Oxfordshire Primary Care Commissioning Committee. Date of Meeting: 3 January 2017 Paper No: 9

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1 Oxfordshire Clinical Commissioning Group Oxfordshire Primary Care Commissioning Committee Date of Meeting: 3 January 2017 Paper No: 9 Title of Presentation: OCCG Primary Care Locally Commissioned Services Is this paper for (Delete as appropriate) Discussion Decision Information Purpose of Paper: This paper provides a summary of the locally commissioned services under the OCCG Contract for Primary Services (formerly Local Enhanced Services). Action Required: OPCCC are asked to note the report. Authors: Jill Gillett, Senior Commissioning Manager Primary Care Sara Wallcraft, Project Manager - Primary Care Louise Carlisle, Primary Care Contracts Officer 1

2 OCCG Primary Care Contract: Summary Quarter 2 The table below summarises the position at the end of Quarter 2 and the forecast position at year end. Activity is collected on a quarterly basis and this represents the most recent financial update. The contract is showing a forecast underspend of 383k. Service No of Practices providing service (Total of 75 at Q2) Budget Q1-2 Planned Q1-2 Actual Variance (o/s : u/s) % Variance Forecast M12 Arrhythmia 35/75 33,537 16,769 15,270-1,499-9% - 2,997 Completion of an Episode of Surgical 71/75 354,116 Care 177, ,683 15,625 9% 31,250 Dermatology (Cancer monitoring) 60/75 56,247 28,123 29,865 1,742 6% 3,483 Diabetes Care 74/75 145, , ,360-4,640-3% - 9,280 DVT Diagnosis 29/75 22,440 11,220 12,690 1,470 13% 2,940 Leg Ulcer Care & Management 65/75 311, , ,665 14,105 9% 28,210 Minor Injuries 70/75 190,520 95,260 99,540 4,280 4% 8,560 Newborn Checks 66/75 27,595 13,797 22,516 8,719 63% 17,437 Near Patient Testing 74/75 410, , ,911 3,762 2% 7,525 Proactive GP Support to Care Homes 34/75 1,000, , , ,238-42% - 420,476 Secondary care-requested procedures 74/75 265, , ,348 19,598 15% 39,196 Warfarin monitoring 74/75 788, , ,566-18,626-5% - 37,252 Primary Care Memory Assessment 30/75 35,000 17,500 9,250-8,250-47% - 16,500 Contingency 35,236 17, , % - 35,236 Total OCCG P. Care Contract 3,674,992 1,837, ,718, ,570-10% - 383,140 2

3 Overview of OCCG Primary Care Locally Commissioned Services Arrhythmia This service covers the use of cardiac event monitors for the diagnosis of patients presenting with suspected arrhythmia/palpitations in practice premises, or within the community. The assessment and treatment of patients presenting with arrhythmia/palpitations has traditionally been carried out in secondary care settings, either requiring a referral from their GP or presentation at A&E and have traditionally required a series of diagnostic tests to be performed. This service allows the GP to make an informed decision for those patients presenting with arrhythmia/palpitations based on the findings of the primary care testing and the interpretation and advice given through secondary care. It is expected that a lesser number of referrals to secondary care would ensue. Completion of an Episode of Surgical Care This service is for practices to provide post-operative wound management that fits within the scope of primary care, such as suture removal, wound monitoring, and dressing changes. This is a service for practices to provide wound management following a surgical procedure in secondary care, where it is either inconvenient or undesirable for the patient to attend at hospital. This enables these services to be kept within primary care, providing care closer to home for patients, and reducing secondary care activity. Issues This service is currently over-budget due to a high numbers of claims for this service in general, and a greater than anticipated number of claims for more complex procedures, which are paid at a higher rate. Audits are underway to ensure that claims are being made appropriately, and practices have been asked to recheck any claims that appear to be higher than anticipated. 3

4 Dermatology (Cancer Monitoring) This service is for patients with certain specific skin cancer diagnoses to have ongoing monitoring in primary care, where appropriate, following national guidelines and in partnership with secondary care. This includes some skin cancers that have been diagnosed as low and medium risk and require ongoing monitoring, and follow-up after diagnosis and treatment once the patient has been discharged from hospital. The aim of this service is to provide care closer to home for patients, ensuring that they are monitored regularly and in a way that is convenient for them, to detect any malignant change/recurrence in-line with national guidelines, as part of the process following discharge from secondary care. Diabetes Care To provide longer GP and nurse appointments which will enable clinicians to focus on improving health outcomes for patients with diabetes by monitoring and improving control of blood pressure, cholesterol and blood glucose levels and reducing the risk of any complications of diabetes, such as cardiovascular disease, kidney failure and lower limb amputation. To promote participation of all OCCG practices in the National Diabetes Audit (NDA) which so that the CCG has robust data across all of Oxon practices on processes and outcomes in people with diabetes To promote in particular measurement of urine Albumin Creatinine Ratio (ACR), an important marker of increased Cardiovascular Disease (CVD) risk and long term risk of renal disease To reduce health inequalities This service was introduced in 2016/17 and utilised the released PMS funding. Deep Vein Thrombosis Diagnosis This service will support practices to provide Deep Vein Thrombosis assessment and identification in practice premises, or within the community. The assessment and treatment of patients with suspected Deep Vein Thrombosis (DVT) is a significant source of admissions to the Oxford Haemophilia and Thrombosis Centre (OHTC) and the Medical Assessment Unit at Horton Hospital. 4

