ANALYSIS OF PRIMARY AND COMMUNITY CARE

Transcription

1 ANALYSIS OF PRIMARY AND COMMUNITY CARE TO SUPPORT THE DEVELOPMENT OF THE PRIMARY AND COMMUNITY CARE STRATEGY A report from BDO to Clinical Commissioning Group May 2013

2 CONTENTS Page Introduction 3 Methodology 4 Analysis Findings 9 Appendix 1 Data Analysis 21 Appendix 1A Level Analysis 23 Appendix 1B Locality Level Analysis 69 Appendix 1C Strategy and Document Review 91

3 INTRODUCTION Background to the Review Background are developing a Primary and Community Care Strategy for the period 2013/14 until 2017/18. This strategy will articulate the strategic context for primary and community care, analyse the current state of services and assess what primary and community care services will need to look like in order to meet the objectives of s Strategic Plan and the TSA Community Based Care Strategy. Drivers for the Primary and Community Care Strategy The now has a statutory responsibility for primary care improvement s Integrated Plan focuses on improving key patient level outcomes: primary care is often a key provider in achieving these improved outcomes Currently there is significant variation in the quality and outcomes provided by practices The Trust Strategic Administrator (TSA) proposals for South East London rely on s delivering a Community Based Care strategy including improving the quality and responsiveness of primary care s QIPP plans assume an increasing level of shift of care from acute services into community and primary care service. We will need to ensure that there is sufficient quality, capacity and capability to take on additional responsibilities The needs to develop a strong working relationship with the NCB, and a clear commissioning strategy for primary care improvement will support this developing relationship. Strategy Development There are three steps to developing the strategy: 1. Undertake an analysis of current quality, variation, capacity and capability and assess against desired levels 2. Generation of options to develop primary and community care to meet strategic objectives 3. Develop strategy including implementation plan. This Document This document summarises and details the analysis phase of the development of the strategy, and sets out the approach that has been taken. The following stage of this process, as described above, will be for stakeholder engagement to continue, and to focus upon options for the development of primary care based upon this analysis.

4 METHODOLOGY Approach Data Sources A comprehensive range of data have been analysed from a variety of sources. Analysis The analysis is categorised into that which indicates Capacity & Capability and Quality & Variability. It is presented for the whole of and for each locality in turn. Priorities Four priority areas have been identified from this analysis. Options A number of options will be developed in order to address these priorities. Data Sources Analysis Priorities Options General Practice Outcome Standards Practice Trend Analysis Primary Care Dashboard GP Patient Survey LES Data/QOF data Engagement and Locality Events Demand & Capacity Data Quality & Variability Capacity & Capability GP Practice Variation Community Based Services Integration (Care Coordination) Access Tbc Tbc Tbc Tbc

5 METHODOLOGY Data Sources Data Sources Practice Trend Analysis General Practice Outcomes Standards Quality and Outcomes Framework GP Demand and Capacity Primary Research Analysis Indicators analysed A&E Attendances, Outpatient New Referrals, A&E Band 5 (Minor) Attendances and referral to Cardiology and Dermatology and the rates used are per 1000 patients to adjust for variations in list sizes. Where the information is available, has been externally benchmarked with London SHA and England averages for the same indicators. Internal Benchmarking High volume specialties analysed Gynaecology, Ophthalmology, Dermatology, Trauma & Orthopaedics and Cardiology. The graphs show the referral rates (per 1000) by each practice grouped into localities where the referral is made by a GP. All indicators that are available have been analysed, graphs showing locality level scores against the total for with London Averages highlighted. All Clinical Indicators that are available have been analysed at practice level. Graphs showing locality level scores against the total for with National Averages highlighted. GP Demand and Capacity data was collected by practices completing the Royal College of General Practitioners treating access toolkit. Data was collated to show demand and capacity for same day and advance appointments across a named week. In addition practice staffing levels were recorded. Graphs provide data from a week decided by the by the practice between 25th February th March GP Patient Surveys We analysed the percentage of standardised answers to three questions in the survey: 1) When did you want to see/speak to your GP? 2) How long till you actually saw/spoke to a GP/Nurse? 3) What did you do if you couldn t get an appointment? We compared the data for to the National Average and then compared the survey results at practice level.

6 METHODOLOGY Data Sources Data Sources Community Data Strategy & Document Review LES Data GP Community Services GP PMS Contract Analysis Combined Community Health Services Reports were reviewed as were CQIN reports where they related to primary care and/or capacity. The main areas were around immunisation, Falls, sickness and cancelled appointments. A review of the priorities set out in the s Integrated Plan was undertaken to ensure consistency. QIPP plans were also reviewed as it was vital that when considering options, those which support delivery of QIPP targets are prioritised. The Dulwich Consultation was also reviewed to ensure that any recommendations made in this review are consistent with this key, linked project. The Community Based Care (TSA) Strategy was also constantly reviewed to ensure findings and plans would support the wider aims of the SEL CBC Strategy. A review of the LESs held by the s practices was undertaken to understand the scope and breadth and performance against targets. Comparisons against target; benchmarking between practice and locality; and where applicable, against national levels of achievement were undertaken. The community services below were also reviewed, and the findings incorporated in this report: -Phlebotomy -Adult audiology -Dermatology -Headache/Neurology -ENT -Ophthalmology A review of the GP contract to understand the range and scope of services to be provided as part of the PMS Contract

7 METHODOLOGY Data Sources Data Sources Dashboard Analysis The indicators analysed are: Patients with hypertension, as a ratio of expected Patients with CHD, as a ratio of expected Patients with COPD, as a ratio of expected Patients with diabetes as ratio of expected Dementia prevalence as % of list size A&E attendance Rate as % of list size 4 week smoking quit rate as % of setters Diabetic patients with an HbA1c of 8% or less LTC patients with smoking status recorded by GP Flu immunisation (wider risk groups) Patients screened for alcohol use as % of newly registered Proportion of patients with recorded BMI (Adults) Medicines management RAG progress on QPI Patient satisfaction with quality of practice care Patient satisfaction with access to GP Benchmarking graphs Each practice is colour coded by locality. Where the data was available, the England, London and averages are displayed. These charts are presented for all of the indicators above. National quartile charts Using the percentile information from the dashboard we grouped the practices according to the national quartile they fall into. Related indicators are presented together for comparison for example Patients with diabetes as ratio of expected and Diabetic patients with an HbA1c of 8% or less.

