SERVICE SPECIFICATION

Size: px
Start display at page:

Download "SERVICE SPECIFICATION"

Transcription

1 Service Commissioner Lead Provider Provider Lead SERVICE SPECIFICATION Long Term Conditions Contract Charlotte Painter City and Hackney GP Confederation Laura Sharpe Period Date of Review 1 Population Needs Core Long Term Conditions Contract There are approximately 80,000 people in City and Hackney with a long term condition. This service offers these patients enhanced primary care via additional reviews, extended appointments, care-planning and treatment targets. The Long Term Conditions (LTCs) Contract rewards City and Hackney GP practices for delivering higher quality care over and above what is in their core GP contracts, which are held with NHS England. The City and Hackney Clinical Commissioning Group (CCG) must improve the quality of care for its patients with LTCs if it is to see any reduction in its high premature mortality rates from cardiovascular disease (CVD) and respiratory disease, and any increase in the proportion of its patients who have an LTC feeling supported to manage their own condition, all of which are key CCG strategic aims, and all of which feature in the CCG Outcome Indicator set. The aim of the contract is to increase standards and reduce variability in access to high quality care between GP practices. The contract is being delivered to an incredibly high standard, the evidence for which comes from the contract s performance dashboard, which charts at a GP practice level achievement against all of the prevalence targets, clinical process targets and intermediate clinical outcomes targets that are part of the contract (intermediate clinical outcomes are measures of therapeutic effect that are considered reasonably likely to predict changes to morbidity and mortality for example blood pressure control is an intermediate clinical outcome, the end point clinical outcome being the rate of heart attacks and strokes over time). The added value of the contract regarding existing services can be quantified in terms of performance in the Quality and Outcomes Framework for England and Wales (QOF). The contract has succeeded in moving the CCG into the upper quintile of QOF for many of its indictors and into the best performing CCG for several indicators. This contract will assist in both maintaining and further improving on these gains. Time to talk Patients with LTCs have reported that they would like more time to discuss concerns with their GP. The aim is to give patients the opportunity to discuss worries, depression, lifestyle, family issues, difficulties managing their illnesses, etc. Cancer Improving our cancer care for our patients in City and Hackney is a priority for the CCG. Every hour, three more Londoners are diagnosed with cancer. On average, one of them will die within 12 months, one will live with their cancer for the rest of their life, and only one will beat it. Despite all the advances in successfully treating the disease, Londoners still have a poorer chance of beating their cancer than elsewhere in the country and we need to close that gap. Tackling the reasons behind late diagnosis of cancer is key to making improvement, as well as addressing the unacceptable variations across in screening rates and access to treatment. Children A CCG priority is the focus on Early Years, identifying needs as early as possible, and providing integrated support to meet these needs and reduce further risks. To give each child the Best Start in Life, we want to facilitate joint 1

2 working between the many professionals involved with children with LTCs, to ensure that no child slips through the gaps, and that, through primary care, there is oversight of children and their families needs and experience of care. 2 Outcomes 1 Preventing people from dying prematurely 2 Enhancing quality of life for people with Long term conditions 3 Helping people recover from episodes of ill health or following injury - 4 Ensuring people have a positive experience of care 5 Treating and caring for people in safe environment and protecting them from avoidable harm - Core LTC contract A detailed list of outcomes and indicators is appended at the end of the specification. The service will contribute towards the CCG outcomes of reducing premature mortality and helping people with long term conditions feel supported to manage their condition. Time to Talk The aim is to give patients the opportunity to discuss worries, depression, lifestyle, family issues, etc. Research shows that the use of a patient prompt sheet acts as an aide-memoire; provides a focus for the consultation; gives patients permission to discuss certain things and helps provide greater tailoring for the patient. Cancer The Planned Care Workstream wishes to drive more quality improvements in patient care and experience. Formal commissioning of primary care to support the CRUK programme is in line with the national agenda and additional time to support a diagnosis of cancer seeks to provide extra capacity in primary care for GPs to have the opportunity to support their patients in a more meaningful way. Children This contract facilitates personalised, structured management of LTCs for children, embedding the established approach to managing adults LTCs. Children under the care of out of borough Trusts have local support and information to support their access to local services, and children and their families are supported to manage their long term conditions. It is intended that unnecessary hospital attendances are reduced through improved local oversight and management of children, there is integrated transition support for children as they move to adults services, and GPs contribute to joint planning for young people with special educational needs and disabilities. 3 Scope of Service 3.1 Service model 2

3 LTC core contract This service is available to all patients registered with a City and Hackney GP and is delivered by local GP practices supported by the GP confederation. The service includes case-finding; prevalence targets for some conditions; annual reviews; care planning; extended consultations and treatment targets. The Confederation is required to achieve population coverage; performance to minimum standards at CCG level and practices must meet minimum standards at a practice level. Time to Talk Eligible patients: adult patients registered with a C&H GP with 2 or more of the following LTCs: 1. Asthma 2. Atrial fibrillation 3. Chronic kidney disease 4. Chronic obstructive pulmonary disease 5. Coronary heart disease 6. Dementia 7. Diabetes 8. Heart failure 9. Hypertension 10. Learning disabilities 11. Severe mental illness 12. Stroke/transient ischaemic attack 13. Peripheral arterial disease Other LTCs such as hypothyroidism, epilepsy, rheumatoid arthritis, osteoporosis, multiple sclerosis, MUS, etc., can be included at the discretion of the clinician. Patients on the Proactive care home visiting and proactive care practicebased contracts are excluded. Patients with sickle cell disease are eligible for a Time to talk consultation irrespective of whether they have any other condition. Cancer This service will be available to adult patients registered with a City and Hackney GP and who have a diagnosis of cancer or who are eligible for bowel cancer screening. Children This service supports primary care identification of children with asthma (and at risk of asthma), diabetes, epilepsy and sickle cell disease. Personalised asthma action plans which are consistently used across primary and secondary care, with prompt follow up after unplanned hospital attendances, are intended to support improved management of asthma. Annual care contacts and oversight of secondary /tertiary management of children with diabetes, epilepsy and sickle cell are intended to integrate care locally for children and their families, with personalised support during transition. Young people (18 to 25 years) with special educational needs and disabilities (SEND) will be supported in their education and health care plan (EHCP) process, recognising the gap in lead health professional for this cohort of young people. 3.2 Care Pathways LTC Core Contract 3

4 Patients with relevant long term conditions will be offered services under the contract and this will be coded by the GP practice. The service is supported by searches created by CEG and EMIS templates to prompt and record activity. The service will need to link with: Clinical Effectiveness Group; peer educators; services referred on to e.g. exercise on referral, National Diabetes Prevention Programme; community specialist nurses; other services commissioned by public health e.g. health checks; smoking cessation. Time to Talk Practice will offer an extended consultation with either the practice nurse or GP (this should be the patient s usual GP where possible) Practices will proactively identify patients Practices will give the patient a prompt sheet in advance of the extended consultation the aim of the prompt sheet is to help the patient focus on what they want to raise in the consultation Patients should be informed that they can bring someone else along (spouse, carer, friend, advocate, etc) The extended consultation can be added onto a CDM annual review The extended consultation could be written up as a care plan The average length of an extended consultation is expected to be 30 minutes (longer for patients who have communication problems or whose first language isn t English) Coded as offered/declined/done Cancer Increase uptake of bowel screening through outreach and endorsement All practices will instigate the systems and participate with the promotion of patient participation in national bowel screening programme. All practices to receive electronic results of bowel screening via lablinks Check bowel cancer screening participation opportunistically at consultations with people aged 59 to 75 (popup reminder to be included in EMIS); endorse and support screening uptake Use CEG search to identify people due for screening invitations (60th birthday pending) or DNA result in last 4 weeks Practices to write to, telephone and provide standardised GP endorsement and information to: People aged 60 due to be invited (1,600 p.a.) for bowel screening for the first time People aged who were invited and failed to participate in bowel screening (11,500 pa) Contact to non-returners of the bowel screening kit to offer an explanation and support complete the test Practices to consider and make additional efforts for patients with difficulties that could include language, literacy, physical disabilities, learning difficulties or who are profoundly deaf Protocol, standardised endorsement letters and health promotion script for calling can be provided to practices by the CCG Cancer Clinical Lead Engage through PPI groups to support work to develop patient literature and other communication materials to encourage bowel screening uptake Work with community groups to discuss ways of increasing uptake in the local population and produce a plan for implementation in 2019/20 for example via community pharmacy cancer champions Referral safety-netting With continued support from the CCG Cancer Lead and the CRUK Primary Care Engagement Facilitator, the GP Confederation will ensure that all practices will: Have a system to ensure the dispatch of all 2 week wait referrals within 24 hours of the patient consultation; Have a system to make all diagnostic referrals where cancer is suspected within 24 hours of the patient consultation; Ensure that all 2 week wait referrals are routinely coded; 4

