient testing was introduced in 2003/2004. At that time it covered 5 drugs which required frequent monitoring as they have potential serious side effects; these were methotrexate, sulphasalazine, sodium aurothiomalate, auranofin (discontinued 2009) and penicillamine. The frequency of recommended monitoring is monthly to 6 monthly. The NES enabled patients to have monitoring and clinical assessments performed locally. This includes blood tests for clinical indicators such as liver and renal function, and enabled patients to have their drug regime managed by their GP (under shared care agreement with the secondary care consultant). This arrangement kept the cost of monitoring down. GP s received a payment of 120 per patient per year as opposed to outpatient appointments at an average first outpatient appointment tariff price of 135 per appointment. It is also more convenient for patients to be seen locally, fitting in around work requirements enabling people to live as normal lives as possible. It is essential this service continues for patient safety reasons. The Locality Commissioning Boards for Ivel Valley, Bedford, Chiltern Vale and Leighton Buzzard took this commissioning decision in the summer of

14 The service should be commissioned from general practices as it is reliant on the general practice registered list of patients. The GP s are the prescriber of the drugs, are responsible and accountable for the patients care, the service requires access to, and use of, the patient register. Shared care protocols are in place between the acute trusts and the general practices (approved by the BCCG Joint Prescribing Committee). This single tender procurement is supported by advice from Hertfordshire, Bedfordshire and Luton Commissioning Support Service. Rationale The highest clinical risk and highest patient numbers are people taking methotrexate and sulphasalazine and this is where we need to focus our limited resource. It is recommended a new service is commissioned to monitor people on methotrexate and sulphasalazine on the following grounds: Cost. We cannot afford for this work to go back into secondary care and secondary care providers do not have the capacity to do it. Patient access and convenience. People want a local service for ease of access; many patients are physically impaired and have transport concerns. Safety. We will commission a service to be compliant with National Patient Safety Agency recommendations with robust call, recall and monitoring in line with national guidance and the BCCG Joint Prescribing Committee shared care protocol. The Service A service will be commissioned to provide locally accessible, comprehensive, high quality monitoring and management of patients prescribed methotrexate and sulphasalazine. Practices will follow shared care guidelines issued by the BCCG Joint Prescribing Sub Committee. They will: Ensure they have a patient register with a robust call and recall system; Provide the frequency of monitoring required by each patient. The service includes phlebotomy, facilitating laboratory analysis, recording results, communicating abnormal results to secondary care consultant, prescribing and sub cutaneous injections, appropriate prescribing of folic acid, updating patient held record in line with National Patient Safety Agency guidance, enable safe disposal of drug waste via secondary care. Supplying and maintaining patient held records. Complete a bi-annual audit of the service. The service will ensure compliant with the National Patient Safety Agency guidelines and will provide evidence to demonstrate this by completing a bi annual audit. Recommendation It is recommended that the Localities of Ivel Valley, Bedford, Chiltern Vale and Leighton Buzzard in Bedfordshire Clinical Commissioning Group commission and procures a GP shared care methotrexate and sulphasalazine monitoring service from General Practices under a single tender arrangement. 5