8 ANALYSIS: FINDINGS

9 ANALYSIS Summary of Findings The findings from this project have been grouped into four priority areas. These priorities have been selected based upon the findings from the analysis, and from discussion with the project steering group. The priority areas are as follows: GP Practice Variation Access Community Based Services Integration (Care Coordination) It is recognised that there will be duplication between these priority areas, and that key themes will run through a number of priorities. However, after discussion it has been agreed that these represent the clearest method for describing the analytical findings, and can be linked both from existing strategic documents and through to options to be set out in the Primary and Community Care Strategy. The following section of the report therefore sets out how the findings of the analysis support the selection of these priorities for the Primary and Community Care Strategy.

10 ANALYSIS GP Practice Variation (1) Domain Findings Data Sources Q&V C&C Q&V C&C Q&V C&C Outlier Practices Lower levels of overall variation but with significant outlier practices in GPOS Identifying Cancer Domain, GPOS Cervical Cytology Domain, Total Number of Minor Surgery Procedures. Demand and Capacity Variation Nearly 80% of practices returned data for the sample period. There is significant variation in demand and capacity between practices. Several practices having twice as much demand than overall capacity on a weekly basis, about 30% of practices have approximately equal demand to capacity, however there are around 60% of practices who have greater capacity than demand (including nursing capacity). On a daily basis demand and capacity is significantly mismatched, but over the week this may appear more balanced than is reality on a day-to-day basis. Same Day Appointment Request There is considerable variability in patients who being report being able to see / speak to GP or Nurse on the same day they request an appointment. Demand and Capacity Data Collection Practices do not routinely collect demand and capacity data. Total numbers/rates of appointments supplied per annum is not collected or monitored by the. ICP Programme Quantitative analysis suggests that the opportunity to identify and risk manage the older population is not being maximised due to the poor take up of the Older People ICP Programme. GPOS Identifying Cancer Domain GPOS Cervical Cytology Domain Total Number of Minor Surgery Procedures. Total Weekly Capacity:Demand Ratio Analysis GP Patient Survey Jan-Sept 2012 Verbal Enquiry LES - ICP Programme performance graphs

11 ANALYSIS GP Practice Variation (2) Domain Findings Data Sources Q&V Q&V C&C C&C Q&V Q&V Feedback to Practices Practices are not provided with regular comprehensive performance against peers; Some pieces of data are not being provided at practice level to practices Some data is provided but not in a timely/actionable way Some data is being provided and in timely way but is not benchmarked against peers If relative performance information is not provided in a timely and actionable manner then opportunity to take remedial action is limited. Enhanced Service Planning There is considerable variation at practice level in how and which enhanced services are provided (e.g. Phlebotomy). No evidence was found that these are arranged in a planned and strategic manner and no evidence was found this reflects where need exists. There was strong evidence patients find this confusing and inequitable. Extended Hours Specifically relating to Extended Hours we have found no evidence that provision is tested against local requirements and there is variability in provision. In addition to this feedback suggests patients are dissatisfied and confused with the current configuration of extended hours. Healthcheck uptake Qualitative evidence suggests there is a staggered roll out rates are low and highly variable (primary prevention) Cardiovascular Screening and Secondary Prevention Qualitative evidence suggests QOF Ratio of expected to ratio is overrepresented in the lower quartile (secondary prevention). Qualitative analysis suggests are weak on secondary prevention and disease management when compared to the national average. GP Practice Dashboard QOF Reports Primary and Community Care Review Analysis Enhanced services graph Feedback from Out of Hospital Engagement event (DN - Check patient survey and strategy documents) LES Graphs Feedback from Out of Hospital Engagement event Demand and Capacity Analysis - % of patients with Healthcheck in 5 years QOF Long Term Conditions Prevalence as Ratio of Expected (practices by quartile) Coronary Heart Disease Total % Points QOF

12 ANALYSIS GP Practice Variation (3) Domain Findings Data Sources Q&V C&C C&C C&C C&C Q&V Q&V Broad Variation Significant practice variation across Mental Health QOF Domain and Flu Vaccine Uptake Over 65s (2012/13 YTD) areas in the Q&V analysis. Clinician Capacity Primary research and quantitative analysis suggests overall demand and capacity can be managed more effectively on a day to day basis without necessarily increasing overall capacity Healthchecks Evidence Base Qualitative information suggests GP are not convinced by evidence base for healthchecks qualitative locality meetings Clinician Capacity Qualitative information suggests there are not enough staff with the right skills available to undertake healthchecks within practices Clinician Capacity / Capability Quantitative evidence suggests of the 25% sample who returned the demand and capacity research under 1 WTE (within the sample of 25%) was identified as a clinician with special interest within CVR (Hypertension) Diabetes Screening QOF Ratio of expected to ratio is significantly overrepresented in the lower quartile and not represented in top quartile (secondary prevention) Diabetic Case Management Performance on management of patients with Diabetes is below national average (both on aggregate DM QOF score and key QOF indicators) but appears to be due to (x outlier practices) rather than sub-optimal performance across. Mental Health QOF Domain Flu Vaccine Uptake Over 65s (2012/13 YTD) Total Weekly Capacity:Demand Ratio Analysis Feedback from Locality Meetings Feedback from Locality Meetings GPSI Demand and Capacity Analysis QOF Long Term Conditions Prevalence as Ratio of Expected (practices by quartile) QOF Long Term Conditions Prevalence as Ratio of Expected (practices by quartile)

