Primary Care Commissioning Committee

Primary Care Commissioning Committee 1. Date of Meeting: 15 th March, 2018 2. Title of Report: Primary Care Commissioning Report 3. Key Messages: The Personal Medical Services ( PMS ) Practices have continued to submit evidence to demonstrate the achievement of key performance indicators ( KPIs ). Based on the evidence submitted at quarter three, the Primary Care Operational Group has recommended that full premium payment is made to those Practices. Significant engagement has continued whilst the Primary Care Commissioning for Quality and Innovation Scheme (CQUIN) has been developed to reflect Practice concerns and align to commissioning intentions. The consultation has included feedback from individual Practices, discussion at Network and Cluster meetings as well as with the Local Medical Committee. Although minor amendments may still need to be made, a final draft has been produced with significant input from Clinical Commissioning Group, Primary Care, Local Medical Committee, Cheshire and Wirral Partnership and Local Authority colleagues. Finance within this scheme has been approved by the Finance, Performance and Commissioning Committee and this scheme is on track for launch at 3 rd April, 2018. 4. Recommendations The Primary Care Commissioning Committee is asked to: Note the work carried out to date by Personal Medical Services Practices at quarter three. Approve the payment of the premium to those Practices by NHS England on the basis of work completed. Note the work carried out to date to develop and negotiation the Primary Care CQUIN. Approve the draft specification, noting that minor changes may still be required before launch. 5. Report Prepared By: Tanya Jefcoate-Malam, Deputy Head of Primary Care March, 2018 Primary Care Commissioning Report 1

PURPOSE NHS WEST CHESHIRE CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE PRIMARY CARE COMMISSIONING REPORT 1. The purpose of this report is to update the Primary Care Commissioning Committee on developments in the commissioning of services from West Cheshire GP Practices, and to request approval to relevant schemes and specifications. PERSONAL MEDICAL SERVICES KEY PERFORMANCE INDICATORS 2. Five West Cheshire Practices remain on a PMS contract, with their premium reducing over four years until April 2020. In order to receive their PMS Premium funding, these five Practices are asked to demonstrate that they are completing work over and above that of a GMS Practice to continue to receive their premium, albeit reducing, over a four year period. In 2017/18, the Key Performance Indicators (KPIs) for these Practices were delayed in circulation due to the Primary Care Commissioning Committee wishing to strengthen these and provide additional scrutiny. One Practice, Fountains Medical Practice, has not had KPIs implemented within 2017/18 whilst the provider continues to be in transition. A summary of the evidence received to date at quarter 3 is detailed within Appendix 1. Full details of these submissions are available upon request. 3. Following review by the Primary Care Operational Group, it has been agreed that all Practices have achieved their KPIs. However, the following issues should be noted: 4. Bunbury Practice have not received referrals for well man checks from other rural Practices to date. This issue was identified within quarter 2 and the Practice has continued to chase their neighbours and support administrative systems to receive referrals. Although the Practice has still not received patients from their neighbours, they have maintained the correct level of activity by inviting in patients from their own list. This has resulted in improved patient outcomes for a number of individuals (e.g. with early cancer symptoms detected). 5. Within the last report, Tarporley Adey identified a number of patients that had experienced issues of delayed discharge at end of life due to a lack of engagement with secondary care colleagues. Following the last committee, these issues were raised with the new clinical lead for end of life, Dr Dan Kelly and the Commissioning Manager for this programme who has highlighted these cases at the End of Life Steering Group. There has also been a commitment to raise this at the next End of Life Palliative Operational Group in order to ensure this stays high on the agenda. This is of particular relevance as the Practice has again raised anecdotal issues of difficulties in having clinician to clinician conversations across providers for patients at end of life. This has been escalated within the Clinical Commissioning Group for further discussion with acute colleagues. Primary Care Commissioning Report 2