5 Ensure that the practice has a safety net process for follow-up of all 2 week wait referrals Practices will be provided with a template for routine recording of this information Ensure that information on 2 week wait referral pathways, diagnostic testing and local pathways is available to locums and new registrars Include patients practices have referred straight for diagnostic tests e.g. test (OGD, CT, MRI) rather than fast track outpatient appointment; use London Cancer safety-netting template. Time to talk for cancer patients via extended practice consultations. This service will be primarily focused on patients diagnosed with cancer, some of which may need more than one consultation because of more complex existing health conditions which have been further complicated by a diagnosis of cancer. Ten minute consultations already exist within QOF therefore the CCG will commission the GP Confederation to ensure that all patients on the QOF Cancer register are offered an additional 20 minutes consultation time. The extended consultation of up to 30 minutes with the patient s GP (usual GP where possible) will Cover issues of multi-morbidity, multiple medications, their interactions and possible side-effects Discuss the cancer diagnosis in context of existing illness both psychological and physical Consultations will be offered to appropriate patients in any of the following circumstances: Once a City and Hackney registered patient has a confirmed diagnosis of cancer notified by secondary care: The practice will identify the named GP for the patient who will provide continuity of care to the patient; The practice will offer the patient an extended consultation to come in to see their GP (usual GP where possible) on receipt of the diagnosis; Once a City and Hackney registered patient has had one of the following: A planned inpatient episode (e.g. surgery) for management of cancer; The first of a planned programme of radiotherapy or chemotherapy; An unplanned emergency hospital admission; Completed a course of radiotherapy/chemotherapy; Been discharged from hospital care (including patients discharged in line with risk stratified pathways breast pathway will be the initial patient group) The GP will keep an overview of each patient s care and referrals and, where clinically appropriate, proactively organise a consultation to review or discuss the care plan. The extended consultations could cover: Reviewing the patient s condition, current health status and recent history; Reviewing the patient s care plan and ensuring that this reflects their wishes; Discussing the diagnosis, tests and treatment options that have been suggested including potential side effects and what the NHS will provide; Ensuring that the patient and their carers have access to emotional support and other local voluntary sector support groups, access to patient information and information about local resources; Reviewing any lifestyle issues as appropriate Arranging annual immunisations and the relevance of involvement in future screening programme activity (and where necessary making arrangements for the patient to be excluded); Undertaking a medication review; Assessment of the carer and their needs; For patients finishing treatment and moving onto self-management: Ensuring they have been offered an individualised Health and Wellbeing event by their cancer care provider as part of the Recovery Package Ensuring they understand warning signs which necessitate representation to secondary care Cleaning of registers 5

6 Practices should undertake a review of cancer registers in year to clean up prevalence data and ensure they are up to date with a view to increasing capacity next year to incorporate people with a past diagnosis of cancer Prostate Cancer - Primary Care Prostate Follow Up Service for stable prostate cancer patients (stratified follow up) Aim: To provide enhanced support for men with stable prostate cancer in the community, including annual holistic needs assessment and ongoing PSA monitoring The primary care provider will be required to: Conduct a quarterly search for patients with prostate cancer (READ code B46 or B834) who are not under secondary care and maintain a register Offer a 30 minute welcome appointment to all newly transferred patients within four weeks of notification transfer from secondary care under the Time to Talk Cancer scheme above (expected numbers for City and Hackney <100 per annum). N.B. Barts Health will be running a nurse led follow up model which will manage the majority of patients on BH pathway. Organise PSA testing as per the instructions on the patient's Treatment Summary, review the results and organise follow up testing or re-referral to secondary care as appropriate. Children Patients with relevant long term conditions will be offered services under the contract and this will be coded by the GP practice. The service is supported by searches created by CEG and EMIS templates to prompt and record activity. The service will need to link with the Trusts under whom their children receive their care, where there are clinical concerns. The GP Confederation (GPC) will liaise with the Commissioner regarding trends in poor communication between Trusts and GPs, to inform commissioning requirements. The GPC and CCG will continue to review and develop necessary information sharing arrangements, where they are required, to enable integrated delivery of care to relevant children. 3.3 Structural Support LTC core contract The C&H GP Confederation (GPC) is contracted to ensure that all practices meet all minimum prevalences and standards. The GP Confederation supports practices to deliver the service and oversees quality and governance (e.g. via audit). All minimum prevalences and standards apply to all practices. Where a minimum prevalence or standard has not been met (recorded prevalence measured 31 st Mar 2019) the GPC is asked to produce a report, calling on the assistance of CEG if needed, outlining what action has been taken to get the practice to the minimum prevalence or standard. The GPC is asked to provide a report on each missed prevalence or standard to be submitted to the CCG s LTC Board. Practices will need to be able to show that they have looked at and acted upon the CEG suite of searches. The GPC is asked to monitor exception reporting levels at an individual practice level and to take action where levels are found to be excessive (e.g. higher than similar practices; higher than the national average). The GPC is asked to provide a report on any action taken to be submitted to the CCG s LTC Board after year end. There is no payment associated with this requirement nor are other payments dependent upon having done this. The CCG will also commission CEG to provide reports on exception reporting use by practice. 6

7 Children The C&H GP Confederation (GPC) is contracted to ensure that all practices meet all minimum prevalences and standards. The GP Confederation supports practices to deliver the service and oversees quality and governance (e.g. via audit). All minimum prevalences and standards apply to all practices. Where a minimum prevalence or standard has not been met (recorded prevalence measured 31 st Mar 2019) the GPC is asked to produce a report, calling on the assistance of CEG if needed, outlining what action has been taken to get the practice to the minimum prevalence or standard. The GPC is asked to provide a report on each missed prevalence or standard to be submitted to the CCG s LTC Board. Practices will need to be able to show that they have looked at and acted upon the CEG suit of searches. The GPC is asked to monitor exception reporting levels at an individual practice level and to take action where levels are found to be excessive (e.g. higher than similar practices; higher than the national average). The GPC is asked to provide a report on any action taken to be submitted to the CCG s LTC Board after year end. There is no payment associated with this requirement nor are other payments dependent upon having done this. The CCG will also commission CEG to provide reports on exception reporting use by practice. Cancer Work with CEG during 2018/19 to develop proxy outcomes demonstrating improved uptake of screening, sourcing best practice sourcing best practice to increase screening Link to referral forms and education materials: 5 Key Performance Indicators Core LTC contract The full list of outcomes and indicators is appended. Final targets will be agreed in May Maintaining performance: GPC level: GPC to meet minimum average prevalence. As a general principle the final targets associated with the minimum prevalence and standards will be set at the lower end of one standard deviation of the 2017/18 results. However, these can be set higher at the discretion of the CCG. GPC to meet minimum average standards As a general principle the final targets associated with the minimum prevalence and standards will be set at the median of the 2017/18 results. However, these can be set higher at the discretion of the CCG. Time to talk Delivery of up to 12,420 extended consultations in-line with the specification. Cancer Key performance indicators and outcomes: Bowel screening quarterly reports % of men and women contacted around their 60th birthday by telephone and offered health promotion to encourage uptake of bowel screening 7