13 ANALYSIS GP Practice Variation (4) Domain Findings Data Sources Q&V Q&V Q&V Q&V Q&V Q&V C&C Childhood Immunisation Completion Childhood immunisation data 11/12 shows under 5 completion of all immunisations is 83% and varies by locality from 79%-88%. Childhood Immunisation Drop-off Childhood immunisation data 11/12 shows drop off from U2 to U5 of 7% across and 13% in B&R. Performance Management System Child - Complicated measurement of current year performance HV CQUIN target relative to previous GP CQUIN performance. Difficult to attribute performance to each party, and to monitor overall trend Childhood Immunisation Performance Management Child - For contribution by Health Visitors measured by individual immunisation the CQUIN targets were not met in 11/12 Flu Performance Flu Variable performance of achievement against the 65% LES target (for example some practices are immunising only 50% of over 65 s). Although overall average is above 65%. Locality Flu Performance Flu - Variability by locality can be seen as B&W are out performing the other localities quite significantly IT Systems Qualitative feedback - IT Systems do not offer easy transparency regarding immunisation status to primary care 2011/12 Immunisation Rates by Locality 2011/12 Immunisation Rates by Locality Childhood Immunisation Graph 11/12 Childhood Immunisation Graph 11/12 Flu Vaccine - Over 65s Flu Vaccination Uptake by Locality (2012/13) (page 36) Locality Meeting Feedback

14 ANALYSIS GP Practice Variation (5) Domain Findings Data Sources Q&V Q&V C&C Q&V Q&V Q&V Mental Health QOF Performance Across QOF mental health (schizophrenia, bipolar disorder and other psychoses) domain, is performing below national average (95%) variability by locality and by practice with eleven practices achieving 100% and three practices achieving 55%. Depression QOF Performance Overall performance in QOF Depression domain and GPOS depression scores is below national average and highly variable by practice and locality. These QOF scores mostly pertain to initial and repeat severity assessment of depression. There is no objective data about the quality and capacity of subsequent access for therapies (eg. IAPT) in the community for this group of patients. QOF Cancer performance Nearly a third of practices are not having regular (at least 3-monthly) multidisciplinary case review meetings for all palliative care patients. Over 80% of practices were reviewing >90% patients with a new diagnosis of cancer within 6 months. The remainder were reviewing >80%, with the exception of one practice who only reviewed just over 50%. Cancer screening 39 out of 47 practices score higher than the London average for Identifying Cancer (higher scores highlight poorer performance), with 13 practices at Trigger 2 levels (more than 2 standard deviations from expected target). Cervical Cancer screening Across, cervical screening performance is slightly below London average, although there is variation between localities, with SSWK performing above average, and B&R below average. Mental Health Domain Total % QOF Points showing locality and practice variation QOF & GPOS depression graph QOF End of Life charts 2011/12 QOF Cancer charts 2011/12 GPOS 2011/12 GPOS cervical screening charts 2011/12

15 ANALYSIS Community Based Services Domain Findings Data Sources Q&V C&C C&C C&C Access to Diagnostics (e.g. Phlebotomy, ECGs, Ultrasound scans) There is considerable variation at practice level in how and which enhanced services are provided (e.g. Phlebotomy, including near patient testing / Warfarin). There is no quantitative evidence around the availability of provision of other community diagnostics (e.g. ECG, Ultrasound Scan) however qualitative feedback from patients suggests this would be valued no clear consensus emerging for patients for what form that might take (i.e. Hub or every practice) Pharmacist Use Qualitative feedback from patients and potential providers (e.g. Pharmacists) was that patients would like to see (and Pharmacists were capable of providing) a far greater range of services, which would extend the opening hours and ease of access for this type of service. Extending the range of services where they are already successful and new initiatives where they have the capability (e.g. Smoking cessation, screening, minor ailment) Community Provider Appointments Quantitative data on the Community Provider services (Health Visiting, District Nursing, AHP) suggests there is potential for improvement relating to appointments cancelled by service Enhanced Services Feedback from Out of Hospital Engagement event Feedback from Out of Hospital Engagement event LES Smoking Cessation Community Performance Data Source: CHS Combined Commissioner reports January-September C&C Range of GP led Outpatient Services The following services were identified as being available in the community; Adult Audiology, Dermatology, Headache / Neurology, ENT, Ophthalmology. There is limited information on the patient eligibility for these services, performance monitoring or whether this range of services remains appropriate currently. Patients reported they were unclear about the rationale for their location. Feedback from Out of Hospital Engagement event Community Service Descriptions

16 ANALYSIS Integration (Care Coordination/ Patient Friendly Care) Domain Findings Data Sources C&C Q&V C&C Q&V Q&V Q&V Q&V Information Management Qualitative feedback from patients suggests there is considerable scope to improve information management in Primary Care, this includes reporting of results, online appointment booking, online repeat prescription and potential for online consultations. As a result of the lack of available information patients reported they were required to repeat their story on numerous occasions. Co-ordinated Services Qualitative feedback suggests lack of joined up, consistent services with different support workers providing care on a daily basis. This results in repetition of both giving and receiving information, conflicting information being provided by the service and a lack of trust between patient and service. Case Management There is quantitative and qualitative information which suggests patients would benefit from explicit co-ordination of their care. Patients expressed a lack of clarity of where within the pathway they sat, a lack of consistency in management and lack of an overall, appropriate care plan. As a result they were required to repeat their story on numerous occasions. Co-production Patients reported a clear desire to be more involved in the co-production (outcomes, process, evaluation, monitoring) of their care. In particular they wanted measures and goals which were more meaningful to them. Falls There was no evidence that Falls are being monitored and performance incentivised in 2012/13 Community Services Contract despite non-achievement of CQUIN targets in 2011/12. Transport There was significant feedback from numerous stakeholders (including patients and providers) that existing transport arrangements do not support the current and planned location of services. Feedback from Out of Hospital Engagement event Feedback from Out of Hospital Engagement event Frail Elderly Group Feedback from Out of Hospital Engagement event LES ICP LES - LTC Feedback from Out of Hospital Engagement event CQUIN Graph (11/12) Feedback from Out of Hospital Engagement event