15 The business case has been assured by the Clinical Investment and Assurance Group (10 th December 2014), and agreed by a special meeting of BCCG Executive (16 th January 2014). It is supported by procurement advice from Central and Eastern Commissioning Support Unit. o o o o o o Service: Locality: GP Acute Treatment Service Chiltern Vale and Ivel Valley Localities Ivel Valley Locality Executive Summary: Minor Injury is currently provided by general practice through a local enhanced service. For the appointment to qualify the practice for the minor injury payment, the patient has to present at the practice within 48 hours of sustaining the injury. The practice is paid a single payment of 50 regardless of whether treatment was required following an assessment. As an example during the period between April 2012 March 2013 there were 3,235 patient contacts for minor injury in Ivel Valley at a total cost of 161,750. An audit in Ivel Valley of Minor Injury Claims for two practices in Q1 2013, it was identified that out of a total 113 people seen, 52 patients received treatment; 51 had no procedure or intervention performed and 10 patients required an A&E consultation. The total cost of seeing these patients in general practice, excluding the 10 patients referred to A&E was 5,150. Had the same patients attended a hospital A&E department the cost would have been 9,713. This figure is based on an average A&E cost of 125 per contact where the patient required treatment and 63 per contact where the patient required assessment only. Whilst the current Minor Injury Service under the LES provides better value for money than an A&E attendance, the LES is being decommissioned from March under national guidelines; the BCCG is not able to commission any enhanced services (as they do not commission core services) we are required to commission successor services as standard NHS contracts. It was agreed that the new GP Acute Treatment service would be commissioned from General Practice to ensure the service provided continuity of care for patients. Where a GP will be able to access the person s full medical history facilitating a holistic approach to care. The service will also: Deliver good quality care, Push the boundaries of general practice; Deliver continuous improvement of patient/ family/carer experience. Provide best value for money Incentivise GPs to provide treatments and interventions that would otherwise be provided in the acute setting. The Rationale The Service will be provided within the nine general practices; offering patients an accessible service, closer to their home and reducing pressure on already overstretched A&E services. 6

16 Patient Experience and Quality - Failure to provide the service will affect the overall quality of care and patient experience, with people: Being turned away from their general practice to attend either A&E or a single centrally based minor injury service Having to drive greater distances to access minor injury treatment at their nearest A&E department or a single centrally based minor injury service. Incurring costs for travel and parking. Delays in accessing treatment due to the length of time travelling to their nearest A&E department and A&E waiting times. Cost - Hospital A&E services are already overstretched and any increased activity will have a negative impact on the BCCG in its objective to meet its financial and performance objectives. The Service The aim is to commission a GP Acute Treatment Service via single tender. The service will be provided by general practice alongside the core ngms, where capacity will be built into the in-hours service between 8.00a.m. 6.30p.m.; ensuring people are seen the same day and prioritised according to their need and the injury sustained. Patients considered by definition to be self-presenting walking wounded will be seen as part of the acute treatment service. GPs will also see Ambulance cases following agreement with the attending paramedic. Any injury/wound of non-traumatic origin would not be considered suitable for the acute treatment service and therefore will be dealt with through normal primary care services. This includes patients who present 48 hours after sustaining the injury/wound. Practices will receive a payment of 50 for each contact where they provide an assessment and acute intervention. Each practice will have a capped budget based on historical activity. However, any activity over and above the practice s capped budget will be absorbed by the practice. The GP Practices will implement 6 monthly patient surveys to capture their patients views of the service to ensure it continually delivers high quality care and improved patient experience. An annual audit will also be performed looking at the: The total number of patients requiring treatment. The total number of patients requiring assessment only The total number of patients requiring a hospital consultation following assessment by a GP. The types of treatment being provided (the service aims to push the boundaries of primary care to provide treatments that would otherwise have required a hospital attendance). Accessibility to patients Health professional resource and time. Recommendation The Bedfordshire Clinical Commissioning Group Executive recommends that localities commission and procures a GP Acute Treatment Service via the competitive tender route. 7