8 % of men and women in the above group sent endorsement letter by practice if not reached by telephone % of men and women aged who have not participated in bowel screening in the last 3 months contacted by telephone and offered health promotion to encourage uptake of bowel screening % of men and women in the above group sent endorsement letter by practice if not reached by telephone Increase in bowel screening uptake across City and Hackney practices 2 week waits quarterly reports Numbers made by practice Numbers of DNAs/delays where the practice took action Follow up of 62 day wait patients supporting secondary care if requested Report patient outcomes on recovery and management of consequences of cancer treatment measures to be agreed during 2018/19 Report on patient experience Time to talk quarterly reports % of appointments offered by practice % of appointments taken up by practice Annual patient experience survey/questionnaire Children The full list of KPIs is appended. Final targets will be agreed in May Maintaining performance: GPC level: GPC to meet minimum average prevalence. As a general principle the final targets associated with the minimum prevalence and standards have been set at the lower end of one standard deviation of the 2016/17 results. However, these can be set higher at the discretion of the CCG. GPC to meet minimum average standards As a general principle the final targets associated with the minimum prevalence and standards have been set at the median of the 2017/18 results. However, these can be set higher at the discretion of the CCG. 6 Reporting Requirements Core LTC Contract Maintaining performance at practice level: GPC to ensure individual practice prevalences are maintained to at least their 2017/18 levels. GPC to ensure individual practice denominators are maintained to at least their 2017/18 levels, having taken account of any changes in practices registers or indicator definitions. Where a prevalence and/or denominator at year end is below its 2017/18 level the GPC is asked to produce a report, calling on the assistance of CEG if needed, outlining what action has been taken and any mitigating factors. The GPC s performance will be assessed at the end of the year (31 st Mar 2019) on the following: CEG LTC Contract Dashboard GPC end of year report detailing: a) Minimum prevalences and standards at practice and GPC level b) Exception reporting levels c) Denominator levels 8

9 The full suite of reports will be considered at the next available prevention workstream (with input from the Children s workstream and the Planned Care workstream). The prevention workstream will then make its recommendation to the GP Contracts Committee who will in turn make a recommendation for payment to the CCG Governing Body / Integrated Commissioning Board. Time to Talk The GPC is asked to provide a report along the following lines: Equity of access report analysed by all nine protected characteristics, where available, and by number of conditions, across all activity variables (consultation offered, patient choice of GP or nurse where offered, consultation declined, uptake of consultation with nurse, uptake of consultation with GP), and at an individual practice level. The report should include the number of eligible patients identified per practice and uptake per practice. The GPC will produce a report detailing the patient experience of at least 200 patients who have had an extended consultation. Cancer Annual / quarterly report (see finance section). Children Maintaining performance at practice level: GPC to ensure individual practice prevalences are maintained to at least their 2016/17 levels. GPC to ensure individual practice denominators are maintained to at least their 2017/18 levels, having taken account of any changes in practices registers or indicator definitions. Where a prevalence and/or denominator at year end is below its 2017/18 level the GPC is asked to produce a report, calling on the assistance of CEG if needed, outlining what action has been taken and any mitigating factors. The GPC s performance will be assessed at the end of the year (31 st Mar 2019) on the following: CEG LTC Children s Dashboard GPC end of year report detailing: d) Minimum prevalences and standards at practice and GPC level e) Exception reporting levels f) Denominator levels The full suite of reports will be considered at the Children s workstream meeting, and in coordination with the prevention workstream recommendations will be made to the Transformation Board who in turn will make payment recommendation to the Integrated Commissioning Board. The Confederation are required to provide qualitative feedback to the Children s workstream on a quarterly basis, regarding the effectiveness of joint / shared care planning and communication between practices and Trusts. This supports the work of the programme board in improving these pathways in year. Payments for the three schedules are fully independent of each other. Budget: Core (adults): 2,461,699 Children: 100,000 Time to Talk: 622,000 Cancer: 136,894 9

10 Overheads: 107,011 Total: 3,427,604 Core LTC contract The recurrent budget for this service is 2,461,699 The CCG will award the GPC 100% of the total contract value ( 2,461,699), if all practices achieve all minimum standards and the GPC achieves all minimum standards (this includes practices prevalences and standards that have not been met but where the CCG s LTC Board agrees that there is sufficient evidence from the Confederation that the standard cannot be achieved). If these conditions are not met then the following financial penalties will apply: For each missed Confederation level standard: 2% penalty ( 49,233.98) (capped at 300,000) For each missed Practice level standard: 0.5% penalty ( 12,308.50) (capped at 50,000 per practice) [No penalties for Greenhouse as unique and challenging population] Indicator L12 Standard 0.5% penalty ( 12,308.50) per practice for missing Q4 improvement target. Penalty calculated at practice level but aggregated to Confederation level Maximum penalty (including L12) capped at 500,000. There are no penalties in relation to exception reporting or denominators. The Confederation is to be paid 1,961,699 in monthly instalments of 163, for delivery of the core contract. Over time we expect this contract to move towards a more outcomes based contract. Further discussions to be held in 2018/19 with the Prevention workstream to explore this in more detail. Time to Talk The available budget is 622,000. The GPC is commissioned to deliver up to 12,420 extended consultations in-line with the specification (see above). For each consultation the GPC will be paid 50. Each practice needs to provide a certain minimum number of extended consultations (in order to demonstrate equity). This number will be established for each practice based on its respective share of the total number of people with LTCs registered with all C&H Practices and the minimum of 20% of its respective share. Worked example There are people with LTCs across all 43 C&H practices Sandringham has 1800 pts with LTCs their respective share of the is 2.4% (1200/75000*100) 2.4% of 12,420 is 298- the minimum number of consultations required is 20% of a practice s relative share so Sandringham need to have provided 20% of 298 (i.e. 60 consultations). 3% of the GPC s total earnings under this Contract (no. of consultation delivered x 50) will be deducted for each practice that does not meet its minimum target. Example: The Confederation delivers 10,000 consultations and consequently stands to earn 500,000. However Sandringham only delivers 20 of the 60 it needed to deliver to meet its minimum therefore the Confederation earns a 3% penalty (3% of 500k i.e., 15k). Cancer The available budget is 136,895 non-recurrent. Bowel screening 10