6. Finally, Western Avenue have experience issues within the quarter with one of the Cheshire and Wirral Partnership Mental Health employees who was providing additional support to the Practice leaving (their psychological wellbeing practitioner). This role is currently in the process of recruited to and mental health nurses have continued to deliver a service for the Practice patients in the absence of this employee. 7. Due to the evidence received at the end of quarter three, the Primary Care Operational Group have recommended that full (but decreasing) premium continues to be made (as previously agreed with NHS England). PRIMARY CARE CQUIN 2018/19 8. A briefing paper setting out the potential proposals for the Primary Care Commissioning for Quality and Innovation Scheme (CQUIN) was shared with the Primary Care Commissioning Committee in January, and with all Practices at network meetings within December and February 2018. 9. Following this briefing paper, a number of individual Practices gave feedback on the proposals. In addition, feedback was received and summarised from each Network Meeting and via a letter from the Local Medical Committee (LMC). 10. This feedback was reviewed by the Clinical Commissioning Group and resulted in a meeting between the Director of Commissioning, Clinical Chair and Primary Care Team with the Local Medical Committee to draft a new specification taking these views into account. They key changes to the specification made included the following: In order to give Practices some reassurance that the Clinical Commissioning Group intends to continue this scheme into the future, a foreword has been added by the Clinical Chair Much of the work carried out within the 2017/18 scheme has carried over and been stabilised with stretch included through an expectation to provide a proactive level of care to patients in residential homes or vulnerable in their own home Additional clarity has been added around the data tools to be used in order to implement new interventions and monitor patient outcomes please note it is likely that one of these tools (Qlik View) will not be available fully in quarter 1 Further work has also taken place to link the coding used within this scheme to that of the Primary Care contract, ensuring that work is joined up and reducing the administrative burden on Practices A number of generalities relating to sign-posting and engagement have been removed More clarity has been given around levels of service offer and whether Practices can opt-out this has been further updated with expectations around time-scales for dressings service implementation and other solutions for services where individual Practices may not wish to deliver e.g. health checks Practices are still asked to work in Clusters, but have the option to receive funding as Practices and funding is not tied to the achievement of specific outcomes. Model of delivery is for Clusters to determine Indicative funding has been added, however this funding is likely to change based on feedback from Practices e.g. weighting towards Practices with a higher elderly population Primary Care Commissioning Report 3

In addition new funding has been included to the value of 1.50 per head of population with a 1% uplift on Local Enhanced Service budgets Clarity has been included for use of the PMS reinvestment (please note this budget is likely to be overspent due to the activity based payments as per the Dressings Options Paper discussed and approved at the last Committee) For Chapters 1 & 2, payment is tied to the submission of a Cluster quarterly feedback report, and engagement with the support and escalation process, both of which have been added to the Appendices Chapters 3 & 4, payment is linked to activity in the main. DRAFT SPECIFICATION 11. The draft specification has been replicated within Appendix 2, but in in summary, requires Practices to work in Clusters to deliver the following: POTENTIAL PROJECT IMPACT 12. The majority of the projects contained within the CQUIN are those already progressing as part of the CCGs Programme Commissioning Intentions, via the West Cheshire Way. These projects have been designed with relevant clinical leads from across the health economy, and also have received extensive public engagement. Therefore, the outcomes from delivering these projects will continue to be monitored within the programmes. 13. However, two projects are not currently monitored within the other programme areas and will be independently monitored via the Primary Care Team, reporting to the Primary Care Operational Group. These are the use of risk stratification (this work will be taken forward and monitored vie the Integrated Care Partnership) and a consistency in approach to dressings provision across West Cheshire. Following the methodology that has been used within Appendix 3, it has been estimated that the reduction in emergency activity as a result of the improved patient outcomes achieved could estimate circa 380k. Primary Care Commissioning Report 4

RECOMMENDATIONS The Primary Care Commissioning Committee is asked to: note the work carried out to date by Personal Medical Services Practices at quarter three; approve the payment of the premium to those Practices by NHS England on the basis of work completed; note the work carried out to date to develop and negotiation the Primary Care CQUIN; approve the draft specification, noting that minor changes may still be required before launch. Tanya Jefcoate-Malam, Deputy Head of Primary Care March 2018 Primary Care Commissioning Report 5