5 Developments in the assessment and identification of DVT mean that this condition can be identified in primary care in an effective and safe way when combined with improved access to Ultrasound. This service is designed to aid the introduction of a primary care DVT assessment service and prevent those with a low probability of a DVT having to attend the hospital DVT clinic. Leg Ulcer Care & Management The aim of the service is to appropriately manage the care of patients with new and existing leg ulceration who would benefit from compression therapy. The objectives of the service are to: To provide nursing assessment and diagnosis of leg ulcers for ambulant patients To provide on-going treatment and evaluation up to healing To provide support for aftercare and prevention of reoccurrence of ulceration To provide educational advice to support patients in the management of their skin Issues This service is currently over-budget, due to a higher number of claims than expected from a number of practices. An audit is underway to ensure that claims are being made appropriately, as per the service specification, and practices have been asked to recheck the data they have submitted for payment ahead of audit visits in the new year. Minor Injuries This is a service for the assessment, treatment, and/or management within primary care of lacerations, minor head injuries that do not meet guidelines for referral to emergency departments, foreign bodies in the skin, ear and nose, non-penetrating foreign bodies in the eye, joint sprains, and superficial burns. This service is aimed at reducing attendance at emergency departments and minor injury units. 5

6 Issues This service is currently over-budget, due to a higher number of claims than expected from a number of practices. An audit is underway to ensure that claims are being made appropriately, as per the service specification, and practices have been asked to recheck the data they have submitted for payment ahead of audit visits in the new year. Newborn Checks In line with current clinical practice all neonates can expect to receive a medical examination within 72 hours of birth. Oxfordshire CCG currently commissions this from secondary care to be carried out before discharge, however, it is recognised that some mothers choose a home birth and that newborns can be discharged from hospital quite quickly meaning the test is not always carried out at the hospital. The aim of commissioning GPs to carry out this examination is to: Support women in their choice to have home based intrapartum care Support a limited number of early discharged newborns Ensure appropriate examination of the newborn is undertaken This service in no way replaces the need for intrapartum care to be provided by the Hospital Maternity Departments, as the normal route. Near Patient Testing The near patient testing shared care monitoring service is designed to be one in which: (i) therapy should normally be initiated in secondary care, for recognised indications for specified lengths of time (ii) maintenance of patients should be properly controlled in line with a shared care protocol (iii) the service to the patient is convenient (iv) the need for continuation of therapy is reviewed regularly (v) the therapy is discontinued when appropriate. (vi) the use of the resources by the National Health Service is efficient It has been shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out in a well-organised way, close to the patient s home. This service is deemed to be best provided by GPs as part of the integrated care package and ensures that responsibility for prescribing and monitoring of these drugs stays together. 6

7 Proactive GP Support to Care Homes This service aims for residential and nursing homes to become the responsibility of one specific GP practice, with as many patients as possible registered with that practice, thus enabling the GP to deliver care to the patients in the home in the most coordinated and efficient way. It provides a weekly visit to the home with the aim of improving the quality of care and reducing emergency admissions. This service aims to address the specific additional primary healthcare needs of patients in nursing and residential care homes, recognising the benefits of working in partnership with the home, and noting the additional input required from GP practices to ensure the highest quality of care and to avoid unnecessary hospital admissions. Issues This service is currently under budget, as not all practices in Oxfordshire have chosen to take up this scheme. Currently, 34 practices are signed up to the scheme, covering 60 homes (out of 109 eligible homes in Oxfordshire). The CCG is looking at ways to encourage practices to sign up to the service, and also at alternative methods of supporting care homes to provide the best quality of care for their residents. Secondary care-requested procedures These are two services for practices to deliver the following: Blood tests at the request of secondary care providers, in advance of an upcoming hospital outpatient appointment. Aural toilet (ear syringing) at the request of secondary care providers, in advance of an upcoming Ear, Nose and Throat Department or other NHS audiology service outpatient appointment. The intended impact is to provide care closer to home for patients, avoid unnecessary hospital appointments, and reduce expenditure in secondary care. Issues This service is currently over-budget, due to a higher number of claims than expected from a number of practices. An audit is underway to ensure that claims are being made appropriately (e.g. in advance of a secondary care attendance), and practices have been asked to recheck the data they have submitted for payment, ahead of audit visits in the new year. 7

8 Warfarin monitoring To monitor patients on warfarin in practice premises or within the community. Therapy is normally initiated in secondary care, for recognised conditions, for specified lengths of time. Patients can have blood taken closer to home. Primary Care Memory Assessment The Primary Care Memory Assessment Service (PCMAS) aims to achieve a user-friendly dementia pathway for easier access to a more timely diagnosis and support services. Primary care is well placed to play a bigger role in the treatment and care of patients with dementia and improve the rate of diagnosis. This supports national strategy to increase timely diagnosis of dementia and recognises that GPs play an active role in the diagnosis and management of patients with dementia. Summary There are continuing pressures on the budget for wound care activity (Completion of an Episode of Surgical Care), leg ulcer management and secondary care-requested procedures, which are by and large offset by underactivity in other services. The main area of underspend is the Proactive GP Support to Care Homes service, where uptake in practices has stabilised around 55%. An initiative proposed by NOXMED and PML earlier in the year has not resulted in a firm proposal for an alternative service. A number of services have been in place for many years and it is thus difficult to attribute a reduction in secondary care activity to these schemes. Contract negotiations with the LMC will commence in January and will include an exploration of options to move from an item of service payment approach to block payments for groups of services where activity is relatively stable year on year. 8