17 ANALYSIS Access (1) Domain Findings Data Sources C&C C&C C&C C&C Demand and Capacity Variation Nearly 80% of practices returned data for the sample period. There is significant variation in demand and capacity between practices. Several practices having twice as much demand than overall capacity on a weekly basis, about 30% of practices have approximately equal demand to capacity, however there are around 60% of practices who have greater capacity than demand (including nursing capacity). On a daily basis demand and capacity is significantly mismatched, but over the week this may appear more balanced than is reality on a day-to-day basis. Demand and Capacity Benchmarking More than 65% of practices in offer more than the closest available RCGP benchmark of 83 appointments per 1,000 patients per week *(nursing and GP appointments), suggesting in general terms that access issues relate more to excess demand on a weekly basis than a significant shortfall in capacity. However, there may be still some shortfall in capacity on a daily basis (Figures 37 and 40). A higher proportion of respondents stated that there were not appointments for the day they wanted compared to the national average. Of those respondents who could not get an appointment for the day they wanted a higher proportion attended A&E / Walk in Centres when compared to the national average Total Weekly Capacity:Demand Ratio Analysis Figures 37 & 40 *RCGP Scotland survey of total demand in 51 GP Practices (2010) ** Most English benchmarks relate to GP appointments only and use 70 appointments/1000 patients/week GP Patient Survey Jan-Sept 2012 GP Patient Survey Jan-Sept 2012 C&C A lesser proportion of respondents were able to see a GP/Nurse on the same day or on the next working day when compared to the national average GP Patient Survey Jan-Sept 2012

18 ANALYSIS Access (2) Domain Findings Data Sources Q&V There is considerable variability in practices seeing / speaking to patients on the same day they request an appointment. GP Patient Survey Jan-Sept 2012 C&C C&C Q&V Q&V C&C Extended Hours Specifically relating to Extended Hours we have found no evidence that provision is tested against local requirements and there is variability in provision. In addition to this feedback suggests patients are dissatisfied and confused with the current configuration of extended hours. Practice Access There is evidence demand is not always matched to supply, particularly on a daily basis, although some practices are achieving this. patients who cannot access a GP service are more likely to choose and attend A&E as the alternative when compared to the national average. Currently A&E attendance data is not being reporting in a format which allows for benchmarking against national average. Signposting Feedback suggests that patients would benefit from better signposting of urgent care services to ensure they access the right place at the right time. Feedback also suggests that traditional signposting methods are not proving successful. Pro-active Care for Long term Conditions Data supported by qualitative feedback from patients suggests that some practices are not embracing proactive care for patients with long-term conditions (take-up of healthchecks, take up of ICP, screening and management of QOF for long-term conditions). There is qualitative evidence that this group of patients access urgent hospital services as an alternative to primary care. Feedback from practices suggests there is both a question regarding the evidence base for Health Checks and their capacity to be able to deliver them. LES Graphs Feedback from Out of Hospital Engagement event Demand and Capacity Analysis Demand & Capacity A&E Activity Data GP Patient Survey A&E Attendance graph Feedback from Locality Meetings Feedback from Out of Hospital Engagement event Feedback from Out of Hospital Engagement event (LTC Group) QOF Data LES Data (Health Checks and ICP) Feedback from Locality Meetings

19 ANALYSIS Access (3) Domain Findings Data Sources Q&V C&C C&C C&C Q&V Access to Diagnostics (e.g. Phlebotomy, ECGs, Ultrasound scans) There is considerable variation at practice level in how and which enhanced services are provided (e.g. Phlebotomy, including near patient testing / Warfarin). There is no quantitative evidence around the availability of provision of other community diagnostics (e.g. ECG, Ultrasound Scan) however qualitative feedback from patients suggests this would be valued no clear consensus emerging for patients for what form that might take (i.e. Hub or every practice) Pharmacist Use Qualitative feedback from patients and potential providers (e.g. Pharmacists) was that patients would like to see (and Pharmacists were capable of providing) a far greater range of services, which would extend the opening hours and ease of access for this type of service. Extending the range of services where they are already successful and new initiatives where they have the capability (e.g. Smoking cessation, screening, minor ailment) Range of GP led Outpatient Services The following services were identified as being available in the community; Adult Audiology, Dermatology, Headache / Neurology, ENT, Ophthalmology. There is limited information on the patient eligibility for these services, performance monitoring or whether this range of services remains appropriate currently. Patients reported they were unclear about the rationale for their location. Transport There was significant feedback from numerous stakeholders (including patients and providers) that existing transport arrangements do not support the current and planned location of services. Enhanced Services Feedback from Out of Hospital Engagement event Feedback from Out of Hospital Engagement event LES Smoking Cessation Feedback from Out of Hospital Engagement event Community Service Descriptions Feedback from Out of Hospital Engagement event

20 ANALYSIS Access (4) Domain Findings Data Sources C&C C&C Q&V C&C C&C Dementia Care QOF Performance Whilst the quantitative analysis does not reveal a problem with dementia care in identification or management within QOF requirements, qualitative feedback suggests management of this condition in particular causes GP practices concern. There is no objective data about the extent of comprehensive provision of care for this group. Capacity and Capability Qualitative feedback suggests; A need for mental health education and training for all healthcare professionals, A greater awareness of mental health issues Capacity in primary care to indentify and manage mental health issues in an integrated manner with physical health. A&E Activity Qualitative feedback suggests that disproportionate numbers of A&E attendances are generated by care home residents, with a peak of activity in the afternoon for this patient group. A&E Attendances There is considerable variation (>100%) in A&E Minor attendance by practice, feedback from locality meetings suggests this could be due specific practice demographics rather than appointment availability. No evidence has been found that specific services or initiatives are targeting these groups. Depression QOF & GPOS Domain Total % QOF Points showing locality and practice variation Feedback from Out of Hospital Engagement event Stakeholder Interviews A&E Minors Graph Feedback from Locality meetings

21 APPENDIX 1: DATA ANALYSIS

22 ANALYSIS Structure and Presentation The following sections set out the detailed findings from the analysis. The Appendices are split into level analysis (all the analysis, focussing on the as a whole) and Locality level analysis (comparison between locality). These appendices include an assessment of both Quality and Variability, and Capacity and Capability. Within each Appendix a series of tables highlight key findings from each chart, with the actual charts following the tables. All findings are referenced to the relevant chart. Category Description Appendix Level Analysis Locality Level Analysis Quality and Variability Capacity and Capability Document and Strategy Review The level analysis addresses the quality and variability, and capacity and capability across the across all metrics. This includes external benchmarking where possible and covers a range of diverse measures The locality level analysis compares the three localities with each other and also with the internal or external benchmarks where information is available. For some indicators, a comparison between the various practices within each locality is also shown. Quality is defined as the effectiveness and safety of care provided, together with patient perception and feedback on the service. This also includes an assessment of the variability of this quality across the The capacity across primary and community care in, in terms of available and accessible services and appointments, and the skills that exist across the area in order to deliver both existing and extended services An overview of strategies that impact on the Primary and Community Care Strategy. Note that the SEL Community Based Care Strategy will be considered in more detail at the development of options stage 1A 1B Within both 1A and 1B 1C