11 A payment of 57,500 will be available on a yearly basis to the GP confederation. 75% ( 43,125) of this budget will be paid to the confederation for demonstrating that all practices have implemented the processes associated with the bowel screening elements of the contract. These include a system for identifying eligible patients and a method of recording contacts made by the practice to the patient and the date of screening undertaken. Practices will also need to have a system to search for patients identified to the practice as a DNA for bowel screening. The confederation should include a report on the numbers of patients actively contacted by practices to take up bowel screening. A further 25% ( 14,375 divided equally across the four targets) will be paid to the GP Confederation will be on achievement each of the following targets: 60% of eligible men and women contacted around their 60th birthday by telephone and offered health promotion to encourage uptake of bowel screening. 90% of men and women in the above group sent endorsement letter by practice if not reached by telephone 60% of eligible men and women aged 6 70 who have not taken up their bowel screening (DNA notifications are sent direct to the practices) in the last 3 months are contacted by telephone and offered health promotion advice and support to encourage uptake of bowel screening 90% of men and women in the above DNA group sent endorsement letter by practice if not reached by telephone Outcomes The service aims to increase bowel screening uptake across all practices in City and Hackney. On publication of the National Bowel Screening data a further payment of 6250 will be made to the Confederation if a 5% improvement is achieved across all City and Hackney practices. An additional payment of 6,250 will be made if a 10% increase in bowel screening uptake is achieved. The GP Confederation should link with NEL vanguard schemes and endeavour to ensure that any proposed schemes for increasing uptake do not overlap with NHSE or Vanguard site initiatives 2 week waits A 300 payment will be made to each practice per quarter ( 51,600) on delivery of the following: Compliance with and maintenance of new systems Numbers made by practice Numbers of DNAs/delays where the practice took action In the following year (2019/20) the outcomes will move to reducing variation between practices on 2ww referrals (with the aim of increasing 2ww referrals per 1,000 population) and reducing emergency presentations at hospital this may include review of relevant referrals to direct access services Time to talk (cancer) Payments will be made on the basis of a quarterly activity report from the confederation of the number of extended sessions of 20 minutes per patient on QOF register at the rate of 35 per patient (up to available budget of 15,295). Children The recurrent budget for this service is 100,000. The CCG will award the GPC 90% of the total contract value ( 90,000), if all practice level minimum standards are achieved. If the asthma personalised plan and annual review standard is not achieved, there will be a Confederation penalty of 9,000 The Confederation is to be paid 90,000 in quarterly instalments of 22,500 for delivery of the children s contract. The CCG will award the GPC 10% of the total contract value ( 9,000) if the prescribed standards (referral to epilepsy nurse and EHCP pathway) are met. 11

12 Overheads Available budget 107,011 will be paid in quarterly instalments, no financial penalties will be associated with this element of the contract. 12

13 Service standards Ensure all patients with a long term condition (or at risk of a long term condition) have their BP, HbA1C and cholesterol con trolled to NICE guideline, QOF or other locally agreed levels. As measured below (proposed changes to current 2017/18 contract in red text): Current KPI % patients <85 years with hypertension whether or not they have any other LTC (such as CHD/Stroke/TIA/PAD/ CKD/AF) with BP 140/90mmHg (130/80 in people who have had previous stroke) Target tbc % pts with CVD or diabetes aged under 75 years prescribed Simvastatin 80mg or Atorvastatin 80mg in the last 6 months (ref Prescribing Dashboard CVD METRIC 3) % pts with CVD or diabetes aged under 75 years prescribed Simvastatin 40mg or Atorvastatin 40mg in the last 6 months % pts with CVD or diabetes aged 75 years or older prescribed Atorvastatin 40mg or Atorvastatin 80mg in the last 6 months (ref Prescribing Dashboard CVD METRIC 3) % of patients at risk of CVD (>20% 10 year risk) prescribed statin (Atorvastatin 20mg or Simvastatin 40mg) (amalgamate above into simpler target incentivising HI statins: u75yrs CVD/DM + Atorva 40-80mg/Simva 80mg Use CEG's trigger tool that identifies diabetes patients over 65 with impaired renal function who may need less tight glycaemic control (i.e. medication review) 50% tbc Patients on diabetes register 140/80mmHg (12m) Remove The % of adults with egfr evidence of CKD and with diabetes or with ACR >30, with BP below 130/80 (ref CKD dashboard METRIC 4) tbc 13

14 Use new CEG search that identifies pts eligible for triple target NDA and who are not achieving 1 or 2 of the targets (excluding patients who are achieving all three targets) tbc Monthly CEG report on progress towards target monitored by GP Confederation Q4: Reach minimum standard of tbc Standard 0.5% penalty ( 12,308.50) per practice for missing Q4 improvement target. Penalty calculated at practice level but aggregated to Confederation level Introduce triple treatment target for people with AF (Statin, BP, anticoagulation) tbc 14

15 15

16 16

17 Childrens Service Standards Area KPIs Outcomes Aligned with 90% of the contract value Patients on the asthma register have personalised care plans that are reviewed at least annually Practice minimum achievement tbc Penalty will be 10% ( 9,000) if minimum threshold is not met Patients are followed up by primary care following A&E attendance Asthma specialist Nurse liaises with Confed regarding practice engagement so focus is on exception reporting and Confederation working with non-engaging practices Reduced unplanned care activity Reduced unplanned care activity Patients with sickle cell are supported in transition Target tbc Care is coordinated and patients can access support in the community Annual care contacts are offered to patients on the diabetes, epilepsy and sickle cell registers Minimum threshold to be agreed Patients are empowered through joined up care 17

18 No penalty attached Aligned with 10% of the contract value Patients on the epilepsy register are referred to the epilepsy specialist nurse With patient consent Penalty 5% Requests for EHCP health information (18-25 years) is provided on time Penalty 5% Care is coordinated and patients can access support in the community Care is coordinated and patients can access support in the community 18

SERVICE SPECIFICATION

SERVICE SPECIFICATION SERVICE SPECIFICATION Service Childhood Immunisation Service Commissioner Lead Sarah Darcy Provider GP Confederation Mary Clarke Provider Lead Period 1 April 2018 to 31 2019 Date of Review December 2018

More information

Operational Focus: Performance

Operational Focus: Performance Operational Focus: Performance Sandra Iskander Changes for 2015/16 Change of focus of 18-weeks and A&E 4-hour wait targets as recommended by Sir Bruce Keogh, Medical Director, NHS England. 18-weeks to

More information

Oldham Council Provision of NHS Health Checks Programme in Partnership with Local GP Practices

Oldham Council Provision of NHS Health Checks Programme in Partnership with Local GP Practices Oldham Council Provision of NHS Health Checks Programme in Partnership with Local GP Practices 1. Population Needs 1. NATIONAL AND LOCAL CONTEXT 1.1 NATIONAL CONTEXT 1.1.1 Overview of commissioning responsibilities

More information

Improving Quality of Life of Long-Term Patient - From the Community Perspective

Improving Quality of Life of Long-Term Patient - From the Community Perspective Improving Quality of Life of Long-Term Patient - From the Community Perspective Dr Caz Sayer, Camden CCG Chair Working with the people of Camden to achieve the best health for all Context The Health and

More information

Outcomes benchmarking support packs: CCG level

Outcomes benchmarking support packs: CCG level Outcomes benchmarking support packs: CCG level NHS South Devon and Torbay CCG Produced with input from: Public Health England Forward and Introduction Local decision making is at the heart of the NHS,

More information

OUTLOOK FOR THE NEXT 5 YEARS OUR PLANS. September 2014

OUTLOOK FOR THE NEXT 5 YEARS OUR PLANS. September 2014 OUTLOOK FOR THE NEXT 5 YEARS OUR PLANS September 2014 1 SUMMARY Our vision for the City and Hackney health economy is: Patients in control of their health and wellbeing; A joined-up system which is safe,

More information

Final. Andrew McMylor / Dr Nicola Jones

Final. Andrew McMylor / Dr Nicola Jones NHS Standard Contract - Service Specification Service Specification Service Final 24hour Ambulatory Blood Pressure Monitoring (24hrABPM) Commissioner Lead Lead Andrew McMylor / Dr Nicola Jones Jeremy Fenwick,

More information

Commissioning for Quality and Innovation (CQUIN) Schemes for 2015/16

Commissioning for Quality and Innovation (CQUIN) Schemes for 2015/16 Commissioning for Quality and Innovation (CQUIN) Schemes for 2015/16 Goal No. Indicator Name Contract 1 Acute Kidney Injury CWS CCG Contract - National CQUIN 2a Sepsis Screening CWS CCG Contract - National

More information

Kingston Primary Care commissioning strategy Kingston Medical Services

Kingston Primary Care commissioning strategy Kingston Medical Services Kingston Primary Care commissioning strategy Kingston Medical Services Kathryn MacDermott Director of Planning and Primary Care Kathryn.macdermott@kingstonccg.nhs.uk kmacdermott@nhs.net 1 Contents 1. Introduction...