17 The business case has been assured by the Clinical Investment and Assurance Group (10 th December 2014), and agreed by a special meeting of BCCG Executive (16 th January 2014). It is supported by procurement advice from Central and Eastern Commissioning Support Unit. o o o o o o Service: Report of: Enhanced Medical Support to Specialist Nursing Home Service West Mid Beds Locality West Mid Beds Locality Executive Summary Agate House Nursing Home in Ampthill provides care for adults with physical disabilities with nursing needs, and for ABI (Acquired Brain Injury) rehabilitation. The unit has 36 beds. All patients have severe, mainly neurological and developmental conditions, e.g. severe Multiple Sclerosis, cerebral palsy, many are epileptic and several vulnerable to status or prolonged seizures, PEG fed patients, those with suprapubic catheters. They all have high dependency on nursing and medical care, are vulnerable to infection and if they develop infection can become very poorly very quickly. The residents of the home are a patient population who are very vulnerable to repeated and lengthy hospital admission without proactive medical and multidisciplinary care. Greensands Surgery has historically been commissioned to provide enhanced medical support to the home, to ensure effective management of the residents there. This has included close communication with the home on a regular basis, a monthly ward round (approx. 2 hours) and monthly review of each patient s Medication Administration Record sheets to ensure optimal prescribing. It is recognised by other clinicians within the locality that the medical needs of the residents of Agate House are significantly higher than most nursing homes, and all practices are in agreement that the extra work associated with effectively managing the residents of the home warrants additional remuneration. Many practices in other areas of the country providing medical support to specialist nursing homes similar to Agate House also remuneration for these services, under a variety of contractual arrangements. For example, the practice delivering medical care to The Gardens nursing home in Sawbridgeworth, Herts receive additional payment within their APMS contract held by the LAT, and the practice delivering medical care to St Elizabeth s Court, Herts receive approximately 80 per patient per annum for their services. This scheme is expected to be funded from the historical LES budget transferring to the Locality in 2014/15. The cost of the scheme is 2,542. Recommendation The Governing Body is asked to approve the procurement of the West Mid Beds Enhanced Medical Support to Specialist Nursing Home Service via a single tender to the relevant practice/s. This is supported by the by procurement advice from Central and Eastern Commissioning Support Unit. 8

18 o o o o o o Service: Report of: Atrial Fibrillation Service West Mid Beds Locality West Mid Beds Locality Executive Summary West Mid Beds Locality has had a successful Local Enhanced Service (LES) in place for a number of years for the proactive identification of patients with Atrial Fibrillation (AF). The LES has remunerated GP practices for proactively screening patients over the age of 65 for AF during a visit to the surgery for another reason, e.g. whilst administering flu vaccination. Identifying people who have AF is vitally important as a means of trying to prevent people from having strokes. AF is the most common sustained cardiac arrhythmia and if left untreated is recognised as a major cause of stroke accounting for some 14% of all strokes. People with AF are five times more likely to have a stroke than those without the condition and the recurrence of AF related stroke is more frequent than that of other strokes. One in twenty patients with AF is expected to suffer a stroke each year. Strokes due to AF are also the most devastating and more likely to lead to death and serious disability. As a result of the LES, WMB has a higher recorded diagnosis rate (prevalence) of AF than the national average and the rest of Bedfordshire (1.6% compared to 1.48% and 1.46% respectively). The Locality also has a slightly lower emergency admission rate for stroke than the rest of Bedfordshire (101 per 100,000 population compared to the Bedfordshire average of 105 per 100,000 population). The current commissioning arrangements for Local Enhanced Services cease at the end of March As a result, the current AF LES has been reviewed by the locality. Clinical commissioners have concluded that the service is still valuable to commission, but that there is an opportunity to expand the scope of the service specification to further incentivise delivery of best practice management for patients once diagnosed with the condition, with the aim of further reducing the incidence of stroke and associated emergency admissions. In addition, there is more scope to proactively target patients at high risk of having AF for screening using evidence based software to identify these patients. A national tool, GRASP-AF, has been developed to support GP practices with reviewing their patients with AF to optimise the number of people on anticoagulation therapy. Practice QOF registers confirm that approximately 35% of patients in Bedfordshire who have previously had a stroke are not receiving anti-coagulation therapy. Whilst there are very valid clinical reasons for some patients not to receive treatment, there is evidence that the GRASP-AF tool can support practices to safely increase the proportion of patients on anticoagulation therapy, thereby helping to reduce the incidence of stoke. This business case therefore supports the continued funding of the West Mid Beds AF service, with a new enhanced element of the specification requiring practices to run the GRASP-AF tool twice per year. The tool will support practices to identify patients at high risk of having AF so that they can be proactively targeted for screening. The tool also supports practices to identify patients whose anticoagulation therapy may be sub-optimal. This service will expect practices to assess patients as recommended by the tool, with the aim of 9