23 APPENDIX 1A: LEVEL ANALYSIS

24 ANALYSIS Level Analysis Capacity & Capability Key In total weekly demand is less than capacity for GP surgery appointments at the 36 practices who completed the research In total Monday and Tuesday both show greater demand than capacity compared to the remaining days in the week - with the gap at the highest level on a Monday In comparison Wednesday, Thursday and Friday show greater capacity than demand with the gap at the highest level on Thursday In total demand and capacity both gradually decrease through the week (i.e. Demand and capacity are at the greatest on Monday and lowest on Friday) Monday shows significantly more demand for appointments than any other day in the week, with Friday being the day that least appointments are requested A proxy for Community Services capacity waste is the cancelled by service appointments and the patient DNAs. The sum of these two equate to circa 13% of capacity being lost to the service. Figure 36 Figure 36 Figure 36 Figure 36 Figure 36 Figure 30-33

25 ANALYSIS Level Analysis Quality and Variability Key The data shows considerable variation amongst practices and localities for different indicators around the usage of secondary care Figures 1-3 Increase in A&E minor attendances across all three localities. Figure 3 39 out of 47 practices score higher than the London average for Identifying Cancer (higher scores highlight poorer performance), with 13 practices at Trigger 2 levels (more than 2 standard deviations from expected target). Figure 10

26 ANALYSIS Level Analysis Quality and Variability Key A large proportion of practices in are in the bottom quartile nationally for screening indicators, particularly for Diabetes Over 40% of practices fall within the lower or 2 nd quartile for patient satisfaction with access. There is considerable variation amongst practices Around 2/3 rd of practices fall within the lower or 2 nd quartile for patient satisfaction with quality. High levels of variation amongst practices Mental health % QOF scores have huge variability within. is also considerably below the national average Childhood Immunisation (Note: current year LES for immunisation has not been used as performance figures are only available for Qtr 1 in ) Despite the presence of a LES and a Community CQUIN for immunisation, does not achieve the national average take up rate of 95% in 2011/12. The is a marked fall off in rates in 2011/12 after the initial early years immunisations, so that children appear not to be fully immunised before entering fulltime education. There is a difference in 2011/12 between localities with South falling below the average of 90% The current year community CQUIN measurement is unclear in that the aim is to reduce the shortfall in MMR, but it does not provide a clear indication of achievement. Potentially the targets are set too low at 50% and 40% reduced shortfall respectively for Under 5 and Under 2 years of age. Its is of interest to note that the targets were not achieved at Q4 in the Community CQUIN for immunisation. Figures 4-6 Figure 7 Figure 8 Figure 9 Figure 12 Figure 12 Figure 12 Figure Figure 13-14

27 ANALYSIS Level Analysis Quality and Variability Key A large proportion of practices in are in the bottom quartile nationally for these indicators, particularly for Diabetes Minor Surgery (Note: this is 3 months data only) Wide range of levels of activity undertaken, some practices undertaking much less per year which raises clinical competency and thresholds for payment questions Wide range of procedures undertaken, but majority are related to contraceptive care rather than typically minor surgery? A small number of practices typically under take the majority of the procedures, particularly relating to minor surgery ( rather than contraception). Notably P5, P22 and P31 Excision and aspiration; and P35 cryotherapy. Total amount of vasectomies undertaken across the s is small with notable variation between localities with SSW locality undertaking very few, even noting that this is just one quarter There is some variation across the Practices for Flu Vaccine take up for the over 65s age group. With P8, P9, P29 and P35 noticeably below the average Figures 4-6 Figure 16 Figure 17 Figures Figure 21 Figure 22 B&W locality are performing notably better than the two other localities for Flu Vaccine take up in the over 65s Figure 23 Very few Health Checks have been undertaken across the by 31 st December All but 5 Practices have undertaken less than 10% of the Checks for eligible patients Very few patients have been called for a Health Check demonstrating that the challenge is in the calling for patients, rather than patients failing to respond There is a direct correlation between those called for and those having had a Health Check completed for the most successful Practice e.g. P42 it is suggestive that Health Checks are not carried out opportunistically Figure 24 Figure 25 Figures 24-25

28 ANALYSIS Level Analysis Quality and Variability Key Limited outcome data is available on the Integrated Care Programme. Whilst almost half of GP practices have signed up for the ICP LES, a very small number appear to have created the register to enable Patient to be called for the Holistic Health -Assessment (HHA) and therefore only a small number (4%) of those eligible for an HHA have had one. All patients following an HHA have some type of intervention with approximately 20% being given advise by the assessor and 80% being referred on for further advise/intervention Community services appeared to not achieve the falls CQUIN target in Although falls are presumably still measured, there is no CQUIN for Falls in the current year. The LES Contract for smoking states; For Practices that achieve a successful quit ratio of 35% or above that will be rated as green for Practices that achieve a successful quit ratio between 28% and 34% will be rated as amber. For all practices that achieve less than 28% will be rated as red... This does not affect payment but may be seen as an indicator for effectiveness with the deciding whether to take forward Practice LESs where the Set to Quit percentage is less than 30% set to quit rate is currently less than 30%, although it is recognised that the final quarter typically has a good return. Even the 30% target is well short of London average Set to Quit rate of 46%. It is interesting to note that although Community Pharmacy Set to Quit rate is only marginally higher than that of the GPs, the verification by CO2 levels is significantly higher. The achievement of 12% Chlamydia screening of the target population for falls very short of the 35% target. SSW Locality achieved just over 6% as the lowest performing Locality and B&W Locality the highest with 17% Interesting to note is those Practices which appear to have a LES are not necessarily the highest performers P1, P5, P33, P35 are below the average for Chlamydia screening Figure 26 Figure 26 Figure 29 Figures Figures Figures Figure 34 Figure 35

29 P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 P21 P22 P23 P24 P25 P26 P27 P28 P29 P30 P31 P32 P33 P34 P35 P36 P37 P38 P39 P40 P41 P42 P43 P44 P45 P46 B&R B&W SSO SOU Rate per 1000 ANALYSIS Level Analysis Outpatient Activity Figure 1 - Outpatient New / Source: S Practice Trend Analysis,