More information

NHS Bradford Districts CCG Commissioning Intentions 2016/17

NHS Bradford Districts CCG Commissioning Intentions 2016/17 NHS Bradford Districts CCG Commissioning Intentions 2016/17 Introduction This document sets out the high level commissioning intentions of NHS Bradford Districts Clinical Commissioning Group (BDCCG) for

More information

West Wandsworth Locality Update - July 2014

West Wandsworth Locality Update - July 2014 Attach 5 West Wandsworth Locality Update - July 2014 1) Introduction The West Wandsworth Locality covers the areas of Roehampton and Putney, and the nine practices that lie in these areas. The 2013 GP

More information

SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE

SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE Revised for: 1 April 2014 APPENDIX 2.4 SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE DORSET COUNTY COUNCIL Page 2 of 12 1. INTRODUCTION 1.1. This Specification

More information

City and Hackney Clinical Commissioning Group Prospectus May 2013

City and Hackney Clinical Commissioning Group Prospectus May 2013 City and Hackney Clinical Commissioning Group Prospectus May 2013 Foreword We are excited to be finally live as a CCG, picking up our responsibilities as commissioners for the bulk of the NHS. The changeover

More information

3. The requirements for taking part in the ES are as follows:

3. The requirements for taking part in the ES are as follows: Enhanced Service Specification Learning disabilities health check scheme Background and purpose 1. This enhanced service (ES) is designed to encourage practices to identify all patients aged 14 and over

More information

The Community Based Target Model

The Community Based Target Model 1 The Community Based Target Model Integrated Single System Leadership and Management The Core (as a minimum all LCNs should encompass) Working with High Impact Changes Lambeth Serving geographically coherent

More information

Preventing Heart Attacks and Strokes The Size of the Prize

Preventing Heart Attacks and Strokes The Size of the Prize Preventing Heart Attacks and Strokes The Size of the Prize Dr Matt Kearney General Practitioner and National Clinical Director for CVD Prevention NHS England and Public Health England The NHS needs a radical

More information

A. Commissioning for Quality and Innovation (CQUIN)

A. Commissioning for Quality and Innovation (CQUIN) A. Commissioning for Quality and Innovation (CQUIN) CQUIN Table 1: Summary of goals Total fund available: 3,039,000 (estimated, based on 2015/16 baseline) Goal Number 1 2 3 4 5 Goal Name Description of

More information

Main body of report Integrating health and care services in Norfolk and Waveney

Main body of report Integrating health and care services in Norfolk and Waveney Item 18.73a ii Norfolk and Waveney Sustainability and Transformation Plan Update for governing bodies and trust boards September 2018 Purpose of report The purpose of this paper is to update members of

More information

Our five year plan to improve health and wellbeing in Portsmouth

Our five year plan to improve health and wellbeing in Portsmouth Our five year plan to improve health and wellbeing in Portsmouth Contents Page 3 Page 4 Page 5 A Message from Dr Jim Hogan Who we are What we do Page 6 Page 7 Page 10 Who we work with Why do we need a

More information

Living With Long Term Conditions A Policy Framework

Living With Long Term Conditions A Policy Framework April 2012 Living With Long Term Conditions A Policy Framework Living with Long Term Conditions Contents Page Number Minister s Foreword 3 Introduction 4 Principles 13 Chapter 1 Working in partnership

More information

Bristol CCG North Somerset CGG South Gloucestershire CCG. Draft Commissioning Intentions for 2017/2018 and 2018/2019

Bristol CCG North Somerset CGG South Gloucestershire CCG. Draft Commissioning Intentions for 2017/2018 and 2018/2019 Bristol CCG North Somerset CGG South Gloucestershire CCG Draft Commissioning Intentions for 2017/2018 and 2018/2019 Programme Area Key intention Primary and community care Sustainable primary care Implement

More information

Metadata for the General Practice Outcome Standards

Metadata for the General Practice Outcome Standards Metadata for the General Practice Outcome Standards Version Status Date Revisions 1.01 Published December 2011-1.02 Published July 2012 The following new standards and indicators have been added: 6b, 25,

More information

Hospital Authority Key Performance Indicator Annual Review

Hospital Authority Key Performance Indicator Annual Review - 1 - For decision on 25.1.2018 AOM-P1352 Hospital Authority 2017 Key Performance Indicator Annual Review Purpose This paper informs Members of the progress of the 2017 Key Performance Indicator (KPI)

More information

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program: QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care

More information

Psychological Therapies for Depression and Anxiety Disorders in People with Longterm Physical Health Conditions or with Medically Unexplained Symptoms

Psychological Therapies for Depression and Anxiety Disorders in People with Longterm Physical Health Conditions or with Medically Unexplained Symptoms Psychological Therapies for Depression and Anxiety Disorders in People with Longterm Physical Health Conditions or with Medically Unexplained Symptoms Guide for setting up IAPT-LTC services 1. Aims The

More information

Reducing Variation in Primary Care Strategy

Reducing Variation in Primary Care Strategy Reducing Variation in Primary Care Strategy September 2014 Page 1 of 14 REDUCING VARIATION IN PRIMARY CARE STRATEGY 1. Introduction The Reducing Variation in Primary Care Strategy should be seen as one

More information

SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE

SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE Revised for: 1 April 2014 Appendix 2.3 SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE DORSET COUNTY COUNCIL Page 2 of 14 1. INTRODUCTION 1.1. This Service

More information

Powys Teaching Health Board. Respiratory Delivery Plan

Powys Teaching Health Board. Respiratory Delivery Plan Powys Teaching Health Board Respiratory Delivery Plan 2016-17 CONTENTS 1. BACKGROUD AND CONTEXT 1.1 The Vision 1.2 The Drivers 1.3 What do we want to achieve? 2. ORGANISATIONAL PROFILE 2.1 Overview 3.

More information

Quality and Leadership: Improving outcomes

Quality and Leadership: Improving outcomes Quality and Leadership: Improving outcomes Podiatry Managers/Allied Health Managers and Leaders 5 March 2014 Shelagh Morris OBE Acting Chief Allied Health Professions Officer 2 http://www.nhsemployers.org/aboutus/latest-news/pages/the-new-nhs-in-2013-infographic.aspx

More information

Lincolnshire JSNA: Chronic Obstructive Pulmonary Disease (COPD)

Lincolnshire JSNA: Chronic Obstructive Pulmonary Disease (COPD) Disease (COPD) What do we know? Summary is a long-term condition, which is affecting increasing numbers of people. There is a wide range of interventions to address COPD, from prevention to the ongoing

More information

Anti-Coagulation Monitoring (warfarin, acenocoumarol, phenindione) Primary Care Service (PCS:01) NHS Standard Contract Service Profile Pack ( )

Anti-Coagulation Monitoring (warfarin, acenocoumarol, phenindione) Primary Care Service (PCS:01) NHS Standard Contract Service Profile Pack ( ) Anti-Coagulation Monitoring (warfarin, acenocoumarol, phenindione) Primary Care Service (PCS:01) This pack contains: Standard Contract Service Profile Pack () 1. Service Specification: (to be inserted

More information

Do quality improvements in primary care reduce secondary care costs?

