Primary Care Commissioning Committee 1. Date of Meeting: 19 th October, 2017 2. Title of Report: Primary Care Commissioning Report 3. Key Messages: The Primary Care Operational Group met in September and made recommendations for approval at the Primary Care Commissioning Committee. These were: o The commissioning of a Care Homes Local Enhanced Service for West Cheshire patients In addition, the following items were noted for information: Work is progressing around Primary Care Estates, with successful Estates and Technology Transformation Bids progressing, the Blacon Parade project now moving forward and increased involvement with the One Public Estate project within Ellesmere Port. Work is also progressing around Primary Care Information and Communication Technology, with work taking place to progress public access to Wi Fi in Primary Care. In addition, following the successful bids for funding from NHS England via the Estates and Technology Transformation Fund, significant work is progressing around the Primary Care IT Infrastructure, along with other ICT related developments. The Primary Care Team has continued to work with Practices via the Support and Escalation Process. Although outcomes are being achieved, work is now taking place to focus on emergency admissions and out of area referrals. Linked to this, contact has been made with Office of National Statistic Clinical Commissioning Group s and best Practice shared. In addition, the Primary Care Operational Group also received an update from NHS England around the outcome of the Willaston procurement process. And finally, the most recent results of the GP Patient Survey were reviewed and priority areas identified.
4. Recommendations The Primary Care Commissioning Committee is asked to: a. Note the content of the report and approve the recommendations of the Primary Care Operational Group as follows: i. Approve the roll-out of the Care Homes Local Enhanced Service following the consultation process ii. Note the progress of work relating to Primary Care Estates and ICT iii. Note the progress of work for the Support and Escalation process and feedback received from Office of National Statistic Clinical Commissioning Groups iv. Note the outcome of the Willaston procurement v. Note the results of the most recent GP survey and action points agreed. 5. Report Prepared By: Tanya Jefcoate-Malam, Deputy Head of Primary Care Sarah Murray, Head of Primary Care Kevin Carbery, Project Manager Jill Baker, Estates Project Manager
PURPOSE NHS WEST CHESHIRE CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE PRIMARY CARE COMMISSIONING REPORT 1. The purpose of this report is to seek approval from the Primary Care Commissioning Committee for one Local Enhanced services and to note a number of points relating to the future commissioning of primary care. DECISION 1 CARE HOMES LOCAL ENHANCED SERVICE SPECIFICATION 2. The current Primary Care (Care Home) Local Enhanced Service (LES) Specification was agreed in 2012. This specification only applies to nursing homes and is in need of review. As part of a wider review of the Primary Care Commissioning for Quality and Innovation Scheme, the specification is being reviewed in order that the Clinical Commissioning Group has an opportunity to explore how enhanced primary care services can be provided more equitably to vulnerable people, regardless of their care setting. 3. A Task and Finish Group made up of colleagues from primary care, the clinical commissioning group, care homes, Cheshire West and Chester Council, the Countess of Chester and the community was established to review the specification and to develop a new specification which takes into account the needs of frail patients in nursing and residential homes. This Group has met regularly throughout the summer to discuss and develop the specification. 4. A draft specification has been agreed by the Task and Finish Group. This has been presented to each Locality Network meeting. Throughout this consultation process, feedback received has been considered and acted upon where appropriate. The draft specification will now be shared with the Local Medical Committee before launch. 5. The draft specification (please see Appendix 1) makes provision for an enhanced service to be provided in all care homes. It also specifies some improvements in the provision and recording of palliative and end of life care and clarifies the need for more robust monitoring of the service and outcomes. 6. The key performance indicators are still to be finalised. This will be done when feedback on the specification has been collated from all Networks. This is likely to be finalised at the beginning of October, and in the meantime, the specification is being shared with relevant stakeholders. It is hoped that the specification can be approved at this stage by the Primary Care Commissioning Committee, on the basis that minor changes may still need to be made before the launch of the scheme. ITEM FOR NOTE 1 PRIMARY CARE ESTATES 7. All projects submitted as part of the Estates and Technology Transformation Fund have been successful in progressing to the next stage of the process. The Clinical Commissioning Group will be submitting updated Project Initiation Documents by