30 P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 P21 P22 P23 P24 P25 P26 P27 P28 P29 P30 P31 P32 P33 P34 P35 P36 P37 P38 P39 P40 P41 P42 P43 P44 P45 P46 B&R B&W SSO SOU Rate per 1000 ANALYSIS Level Analysis A&E Activity Figure 2 - A&E (Combined) / Source: S Practice Trend Analysis,

31 P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 P21 P22 P23 P24 P25 P26 P27 P28 P29 P30 P31 P32 P33 P34 P35 P36 P37 P38 P39 P40 P41 P42 P43 P44 P45 P46 B&R B&W SSO SOU A&E Minor Activity per 1000 population ANALYSIS Level Analysis A&E Minors Activity Figure 3 - A&E Band 5 (Minors) Activity Source: S Practice Trend Analysis,

32 ANALYSIS Level Analysis Long Term Conditions This graph shows the number of practices in falling into each national quartile, for the screening indicators when comparing patients with clinical conditions as ratio of expected Figure 4 - QOF Prevalence as Ratio of Expected (practices by quartile) Lower quartile 2nd quartile 3rd quartile Upper quartile Hypertension CHD COPD Diabetes Source: Primary Care Dashboard, QOF

33 ANALYSIS Level Analysis These graphs show the number of practices in falling into each national quartile Diabetes Indicators Lower quartile 2nd quartile 3rd quartile Upper quartile GP Survey Satisfaction Indicators Lower quartile 2nd quartile 3rd quartile Upper quartile Diabetes as ratio of expected HbA1c <8 14 Satisfied with Quality Figure 5 Figure 6 Source: Primary Care Dashboard, QOF Satisfied with Access

34 P37 P40 P43 P6 P19 P16 P5 P29 P27 P18 P9 P42 P4 P17 P3 P32 P26 P25 P46 P15 P33 P30 P23 P14 P20 P11 P24 P10 P21 P22 P8 P44 P39 P31 P36 P34 P45 P1 P12 P13 P28 P38 P7 P41 P2 P % 90.0% ANALYSIS Level Analysis Patient Satisfaction Figure 7 - % of patients satisfied with access SSWK B&R B&W England Average London Average Average 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Source: Primary Care Dashboard, QOF

35 P6 P37 P14 P29 P27 P11 P15 P42 P21 P32 P13 P18 P30 P33 P40 P45 P22 P4 P9 P44 P43 P19 P16 P10 P3 P5 P23 P34 P12 P1 P26 P17 P46 P35 P31 P39 P38 P7 P20 P36 P25 P8 P24 P2 P % 90.0% ANALYSIS Level Analysis Patient Satisfaction Figure 8 - % of patients satisfied with quality SSWK B&R B&W England Average London Average Average 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Source: Primary Care Dashboard, QOF

36 % Points Scored ANALYSIS Level Analysis Mental Health 100.0% Figure 9 - Mental Health Domain Total % QOF Points showing locality and practice variation 95.0% 90.0% 85.0% 80.0% 75.0% National Average 70.0% 65.0% 60.0% 55.0% For Mental Health Domain Total % QOF points graph below there are three practices scoring below 55.5% and eleven practices scoring 100% 50.0% B&R B&W SSWK Sou Source: Quality Outcomes Framework,

37 Points Scored ANALYSIS Level Analysis - Cancer Figure 10 - Identifying Cancer Points Achieved using General Practice Outcomes Standards Framework showing locality and practice variation 39 out of 47 practices score higher than the London average for Identifying Cancer (higher scores highlight poorer performance), with 13 practices at Trigger 2 levels (more than 2 standard deviations from expected target) London Average The dots on the chart show that for Cancer Domain Total % QOF points there is one practice scoring below 0.50 and one practice scoring B&R B&W SSWK Sou High scores highlight good performance Source: General Practice Outcomes Standards,

38 % Points ANALYSIS Level Analysis - Screening Figure 11 - Cervical Cytology Points Achieved using General Practice Outcomes Standards Framework showing locality and practice variation London Average The dots on the chart show that for Mental Health Domain Total % QOF points there is one practice scoring below 40.0 and one practice scoring above B&R B&W SSWK Sou High scores highlight good performance Source: General Practice Outcomes Standards,

39 % of Children Immunised ANALYSIS Level Analysis Childhood Immunisation Rates Figure /12 Immunisation Rates by Locality U2 Average U5 Average National Target* B&R Average B&W Average SSWK Average Average Source: Childhood Immunisation data 2011/12 * Department of Health Strategic Document, Immunisation-Appendices.pdf

40 % achievement of target % achievemnt of target ANALYSIS Level Analysis Childhood Immunisation Rates Figure 13 - Reduced shortfall of MMR 2 immunisations through Health Visitor Team involvement Figure 14 - Reduced shortfall of preschool booster immunisations through Health Visitor Team involvement Actual Target Actual Target Q1 Q2 Q3 Q4 0 Q1 Q2 Q3 Q4 Source: Community CQUIN Report Qtr v5

41 ANALYSIS Level Analysis Childhood Immunisation Rates Figure 15 - Reduced shortfall of preschool booster immunisations through Health Visitor Team involvement, FU and immunisation 50% 45% 40% 35% 30% 25% 20% Q4 target Q4 actual 15% 10% 5% 0% 1st DTaP/IPV/Hib PCV 1st MMR 2nd MMR Preschool Booster Source: GSTFT CHS CQUIN report 2011/12 Qtr 4 v2

42 ANALYSIS Level Analysis Minor Surgery Figure 16 - Minor Surgery - All Procedure Types ( ) Injections of Goserelin / Leuprorelin Acetate Aspiration Excision Cryotherapy IUDs fitted Insertion of subcutaneous contraceptive Patients with Dermal implant fitted Introduction of Mirena coil Patients with IUD fitted Patients with IUS (Mirena) fitted Injection Patients with IUD removed IUDs checked Use of non-specific minor surgery codes Removal of subcutaneous contraceptive Patients with Dermal implant removed Implant insertion - non-contraceptive Cautery Removal of Mirena coil Patients with IUS (Mirena) removed Bilateral vasectomy for contraception Check of Mirena coil IUDs removed Other minor surgery IUDs replaced Morning after IUDs fitted Injection of sclerosing substance into haemorrhoid Number of Procedures in 3 months Source Document: QMS Stats on date 2012/12/31for PCT Data for latest 3 months available ending 31 Dec 2012