Do quality improvements in primary care reduce secondary care costs? Evidence in brief: Do quality improvements in primary care reduce secondary care costs? Findings from primary research into the impact of the Quality and Outcomes Framework on hospital costs and mortality

More information

Mental Health Financial Planning Frequently asked questions

Mental Health Financial Planning Frequently asked questions Mental Health Financial Planning Frequently asked questions 1. What is Mental Health Investment Standard (MHIS)? How is it calculated? The Mental Health Investment Standard (MHIS) was previously known

More information

NEW MODELS OF CARE AND THE PREVENTION AGENDA: AN INTEGRAL PARTNERSHIP CHAIR: ROB WEBSTER, CHIEF EXECUTIVE, NHS CONFEDERATION

NEW MODELS OF CARE AND THE PREVENTION AGENDA: AN INTEGRAL PARTNERSHIP CHAIR: ROB WEBSTER, CHIEF EXECUTIVE, NHS CONFEDERATION NEW MODELS OF CARE AND THE PREVENTION AGENDA: AN INTEGRAL PARTNERSHIP CHAIR: ROB WEBSTER, CHIEF EXECUTIVE, NHS CONFEDERATION 10.10am 10.30pm 11.15am 12.00pm 12.45pm 1.30pm 2.15pm 2.45pm 3.30pm Interview

More information

Commissioning for quality and innovation (CQUIN): 2014/15 guidance. February 2014

Commissioning for quality and innovation (CQUIN): 2014/15 guidance. February 2014 Commissioning for quality and innovation (CQUIN): 2014/15 guidance February 2014 1 NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning

More information

briefing Liaison psychiatry the way ahead Background Key points November 2012 Issue 249

briefing Liaison psychiatry the way ahead Background Key points November 2012 Issue 249 briefing November 2012 Issue 249 Liaison psychiatry the way ahead Key points Failing to deal with mental and physical health issues at the same time leads to poorer health outcomes and costs the NHS more

More information

Integrated Care theme / Long Term Conditions priority

Integrated Care theme / Long Term Conditions priority Integrated Care theme / Long Term Conditions priority Professor Ruth Chambers OBE Clinical lead for LTC priority/clinical lead for Flo telehealth exemplar of Integrated Care WMAHSN Integrated Care & other

More information

Integrated heart failure service working across the hospital and the community

Integrated heart failure service working across the hospital and the community Integrated heart failure service working across the hospital and the community Lynne Ruddick Professional Lead (South) British Heart Foundation 31st October 2017 Heart Failure is an epidemic. NICE has

More information

O U T C O M E. record-based. measures HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT

O U T C O M E. record-based. measures HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT record-based O U Michael Goldacre, David Yeates, Susan Flynn and Alastair Mason National Centre for Health Outcomes Development

More information

CA1 Enhanced Supportive Care for Advanced Cancer Patients

CA1 Enhanced Supportive Care for Advanced Cancer Patients CA1 Enhanced Supportive Care for Advanced Cancer Patients Scheme Name QIPP Reference Eligible Providers CA1 Enhanced Supportive Care (ESC) Access for Advanced Cancer Patients QIPP 16-17 S23- Cancer Cancer

More information

21 March NHS Providers ON THE DAY BRIEFING Page 1

21 March NHS Providers ON THE DAY BRIEFING Page 1 21 March 2018 NHS Providers ON THE DAY BRIEFING Page 1 2016-17 (Revised) 2017-18 (Revised) 2018-19 2019-20 (Indicative budget) 2020-21 (Indicative budget) Total revenue budget ( m) 106,528 110,002 114,269

More information

NICE guideline Published: 22 September 2017 nice.org.uk/guidance/ng74

NICE guideline Published: 22 September 2017 nice.org.uk/guidance/ng74 Intermediate care including reablement NICE guideline Published: 22 September 2017 nice.org.uk/guidance/ng74 NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

Working with GPs to help deliver the NHS Health Checks Programme

Working with GPs to help deliver the NHS Health Checks Programme Working with GPs to help deliver the NHS Health Checks Programme Dr Matt Kearney GP Castlefields, Runcorn National Clinical Advisor Public Health England and NHS England Why do we need GP engagement? 1.

More information

SUPPORTING PLANNING 2013/14 FOR CLINICAL COMMISSIONING GROUPs

SUPPORTING PLANNING 2013/14 FOR CLINICAL COMMISSIONING GROUPs SUPPORTING PLANNING 2013/14 FOR CLINICAL COMMISSIONING GROUPs December 2012 SUPPORTING PLANNING 2013/14 FOR CLINICAL COMMISSIONING GROUPS First published: 21 December 2012 2 Contents 1. INTRODUCTION...

More information

Council of Members. 20 January 2016

Council of Members. 20 January 2016 Council of Members 20 January 2016 Feedback on election process: Council of Members Chair and Deputy Chair Malcolm Hines, Chief Financial Officer Minutes of last meeting: 14 October 2015 Dr. Richard Proctor,

More information

SWLCC Update. Update December 2015

SWLCC Update. Update December 2015 SWLCC Update Update December 2015 Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth NHS Clinical Commissioning Groups and NHS England Working together to improve the quality of care in South West

More information

General Practice Outcome Standards: Technical Annex

General Practice Outcome Standards: Technical Annex General Practice Outcome Standards: Technical Annex 1 NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources

More information

Stockport Strategic Vision. for. Palliative Care and End of Life Care Services. Final Version. Ratified by the End of Life Care Programme Board

Stockport Strategic Vision. for. Palliative Care and End of Life Care Services. Final Version. Ratified by the End of Life Care Programme Board Stockport Strategic Vision for Palliative Care and End of Life Care Services Final Version Ratified by the End of Life Care Programme Board on 8 th February 2012 Clinical Commissioning Pathfinder Contents

More information

Evaluation Tool* Clinical Standards ~ March 2010 Chronic Obstructive Pulmonary Disease** Services

Evaluation Tool* Clinical Standards ~ March 2010 Chronic Obstructive Pulmonary Disease** Services Evaluation Tool* Clinical Standards ~ March 2010 Chronic Obstructive Pulmonary Disease** Services *Formerly known as Self-Assessment Framework ** Chronic Obstructive Pulmonary Disease (COPD) Standard 1:

More information

National Clinical Audit programme

National Clinical Audit programme National Clinical Audit programme Danny Keenan Medical Director www.hqip.org.uk Who are HQIP? HQIP is a not-for profit, professional/patient partnership, aiming to change and improve health and social

More information

Draft Commissioning Intentions

Draft Commissioning Intentions The future for Luton s primary care services Draft Commissioning Intentions 2013-14 The NHS will have less money to spend over the next three years. Overall, it has to make 20 billion of efficiency savings

More information

Chapter 2. At a glance. What is health coaching? How is health coaching defined?

Chapter 2. At a glance. What is health coaching? How is health coaching defined? Chapter 2 What is health coaching? This chapter describes: What health coaching is and it s applications How health coaching relates to wider systems and programmes of care How health coaching relates

More information

Commissioning for Value insight pack

Commissioning for Value insight pack Commissioning for Value insight pack NHS England Gateway ref: 00525 Contents Introduction: the call to action The approach Where to look using indicative data Phase 2 & 3 Why act what benefits do the population

More information

DRAFT Service Specification GP-led Urgent Treatment Centre (UTC) Service

DRAFT Service Specification GP-led Urgent Treatment Centre (UTC) Service DRAFT Service Specification GP-led Urgent Treatment Centre (UTC) Service Executive summary: The Cornwall Sustainability and Transformation Plan known as Shaping our Future will describe a new model of

More information

London Councils: Diabetes Integrated Care Research

London Councils: Diabetes Integrated Care Research London Councils: Diabetes Integrated Care Research SUMMARY REPORT Date: 13 th September 2011 In partnership with Contents 1 Introduction... 4 2 Opportunities within the context of health & social care

More information

A Step-by-Step Guide to Tackling your Challenges

A Step-by-Step Guide to Tackling your Challenges Institute for Innovation and Improvement A Step-by-Step to Tackling your Challenges Click to continue Introduction This book is your step-by-step to tackling your challenges using the appropriate service