November 2017. The projects have been prioritised by the Clinical Commissioning Group based on the projects readiness (land, cluster working etc.) and ability to complete the work within the timescales (March 2019). There are complications with each project and these need to be monitored, particularly Lache and Handbridge, Malpas and Kelsall. The funding being sought for the projects that are progressing is 13.08m. 8. In addition to this funding, the Clinical Commissioning Group are working closely with the Local Authority to consider whether funding may be available through private developers of local developments and housing estates to understand whether there is an opportunity to secure additional investment to improve health services. This work is progressing and initial results have been positive. 9. Cheshire West and Chester Council and Sanctuary have agreed to partner on a revised scheme to complete the Blacon Parade development. It is proposed to maintain a health facility on the ground floor and provide a mix of residential (16 units) on the first and second floors. 10. The space requirements for The Elms Medical Centre to relocate their branch surgery to the development has been discussed with the practice and they have expressed an interest in being in the building. The allocated space within the development would be a discreet unit that the doctors would be responsible for maintaining. The internal finishes and the external works would be the responsibility of the landlord. This will vastly reduce the annual costs that the Practice will need to contribute. 11. The One Public Estate Project in Ellesmere Port envisages bringing all the public sector organisations in the town, including Health, to be located on one site. The two GP practices closest to the new build site in Civic Way are interested in utilising the opportunity to develop new premises and provide a greater range of GP services. 12. The funding for the project is from Cheshire West and Chester Council and capital receipts from vacated premises. Due to the value of the receipts it is anticipated that they will be a capital short fall. A Project Initiation Document is being prepared to inform the Clinical Commissioning Group and NHS England of the implications of the capital shortfall. 13. There will be long term revenue consequence for the Clinical Commissioning Group post April 2018 if we take on fully delegated responsibility for commissioning primary care. 14. A Memorandum of Understanding has been signed by all the stakeholders. This should allow the Local Enterprise Partnership funding to be allocated and spent to progress to RIBA Stage 2. A consultancy firm (Perfect Circle) has been commissioned to produce a report on the brief and the visioning of the One Public Estate Project. This document, which has now been shared, makes some assumptions that need to be challenged. 15. The next stage will be for all parties to sign up to a Multi-party Agreement in the autumn.
ITEM FOR NOTE 2 PRIMARY CARE INFORMATION COMMUNICATION AND TECHNOLOGY ICT 16. NHS Digital is working to make sure that everyone can access free WiFi in NHS sites in England, as set out in the NHS England General Practice Forward View (April 2016). NHS England have devolved funding of 120,639 to NHS West Cheshire Clinical Commissioning Group as an in-year revenue transfer in order for them to arrange provision of Wi-Fi services for patients (within practice settings) by 31 st December 2017. 17. The roll-out of the Cheshire Shared IT Network is a dependency regarding the technical infrastructure required by practices to provide public WiFi. It is likely that public WiFi will be operational in the vast majority of the 36 practices by December 2017, with the rest of them active in January 2018. A cabling provider is contacting practices to arrange convenient dates to install the cables for the access points that will form part of the set-up for enabling both patient and staff WiFi. 18. NHS West Cheshire Clinical Commissioning Group are utilising the Estates and Technology Transformation Fund (ETTF) that was awarded for implementing a Virtual Desktop Infrastructure (VDI) and the components that underpin this. NHS England provided the Clinical Commissioning Group with 1,061,724 at the end of 2016-17 to progress the VDI projects and Docman Vault. 19. A summary of the progress of these projects is details below: Cheshire Shared IT Network: The implementation of Community of Interest Network (COIN) to improve connectivity between sites and to enable other programmes of work. To date, sixteen sites have migrated to this new network with the vast majority of Practices having dates in the diary to complete this migration by the end of November, 2017. Single Domain / North West Shared Infrastructure Service (NWSIS) This solution provides the central authentication and administration of users allowing staff to roam between any connected location using the same user name and password on any device. To date, three Practices have migrated, with the remainder of Practices to be transferred soon. Corporate WiFi: The implementation of a corporate wireless solution at every GP practice to improve mobility working. This utilises the same cabling and access point as patient WiFi and requires practices to be on the single domain, and will be rolled-out as the patient Wi Fi solution is finalised. This is already being piloted in two Practices. Centralised Storage / VDI Centralised storage: The migration of primary care data, currently held on local data servers to a corporate data centre, improving back-ups, data security and resilience, while reducing the administrative burden on practices. VDI: Migrating primary care desktop computers to a virtual desktop environment, improving the security and resiliency within practice, while enabling mobile working between practices and other NHS sites. Both of these solutions are on-going, with progress being made and testing taking place. This work has been somewhat delayed due to the Cyber Attack that occurred within May 2017. This attack resulted in a number of Practice s suffering issues relating to their patient check-in screens that were repaired and replaced as a matter