43 P5 P35 P1 P11 P31 P21 P2 P30 P38 P22 P34 P10 P32 P45 P15 P20 P42 P46 P8 P28 P44 P47 P6 P29 P14 P37 P17 P33 P39 P18 P27 P26 P7 P19 P12 P36 P23 P13 P25 P16 P24 P40 P4 P41 P3 P9 Number of Procedures ANALYSIS Level Analysis Minor Surgery Figure 17 - Total Number of Minor Surgery Procedures Source Document: QMS Stats on date 2012/12/31for PCT Data for latest 3 months available ending 31 Dec 2012

44 Number of procedures in 3 months Number of Procedures in 3 months Number of Procedures in 3 months Number of Procedures in 3 months ANALYSIS Level Analysis Minor Surgery Figure 18 - Cryotherapy (Total procedures = 170) Figure 19 - Aspiration (Total procedures = 229) P35 P1 P38 P11 P5 P22 0 P5 P31 P22 P45 P30 P33 P Figure 20 - Excision (Total procedures = 207) P5 P31 P22 P34 P11 P1 P10 Source Document: QMS Stats on date for PCT. Data for latest 3 months available ending 31 Dec Figure 21 - Bilateral Vasectomy for Contraception (shown by Locality due to low volume) (Total procedures = 17) Total

45 % of patient uptake ANALYSIS Level Analysis Flu Vaccine Figure 22 - Flu Vaccine Uptake Over 65s (2012/13 YTD) % Uptake Average LES Target P4 P19 P23 P30 P38 P41 P7 P14 P17 P22 P32 P43 P1 P3 P9 P12 P15 P25 P28 P34 P36 P40 P44 Source Document: Flu take up Current Year to Date: Flu payments (report) Sept-Jan 2013 as at

46 % of patient uptake ANALYSIS Level Analysis Flu Vaccine Figure /13 Over 65s Flu Vaccination Uptake by Locality % Uptake B&R Average B&W Average SSWK Average Average Source Document: Flu take up Current Year to Date: Flu payments (report) Sept-Jan 2013 as at

47 P41 P3 P9 P36 P39 P38 P29 P8 P30 P19 P4 P40 P16 P43 P28 P46 P13 P24 P12 P23 P45 P33 P18 P1 P44 P20 P25 P22 P7 P10 P15 P2 P35 P21 P26 P31 P27 P32 P11 P34 P5 P37 P6 P14 P17 P42 % of eligible Patients with Health Check completed ANALYSIS Level Analysis Health Checks 35% 30% 25% Figure % of patients with NHS Health Check in last 5 years* (eligible at time of check) LES target % expected to be invited in LES target % expected to be completed in % 15% 10% 5% 0% Source Document: QMS Stats on date 2012/12/31 for PCT *Health checks started in January 2012

48 P41 P3 P9 P42 P17 P14 P6 P37 P11 P32 P5 P34 P27 P21 P35 P7 P26 P31 P2 P15 P10 P22 P23 P25 P44 P1 P18 P20 P33 P45 P24 P46 P13 P43 P12 P28 P16 P40 P19 P4 P30 P8 P29 P38 P39 P36 % of eligible Patients with no Health Check or invite ANALYSIS Level Analysis Health Checks Figure % of patients currently eligible for NHS Health Check, WITHOUT an invitation (or check) in last 5 years 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source Document: QMS Stats on date 2012/12/31 for PCT

49 % Achievement ANALYSIS Level Analysis Integrated Care Programme 100% Figure 26 ICP Achievement Against Range of Requirements ( ) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of Practices signed-up Patients on ICP Register - Elderly at Risk Patients on the ICP register who are eligible for a Holistic Health Assessment HHAs carried out year to date Of patients having had an HHA % referred or signposted to other services Of patients having had an HHA % given health promotion and lifestyle advice Source Document: QMS Stats on date 2012/12/31 for PCT

50 ANALYSIS Level Analysis Smoking Cessation target % Quitters at 4 wks (Set to Quit) = 30% London average % Quitters at 4 wks = 46% 70% Figure 27 - GP Totals: Quitters at 4 weeks 90% Figure 28 - Community Pharmacy Totals: Quitters at 4 weeks 60% 80% 50% 40% 70% 60% 50% 30% 40% 20% 30% 10% 0% % quitters at 4 weeks % CO verified (of quitters) % not quit % lost to follow up 20% 10% 0% % quitters at 4 weeks % CO verified (of quitters) % not quit % lost to follow up % not reported Source: Local Outcome Summary Report: GP YTD (Smoking) and Local Outcome Summary Report: CP YTD (Smoking)

51 Number of Falls ANALYSIS Level Analysis - Community Services Figure 29 - Number of falls outturn Lambeth and Number of Falls Target Q1 Q2 Q3 Q4 Annual target only appears to have been set; showing in Q4 Source: GSTFT CHS CQUIN Report Qtr 4 V2; Actual number of falls for patients admitted to community services at GSTFT except Inpatients

52 Number of Appointments Number of Appointments Number of Appointments Number of Appointments ANALYSIS Level Analysis Community Services Figure 30 - Number of Cancelled Appts in Community Services Month Figure 32 - Number of DNAs to Community Services Figure 31 - Percentage of Cancelled Appts in Community Services Month Figure 33 - Percentage of DNAs to Community Services Month Month Source: CHS Combined Commissioner reports January-September

53 % of population screened ANALYSIS Level Analysis - Chlamydia Screening SW target is 35% of eligible population 18% Figure 34 - Chlamydia Screening - % Screened 2011/12 16% 14% 12% 10% 8% % Screened Average 6% 4% 2% 0% B&R Average B&W Average SSWK Average Source: Chlamydia LES Payment (report)

54 % of patients screened ANALYSIS Level Analysis - Chlamydia Screening SW target is 35% of eligible population 60% Figure 35 - Chlamydia Screening - % Screened Practices with LES 50% 40% 30% % Patients Screened Average 20% 10% 0% P1 P2 P5 P7 P11 P18 P21 P24 P30 P33 P35 P38 P43 P46 Source: Chlamydia LES Payment (report), sorted by LES holding Practices