More information

Suffolk Health and Care Review

Suffolk Health and Care Review Suffolk Health and Care Review Update on Health and Social Care System Redesign and Re-commissioning of GP Out of Hours, 111 and Community Healthcare services An Insight into the Health and Social Care

More information

SCHEDULE 2 THE SERVICES Service Specifications

SCHEDULE 2 THE SERVICES Service Specifications SCHEDULE 2 THE SERVICES Service Specifications Service Specification No Service ParaDoc Commissioner City and Hackney CCG Commissioner Lead Leah Herridge Provider CHUHSE Provider Lead Date of Review September

More information

Telford and Wrekin Clinical Commissioning Group. Prospectus 2013/2014

Telford and Wrekin Clinical Commissioning Group. Prospectus 2013/2014 Telford and Wrekin Clinical Commissioning Group Prospectus 2013/2014 Who we are Telford and Wrekin Clinical Commissioning Group (CCG) is responsible for healthcare in the Telford and Wrekin area. We Plan

More information

Review of Local Enhanced Services

Review of Local Enhanced Services Review of Local Enhanced Services 1. Background and context 1.1 CCGs are required to prepare for the phasing out of LESs by April 2014 by reviewing the existing LES portfolio and developing commissioning

More information

West Midlands Strategic Clinical Network & Senate Improving the detection and management of Atrial Fibrillation in Primary Care

West Midlands Strategic Clinical Network & Senate Improving the detection and management of Atrial Fibrillation in Primary Care West Midlands Strategic Clinical Network & Senate Improving the detection and management of Atrial Fibrillation in Primary Care Good Practice Guide Improving the detection and management of Atrial Fibrillation

More information

THE SERVICES. A. Service Specifications (B1) Ian Diley (Suffolk County Council)

THE SERVICES. A. Service Specifications (B1) Ian Diley (Suffolk County Council) THE SERVICES A. Service Specifications (B1) Service Specification No. Service Early Supported Discharge for Stroke Patients v5.0 Commissioner Lead Dr Mark Lim, T Woor (Suffolk Stroke Review Project Board)

More information

Alison Jamson, Head of Quality & Clinical Standards NHSMK&N Commissioning Support Hub

Alison Jamson, Head of Quality & Clinical Standards NHSMK&N Commissioning Support Hub Enc 11/10f Subject: Meeting: NHSMK CQUIN Schemes MK Commissioning Board Date of Meeting: 13 December 2011 Report of: Alison Jamson, Head of Quality & Clinical Standards NHSMK&N Commissioning Support Hub

More information

Enhanced service specification. Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people

Enhanced service specification. Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people Enhanced service specification Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people 1 Enhanced service specification Avoiding unplanned admissions: proactive case

More information

NHS Rushcliffe CCG Governing Body Meeting. CCG Improvement and Assurance Framework. 15 March 2018

NHS Rushcliffe CCG Governing Body Meeting. CCG Improvement and Assurance Framework. 15 March 2018 RCCG/GB/18/039 NHS Rushcliffe CCG Governing Body Meeting 15 March 2018 Introduction 1. This paper provides the Governing Body with an update on the progress being made by the Greater Nottingham CCGs in

More information

End of Life Care. LONDON: The Stationery Office Ordered by the House of Commons to be printed on 24 November 2008

End of Life Care. LONDON: The Stationery Office Ordered by the House of Commons to be printed on 24 November 2008 End of Life Care LONDON: The Stationery Office 14.35 Ordered by the House of Commons to be printed on 24 November 2008 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1043 Session 2007-2008 26 November

More information

Healthy London Partnership. Transforming London s health and care together

Healthy London Partnership. Transforming London s health and care together Healthy London Partnership Transforming London s health and care together London-wide transformation In 2014, two publications set out London s transformation priorities NHS Five Year Forward View Better

More information

Balanced Scorecard Performance Report 2017/18 Western Isles Health and Social Care Integration Partnership. v.1. December 2017

Balanced Scorecard Performance Report 2017/18 Western Isles Health and Social Care Integration Partnership. v.1. December 2017 IJB 19.12.17 ITEM: 7.1 PURPOSE: For Assurance Balanced Scorecard Performance Report 2017/18 Western Isles Health and Social Care Integration Partnership v.1 December 2017 Public Health Intelligence & Information

More information

Westminster Partnership Board for Health and Care. 17 January pm pm Room 5.3 at 15 Marylebone Road

Westminster Partnership Board for Health and Care. 17 January pm pm Room 5.3 at 15 Marylebone Road Westminster Partnership Board for Health and Care 17 January 2018 4.30pm - 6.00pm Room 5.3 at 15 Marylebone Road Agenda Item # Item and discussion points Lead Papers Timing 1 Preliminary business Welcome

More information

Final. Andrew McMylor / Dr Nicola Jones. Jeremy Fenwick, Battersea Healthcare CIC

Final. Andrew McMylor / Dr Nicola Jones. Jeremy Fenwick, Battersea Healthcare CIC NHS Standard Contract - Service Specification Service Specification Service Commissioner Lead Lead Final Primary Care Based 12-Lead Electrocardiogram Service Andrew McMylor / Dr Nicola Jones Jeremy Fenwick,

More information

2015/16 CQUIN Schemes

2015/16 CQUIN Schemes Barnet, Enfield & Haringey Mental Health Trust 2015/16 CQUIN Schemes Version: 3.0 Version Date Revision Author 1.0 30/03/15 Excel to Word Document A Bland 2.0 01/04/15 1 st Discussion with BEHMHT A Bland

More information

17. Updates on Progress from Last Year s JSNA

17. Updates on Progress from Last Year s JSNA 17. Updates on Progress from Last Year s JSNA 3. The Health of People in Bromley NHS Health Checks The previous JSNA reported that 35 (0.5%) patients were identified through NHS Health Checks with non-diabetic

More information

All clinical areas of the Trust All clinical Trust staff All adults with limited prognosis Palliative care team Approved. Purpose of this document

All clinical areas of the Trust All clinical Trust staff All adults with limited prognosis Palliative care team Approved. Purpose of this document Trust Policy and Procedure Document Ref. No: PP(15)310 End of Life Care For use in: For use by: For use for: Document owner: Status: All clinical areas of the Trust All clinical Trust staff All adults

More information

The PCT Guide to Applying the 10 High Impact Changes

The PCT Guide to Applying the 10 High Impact Changes The PCT Guide to Applying the 10 High Impact Changes This Guide has been produced by the NHS Modernisation Agency. For further information on the Agency or the 10 High Impact Changes please visit www.modern.nhs.uk

More information

Stage 2 GP longitudinal placement learning outcomes

Stage 2 GP longitudinal placement learning outcomes Faculty of Life Sciences and Medicine Department of Primary Care & Public Health Sciences Stage 2 GP longitudinal placement learning outcomes Description This block focuses on how people and their health

More information

Oxford Condition Management Programs:

Oxford Condition Management Programs: Oxford Condition Management Programs: Helping your employees learn, be encouraged and get support. Committed to helping improve the health and well-being of those we serve and improve the health care

More information

ANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010

ANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010 ANEURIN BEVAN HEALTH BOARD Stroke Delivery Plan Template for 2009/2010 Objective Action Desired Output / Monitor and manage all those at risk of stroke and, refer as appropriate to smoking cessation services,

More information

The incentives framework for ACOs

The incentives framework for ACOs New care models The incentives framework for ACOs Accountable Care Organisation (ACO) Contract package - supporting document Our values: clinical engagement, patient involvement, local ownership, national

More information

Sunderland Health & Care System Strategic Plan Version 1.0 Working Draft

Sunderland Health & Care System Strategic Plan Version 1.0 Working Draft Sunderland Health & Care System Strategic Plan 2014-2019 Version 1.0 Working Draft 1 Contents 1.0 Sunderland Health & Care System... 3 2.0 Our Vision and Strategic Objectives... 5 2.1 Our Vision for 2018/19...