of priority. However, work continues in order to progress this project, and to identify relevant hardware and software improvements / replacements that can now take place, owing to a successful bid through NHS England to access 200 laptops for Practices by the end of 2016/17. Further funding of 867,265 is allocated from NHS England for 17-18 to fund the rollout of VDI infrastructure to all practices. 20. Whilst this work is taking place, the Clinical Commissioning Group continues to work with the Commissioning Support Unit and Practices to identify developments in other systems, e.g. Docman, that could lead to improved working practices and patient records access. This work is progressing. 21. Finally, The Health and Social Care Network (HSCN) is a new data network for health and social care organisations. It will provide the underlying network arrangements to support the integration and transformation of health and social care services by enabling health and social care organisations to access and share information more reliably, flexibly and efficiently. 22. Funding of 118,108 has been devolved to NHS West Cheshire Clinical Commissioning Group from NHS England / NHS Digital to support existing Clinical Commissioning Group and GP data network service continuity (i.e. services originally obtained under the N3 agreement) and replacement Health and Social Care Network (HSCN) services. This work links to that already being carried out and described above. 23. Information regarding the progress of these projects is being regularly given to Practices via Locality Networks, Practice Managers Forum and ICT Operational Group. In addition, a user friendly newsletter has been devised and circulated. ITEM FOR NOTE 3 PRIMARY CARE SUPPORT AND ESCALATION PROCESS 24. The Primary Care Team has continued to work closely with Practices identified as at variance to Clinical Commissioning Group average within a number of indicators. A summary of this work, and the Practices identified is contained within the table below: AUGUST 2017 Primary Care Dashboard Thematic Area: Planned Care Practices formally entering process due to being above average: None identified to being above average: Whitby Warren City Walls Great Sutton Wearne Great Sutton Francey to being below average: Willaston Neston Medical Tarporley Adey Handbridge Bunbury
Data: Difference from clinical commissioning group average for GP outpatients: Whitby Warren +44.02 City Walls +36.38 Great Sutton Wearne +31.03 Great Sutton Francey +22.99 Data: Difference from clinical commissioning group average for GP outpatients: Willaston -82.06 Neston Medical -75.14 Tarporley Adey -41.20 Handbridge -39.50 Bunbury -29.17 Progress to date: Significant work has taken place with Whitby Warren Practice, with audits carried out, peer review instigated and education sessions in the process of being organised. This has had a positive effect and GP referrals to planned care services have now reduced by 21.3% in year. Work is also continuing with the Great Sutton Practices who have been presented with a further breakdown of their data. The Practice are now in the process of undertaking patient level audits to determine whether any themes are identified and the need for care pathways to be changed can be evidenced. City Walls has been identified within the past two dashboards as being at least one standard deviation above Clinical Commissioning Group average in two planned care indicators. Informal conversations are now taking place with this Practice in order to identify any support the Practice would like from the Clinical Commissioning Group. Thematic Area: Unplanned Care Practices formally entering process due to being above average: Westminster to being above average: York Road Great Sutton Francey Old Hall Great Sutton Wearne Data: Difference from clinical commissioning group average for emergency admissions: Westminster +46.89 York Road +8.46 Great Sutton Francey +22.29 Old Hall +16.35 Great Sutton Wearne +28.46 to being below average: Village Surgeries Malpas Tarporley Adey Tarporley Campbell Data: Difference from clinical commissioning group average for emergency admissions: Village Surgeries -39.12 Malpas -25.76 Tarporley Adey -22.38 Tarporley Campbell -22.96
Progress to date: The Practices identified have received significant input from the Clinical Commissioning Group in order to support the Practices and patients to consider alternative pathways for emergency activity, if this activity could have been avoided. An Ellesmere Port and Neston data pack has been produced that provides an in-depth breakdown of this activity information and has provided focus for the Practices identified above. This work has been positive and has demonstrated significant engagement from all of the Practices involved, leading to the development of further services within this patch, working collaboratively across providers to support patients throughout the winter period. Thematic Area: Primary Care Quality Practices formally entering process due to being above average: None identified to being above average: Great Sutton Francey Great Sutton Wearne to being below average: None Progress to date: Both Practices are performing below average for the GP Survey and Friends & Family Test. However, the Practices are keen to improve their patient engagement and are now working collaboratively with a Patient Participation Group Chair from a neighbouring Practice with above average results to improve. Thematic Area: Primary Care Clinical Quality Practices entering process due to being two standard deviations from average: N/A to being above average: Westminster Frodsham to being below average: None Progress to date: As noted above, these Practices have been identified for some months within this thematic area. Work is carrying on within these Practices to investigate coding differences and whether best Practice can be shared from higher performing Practices that share a similar