55 ANALYSIS Demand & Capacity Analysis - Key Findings The Demand and Capacity analysis represented the first of a several stage process, and as such is only a snapshot of the annual picture. The findings should be viewed simultaneously in order to provide a complete picture of the situation for the period studied- no single graph can be interpreted in isolation. It is possible to infer the following conclusions: a) weekly demand and capacity graph highlights that, broadly speaking patient demand is met by capacity supplied during the week across the - but see note (f) on capacity supplied (Figure 36). b) When investigated further, total practice level demand:capacity suggests there is considerable variation between practice demand and capacity, with many practices having more capacity than demand over the week. However some of this may include excess nursing capacity (Figure 37). c) In order to understand this variation on a daily basis, two practices which showed equal demand and capacity (i.e. Offering equal appointments to patient demand) were chosen to be analysed from the perspective of daily variation. This highlighted that one practice was consistently offering appointments equal to demand (or offering extra appointments on a daily basis), whereas the other had significant fluctuations in daily appointments (on certain days they were offering too many appointments for the demand but on others they were offering less than the total demand (Figures 38-39)). d) To provide benchmarking where available, RCGP research in England suggested practices routinely offering more than 70 GP appointments per 1,000 patients per week were more often able to meet patient demand than those offering fewer than 70. Those offering a supply of less than 70 GP appointments per 1,000 per week often experienced difficulty with access. e) In addition, the RCGP estimated that in the closest available benchmark for total capacity (GP and nursing) the contact rate for Scottish practices was approximately 83 face to face contacts per 1,000 patients per week, (62 of these being GP contacts) for an average standardised practice. It is likely that many practices would require more than this in order to meet demand. f) More than 95% of practices in offer more than 70 total appointments per 1,000 patients per week, and 65% offer more than 83 total appointments per week, suggesting in general terms across the that access issues largely relate to daily demand variation, and high levels of demand, rather than capacity supplied (Figures 37 and 40).

56 Weekly Demand and Capacity ANALYSIS Demand & Capacity Analysis - Key Findings Figure 36 - Total Weekly Demand and Capacity Capacity Demand Monday Tuesday Wednesday Thursday Friday Total Source: GP Demand and Capacity Primary Research, March April 2013

57 P20 P2 P5 P30 P21 P33 P46 P9 P35 P10 P40 P15 P8 P1 P34 P25 P42 P29 P36 P17 P37 P16 P11 P12 P19 P45 P13 P38 P43 P7 P32 P18 P27 Demand > Capacity Capacity > Demand Weekly Ratio of Capacity:Demand ANALYSIS Demand & Capacity Analysis - Key Findings 4.00 Figure 37 - Total Weekly Capacity:Demand Ratio Outlier practices excluded Source: GP Demand and Capacity Primary Research, March April 2013

58 Ratio of Capacity:Demand Ratio of Capacity:Demand ANALYSIS Demand & Capacity Analysis - Key Findings Figure 38 - Practice 30 Daily Capacity:Demand Ratio Figure 39 - Practice 9 Daily Capacity:Demand Ratio Illustration of practices with seemingly well matched demand and capacity on a weekly basis this can mask daily variation which is critical to consider see Figure 39 Source: GP Demand and Capacity Primary Research, March April 2013

59 Number of appointments offered per 1000 registered patients per week P20 P2 P5 P30 P21 P33 P46 P24 P6 P28 P9 P35 P10 P40 P15 P8 P1 P34 P25 P42 P29 P36 P17 P37 P16 P11 P12 P19 P45 P13 P38 P43 P7 P32 P18 P27 ANALYSIS Demand & Capacity Analysis - Key Findings 160 Figure 40 - practices number of appointments (GP & Nursing) offered per 1000 registered patients per week RCGP Benchmark for GPs RCGP Benchmark for GPs & Nurses Source: GP Demand and Capacity Primary Research, March April 2013 Benchmark provided by RCGP Guidelines -

60 ANALYSIS Level Analysis - GP Patient Survey Figure 41 - Reason for not being able to get an appointment/ appointment offered inconvenient National Average There weren't appointments for the day I wanted There weren't appointments for the time I wanted I couldnt see my preferred GP I couldn't book ahead at my GP surgery Figure 42 - What did you do on that occasion? National Average Went to the appointment I was offered Got an appointment for a different day Had a Went to A&E/ a consultation walk-in centre over the phone Saw a pharmacist Decided to contact my surgery another time Didnt see or speak to anyone Source: GP Patient Survey Results Jan Sept 2012

61 ANALYSIS Level Analysis - GP Patient Survey Figure 43 - How long was it until you actually saw or spoke to a GP/Nurse National Average On the same day On the next working day A few days later A week or more later Source: GP Patient Survey Results Jan Sept 2012

62 % of appointments on the same day ANALYSIS Level Analysis - GP Patient Survey Figure 44 - How long was it until you actually saw/spoke to a GP/Nurse? (% On the same day) 70% 60% 50% 40% 30% Average 20% 10% 0% P4 P19 P23 P30 P38 P41 P7 P14 P17 P22 P32 P44 P1 P3 P9 P12 P15 P25 P28 P34 P36 P40 P45 Source: GP Patient Survey Results Jan Sept 2012

63 ANALYSIS Community Diagnostics - Phlebotomy The Phlebotomy Review (July 2012) - 83% of practices take blood at the practice - Of those which don't, 43% said they would be willing to do so - There is an average of 15 sessions per practice per month that patients can access phlebotomy - Most practices reported requesting up to 500 blood tests per month from their practice-based phlebotomy services (with two significant outliers of over 1200) however with significant variation between practices - 83% of Practices reported that they fund the Phlebotomy services that are provided on site. However, no evidence of specific LES payments associated with these services could be found in primary care contracts. Other providers account for the other 17%. Suggested improvements: - More sessions available at the practice wider hours of opening - More flexible locations including co-locating with other diagnostic or therapeutic services to save unnecessary patient journeys - Shorter waiting times from ordering a test to getting results Three options described (none selected as yet): - Universal practice-based services (except in the smallest practices) - Locality-based services - Mobile services