More information

End of Life Care Strategy

End of Life Care Strategy End of Life Care Strategy 2016-2020 Foreword Southern Health NHS Foundation Trust is committed to providing the highest quality care for patients, their families and carers. Therefore, I am pleased to

More information

Welcome to. Northern England and the Five Year Forward View for Mental Health. Thursday 2 February 2017 at the Radisson Blu, Durham

Welcome to. Northern England and the Five Year Forward View for Mental Health. Thursday 2 February 2017 at the Radisson Blu, Durham Welcome to. Northern England and the Five Year Forward View for Mental Health Thursday 2 February 2017 at the Radisson Blu, Durham Introductions Chairs: Catherine Haigh, Chair of North East together and

More information

Changing for the Better 5 Year Strategic Plan

Changing for the Better 5 Year Strategic Plan Quality Care - for you, with you 5 Year Strategic Plan Contents: Section 1: Vision and Priorities for Change 3 Section 2: About the Trust 5 Section 3: Promoting Health & Wellbeing and Primary Care 6 Section

More information

Keenan Pharmacy Care Management (KPCM)

Keenan Pharmacy Care Management (KPCM) Keenan Pharmacy Care Management (KPCM) This program is an exclusive to KPS clients as an additional layer of pharmacy benefit management by engaging physicians and members directly to ensure that the best

More information

National Primary Care Cluster Event ABMU Health Board 13 th October 2016

National Primary Care Cluster Event ABMU Health Board 13 th October 2016 National Primary Care Cluster Event ABMU Health Board 13 th October 2016 1 National Primary Care Cluster Event - ABMU Health Board Introduction The development of primary and community services is a fundamental

More information

Integrated Health and Care in Ipswich and East Suffolk and West Suffolk. Service Model Version 1.0

Integrated Health and Care in Ipswich and East Suffolk and West Suffolk. Service Model Version 1.0 Integrated Health and Care in Ipswich and East Suffolk and West Suffolk Service Model Version 1.0 This document describes an integrated health and care service model and system for Ipswich and East and

More information

Performance and Quality Report Sean Morgan Director of Performance and Delivery Mary Hopper Director of Quality Dino Pardhanani, Clinical Director

Performance and Quality Report Sean Morgan Director of Performance and Delivery Mary Hopper Director of Quality Dino Pardhanani, Clinical Director Sutton CCG Clinical Commissioning Group Governing Body Date Thursday, 06 September 2018 Document Title Lead Director (Name and Role) Clinical Sponsor (Name and Role) Performance and Quality Report Sean

More information

DRAFT BUSINESS PLAN AND CORPORATE OBJECTIVES 2017/8

DRAFT BUSINESS PLAN AND CORPORATE OBJECTIVES 2017/8 DRAFT BUSINESS PLAN AND CORPORATE OBJECTIVES 2017/8 West London Clinical Commissioning Group This document sets out a clear set of plans and priorities for 2017/18 reflecting West London CCGs ambition

More information

Competencies for NHS Health Check Enhanced Service using the General Level Framework & Service Specification

Competencies for NHS Health Check Enhanced Service using the General Level Framework & Service Specification Competencies for NHS Health Check Enhanced Service using the General Level Framework & Service Specification This is a comprehensive mapping of the GLF against the enhanced service specification (where

More information

THE EMERGING PICTURE OF NEW CARE MODELS IN THE ENGLISH NHS

THE EMERGING PICTURE OF NEW CARE MODELS IN THE ENGLISH NHS THE EMERGING PICTURE OF NEW CARE MODELS IN THE ENGLISH NHS ICCHNR SYMPOSIUM University of Kent at Canterbury 15 th -16 th September 2016 Dr John M Ribchester GP Chair and Clinical Lead for Encompass MCP

More information

The National Audit on Schizophrenia. A Commissioners Perspective. Dr Sohrab Panday General Medical Practitioner

The National Audit on Schizophrenia. A Commissioners Perspective. Dr Sohrab Panday General Medical Practitioner The National Audit on Schizophrenia A Commissioners Perspective Dr Sohrab Panday General Medical Practitioner Mental Health Clinical Lead Peterborough LCG Amber Valley LCG Hardwick CCG NHS England Clinical

More information

INNOVATION, HEALTH AND WEALTH A SCORECARD

INNOVATION, HEALTH AND WEALTH A SCORECARD INNOVATION, HEALTH AND WEALTH A SCORECARD Page 2 CONTENTS 4 EXECUTIVE SUMMARY 6 INTRODUCTION 7 3 MILLION LIVES 9 INTRA-OPERATIVE FLUID MANAGEMENT/OESOPHAGEAL DOPPLER MONITORING 11 CHILD IN A CHAIR IN A

More information

DRAFT OUTCOME FRAMEWORK REPORT

DRAFT OUTCOME FRAMEWORK REPORT Shaping health and care in Mid-Nottinghamshire Mid-Nottinghamshire Better Together Programme DRAFT OUTCOME FRAMEWORK REPORT December 2014 Introduction Purpose of Framework and approach In mid-nottinghamshire,

More information

Aneurin Bevan Health Board. Living Well, Living Longer: Inverse Care Law Programme

Aneurin Bevan Health Board. Living Well, Living Longer: Inverse Care Law Programme Aneurin Bevan Health Board Living Well, Living Longer: Inverse Care Law Programme 1 Introduction The purpose of this paper is to seek the Board s agreement to a set of priority statements for an Inverse

More information

National Clinical Audit & Patient Outcome Programme: An update

National Clinical Audit & Patient Outcome Programme: An update National Clinical Audit & Patient Outcome Programme: An update Jenny Mooney Director of Operations www.hqip.org.uk Healthcare Quality Improvement Partnership Our structure and funding The National Clinical

More information

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE SCOPE

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE SCOPE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE 1 Guideline title SCOPE Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes 1.1 Short title Medicines

More information

Local Enhanced Service Agreement 1 July March 2016

Local Enhanced Service Agreement 1 July March 2016 Local Enhanced Service Agreement 1 July 2013 31 March 2016 Recognition and Management of People with Dementia and their Family/Carers in General Practices in Bristol Agreement between NHS Bristol Clinical

More information

South East London Area Prescribing Committee (APC) 9 October at Lower Marsh. Final minutes

South East London Area Prescribing Committee (APC) 9 October at Lower Marsh. Final minutes South East London Area Prescribing Committee (APC) 9 October at Lower Marsh Final minutes 1. Welcome, Introductions and Apologies received. 2. Conflicts of Interest declarations The Chair requested any

More information

Enhanced service specification. Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people 2016/17

Enhanced service specification. Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people 2016/17 Enhanced service specification Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people 2016/17 NHS England INFORMATION READER BOX Directorate Medical Commissioning

More information

NHS Leeds West CCG Clinical Commissioning Strategy. 2013/14 to 2015/16

NHS Leeds West CCG Clinical Commissioning Strategy. 2013/14 to 2015/16 NHS Leeds West CCG Clinical Commissioning Strategy 2013/14 to 2015/16 Working together locally to achieve the best health and care in all our communities 1 Contents Section 1: Summary Page 3 Section 2:

More information

Dany Bell Macmillan National Programme Lead Treatment and Recovery

Dany Bell Macmillan National Programme Lead Treatment and Recovery Dany Bell Macmillan National Programme Lead Treatment and Recovery Acrylic effect painted panels Implementing Recovery Package and Stratified Pathways: A case Study of implementing the Recovery Package

More information