APPENDIX 1 Summary of PMS Evidence per Practice Garden Lane Medical Centre: This Practice was asked to continue to act as technological champions for the CCG, increasing usage of Patient Online Access and E-Consult. In both of these regards, the Practice continues to improve uptake and has continued to support the CCG and other Practices in the use of E-Consult. The Practice has also continued to work within their Cluster and with the University to consider appropriate pathways for university students, particularly around mental health issues. A Project Impact Statement for funding to support this work has been submitted (please see below). Tarporley Adey This Practice was asked to link to our End of Life Clinical Lead, championing the use of the EPACCs template, and working collaboratively with the Hospital Discharge Team to co-ordinate early discharges where possible. The Practice has continued to provide evidence demonstrating their achievement in these KPIs. The Practice has met and formed links with the former end of life clinical lead, and is now in the process of forming links with the new clinical lead. The Practice has also provided case examples to be discussed at the end of life steering group to support improved pathways for end of life patients and where possible, speed up discharge to enable preferred place of care. The Practice has also identified a weakness in their end of life coding and is targeting this to lead to improvement. Western Avenue The Practice was asked to continue to be high performers for a number of outcomes measures, including QOF and screening. The Practice was also asked to follow-up inappropriate A&E attendances, support the Starting Well Programme and implement a range of services to support their population. Although the Practice has been able to demonstrate that they remain high performers, or are planning to achieve this by year end for QOF and a number of screening indicators, further questions have been posed to the Practice towards how they are demonstrating that they have supported the Starting Well Programme priorities, and also how they are continuing to provider the mental health services. Further details of these issues are contained below. Bunbury Practice This Practice was asked to continue to provide a well man clinic, but working with other Practices within the Cluster to roll these out and offer more widely. The Practice was also asked to work with the CCG to pilot, and use the electronic care plan template, and support discharge planning pathways with local hospitals. Due to a number of reasons, it does not appear that this Practice has yet been able to provide well man appointments to other Practices within the Cluster. However, the Practice has continued to provide these to their own patients. Further questions have been posed to the Practice to understand this issue further, and whether discharge planning pathways have had a positive patient impact. Further details can be found within the section below. Fountains Practice Throughout 2017/18, due to the Fountains Practice undergoing a transition in partnership, KPIs had not been agreed. These are to be reinstated in 2018/19. Primary Care Commissioning Report 6

APPENDIX 2 DRAFT Primary Care CQUIN Specification 2018/19 Primary Care Commissioning for Quality and Innovation Scheme 2018/19 Specification Primary Care Commissioning Report 7

APPENDIX 3 Primary Care CQUIN Impact Evidence Use of risk stratification tools with the Clusters / Care Communities: Research (please see Appendix 3) has demonstrated that using risk stratification on its own will not lead to a reduction in secondary care emergency activity. However, once at risk patients are identified, care planning for frailty and vulnerability can lead to a reduction in emergency activity. West Cheshire data has been reviewed to identify the most at risk population. If the evidence below was used, these patients should see a reduction in their emergency activity by 7%, owing to being identified and additional interventions put into effect to improve their outcomes. If this 7% reduction occurred for the entire at risk population, this would relate to a total population of 5,266 patients, saving in the region of 1.1m to the local health economy in emergency secondary care activity. As this patient co-hort is likely to be too large to review and support owing to current capacity, this has been reduced to the patient co-hort with a risk score of 50-70 (those that could be considered at moderate risk). If interventions for these patients had a positive impact, Practices would support the reduction of 3 patients per month s emergency activity on average. This work is not likely to have significant impact within quarter 1, as Practices will be planning amendments to current interventions, identifying patients for the first time, and in some localities, starting to implement new interventions. Therefore, for the year, activity savings are likely to be in the region of 277,092.75 Consistency in approach to dressings service provision across West Cheshire: By providing a more consistent level of service for simple and complex dressings across West Cheshire is likely to reduce A&E attendances from patients for this purpose by around 25%. This would lead to an annual activity saving within the acute provider of approximately 100k. Total project impact for 2018/19 = 377,092.75 Primary Care Commissioning Report 8