19 maintaining higher than average diagnosis rates for the condition, and further reducing emergency admission rates associated with stroke. This service can only be offered by general practices (the GRASP-AF software required to deliver this service can only be used by general practices within their practice systems), and therefore it is proposed that this is procured as a single tender from practices within West Mid Beds. The cost of the scheme is expected to be 18,597, with continued anticipated financial benefits of 23,000 per annum and significant quality benefits, including reduced incidence of stroke and stroke-related mortality. This scheme is expected to be funded from the historical LES budget transferring to the Locality in 2014/15. Recommendation The Governing Body is asked to approve the procurement of the West Mid Beds AF Service via a single tender to practices.. This is supported by the by procurement advice from Central and Eastern Commissioning Support Unit. o o o o o o Service: Locality: General Practice Service for Homeless People Bedford & Leighton Buzzard Bedford & Leighton Buzzard Localities Executive Summary Within Bedford and Leighton Buzzard Locality we have two practices who deliver the homeless service via a local enhanced service agreement. The Executive took a decision in Summer 2013 that they wish that the homeless service continue. The BCCG Executive in the summer had agreed that the homeless enhanced service in Leighton Buzzard and Bedford should not be decommissioned as it is a valuable service for some of the most vulnerable patients. Procurement advice is that the service should be procured under AQP or competitive tender as there is potentially more than one capable provider.. The homeless patients are currently registered with the two practices who provide the current service. The service should be commissioned from these two general practices as it dependent on their list of registered patients. These people are registered on the practices list despite being homeless. Many of these patients lead chaotic lives with co-morbidities including substance misuse. It is vitally important to maintain consistency in service provision through the registered list, to ensure a safe, high quality service from staff who have a high level of skill and expertise. 10

20 The current enhanced service arrangement have been in place for a number of years and over this period both of these practices have developed a rapport with an extremely vulnerable group of people and a high level of trust has developed which has enabled healthcare and support for these patients. The Practices are geographically well placed within the towns which they serve and this ease of access has undoubtedly contributed to the success of the current provision. One practice runs an outreach in the homeless shelter. The Service Outline Provides a direct access to Primary Healthcare for the homeless and rootless Maintains an up-to-date practice register for homeless patients Offers flexible appointment systems including walking in surgeries and longer appointment times for patients with multiple needs. Arrangements with local pharmacies that allow for the administration of single or daily doses of prescription drugs. Provision of blood borne virus screening Provision of outreach service in the day centre and night centre. Adherence to guidelines on the prescription of drugs in particular if medication has a street value or potential toxicity. Recommendation To commission a General Practice service for homeless people under a single tender arrangement. This is supported by a special meeting of BCCG Executive (16 January 2014) but not by procurement advice from Central Eastern Commissioning Support Unit. o o o o o o Service: Locality: Anticoagulation Service All Localities Executive Summary Anticoagulation Clinics are attended by patients who have had clots, such as a Deep Vein Thrombosis (DVT), or who have a condition which puts them at risk of a stroke, for example Atrial Fibrillation and patients are often given oral anticoagulants to reduce the risk of future clots. The Anticoagulant Clinics monitor the treatment of patients taking oral anticoagulants. Across BCCG 31 of our 55 practices are currently offering any level of anticoagulation service to the practice population under an Enhanced Service Contract. Within the Bedford Locality Horizon Health Choices Ltd are providing this service on behalf of some of the practices. The remaining population on anticoagulants is serviced by local hospital anticoagulation clinics. 11

21 The futures of anticoagulation services were, until recently, part of the wider cardiology service redesign project and future procurement. However It has been agreed to exclude it from that project and the service will need to be re-procured (given its scale most likely through competitive tender). Given the timescales, it is proposed to undertake tender waiver until the service can be fully procured during 14/15 (status similar to phlebotomy) Recommendation The Governing Body are asked to approve the recommendation to a tender waiver whilst a full review and procurement of anticoagulation services takes place across Bedfordshire Clinical Commissioning Group no later than January 2015 but with the intention of commencing this August 2014 following the development of the specification. 12