demographic group of patients. Thematic Area: Medicines Management Practices formally entering process due to being above average: None identified to being above average: Old Hall Great Sutton McAlavey Neston Surgery to being below average: None Progress to date: Work is ongoing between the Medicines Management Team and the Practices identified to support the appropriate medicines usage. However, the Medicines Management Team have fed-back that the indicators used within the Primary Care Dashboard for this purpose are in need of updating. Therefore, a meeting is planned to take place between the Primary Care and Medicines management Team to agree more relevant indicators. Progress on this will be shared at the next meeting. 25. Not only has the work via this process achieved positive results for patient care, with coding inaccuracies identified and care pathways clarified to enable patients greater choice of provider, the reduction in appropriate utilisation of Secondary Care clinics has resulted in an activity and financial saving for the local health economy of approximately 81k. A Best Practice Guide has been created to share this good work with Practices across West Cheshire. 26. Although the reduction in hospital utilisation to date is below what the Clinical Commissioning Group expected to achieve based on the similar work that took place throughout 2016/17, the Primary Care Team is working closely with the Planned Care Team in order to identify whether better value for the local health economy can be gained through reducing unnecessary referrals to out of area providers. This work is ongoing, although the majority of Practices are supportive of this approach. 27. In addition, contact has been made with Office of National Statistic Clinical Commissioning Group s in order to understand whether they have also implemented a Primary Care Dashboard and Support and Escalation Process, and whether any best practice can be shared. Out of the nine Clinical Commissioning Group s contacted, five have implemented a similar dashboard and process, with six confirming they commission similar Local Enhanced Services to West Cheshire Clinical Commissioning Group. Due to the difference that West Cheshire is still facing in comparison to its peers for Planned Care activity (via all Outpatients Attendances) it was agreed at the Primary Care Operational Group that the comparator indicator would stay at the Clinical Commissioning Group average for the present time.
ITEM FOR NOTE 4 WILLASTON PROCUREMENT 28. Following an open procurement process, NHS England has approved the award of an Alternative Medical Services Contract with effect from 11th September 2017 to Cheshire and Wirral Partnership Trust. The contract value of the successful bidder is a set price of 81.15 ( 85.35 less 4.20 for out of hours opt-out) for the capitation payments per weighted patient. This is equivalent to the General Medical Services (GMS) price. This capitation payment is designed to cover the Essential & Additional Services element of the contract as per the NHS (General Medical Services Contracts) Regulations. An additional payment of 8.21 per weighted patient will be paid for weekend working as defined in the service specification. 29. In addition to capitation payments, the successful Bidder will be eligible for National Enhanced Services and Quality and Outcomes Framework (QOF) payments in line with GMS contracts. The Bidder will also be eligible for reimbursement of rent and rates expenditure on current premises, as per the NHS (General Medical Services Premises Costs) Directions 30. Work is now taking place by Cheshire and Wirral Partnership Trust to mobilise the contract, with regular monitoring taking place via NHS England, reporting to the Clinical Commissioning Group. ITEM FOR NOTE 5 GP PATIENT SURVEY RESULTS 31. The GP survey results for the financial year 2016/17 have now been received by the Clinical Commissioning Group. Although there are some trends of improvement for the Clinical Commissioning Group and within individual Practices, there are some areas of risk that may need further investigation. 32. Areas of high performance for the Clinical Commissioning Group are as follows: Making appointments online although is still below national average, has increased Convenience of appointment has remained high Experience of making an appointment this is also a high indicator for the Clinical Commissioning Group Explaining test results and treatments is another high indicator for the Clinical Commissioning Group Satisfaction with opening hours remains high for the Clinical Commissioning Group and is above national average Overall experience of care and recommendation to a person from out of the area also remains high 33. The areas that we may wish to focus on to improve results are as follows: Accessing your GP surgery over the telephone has fallen and is below national average How helpful are receptionists is now below national average Seeing the GP you prefer continuity of care is below national average and has fallen Involving you in decisions about your care although this has dropped since the last publication, is still higher than national average.
34. On the whole, performance for the Clinical Commissioning Group has improved, potentially supporting the theory that additional services and changes in pathways instigated by Practices and the Clinical Commissioning Group had led to increased patient satisfaction. Individual performance will continue to be monitored and acted upon via the Primary Care Dashboard. RECOMMENDATIONS The Primary Care Commissioning Committee is asked to: Note the content of the report and approve the recommendations of the Primary Care Operational Group as follows: vi. Approve the roll-out of the Care Homes Local Enhanced Service following the consultation process vii. Note the progress of work relating to Primary Care Estates and ICT viii. Note the progress of work for the Support and Escalation process and feedback received from Office of National Statistic Clinical Commissioning Groups ix. Note the outcome of the Willaston procurement x. Note the results of the most recent GP survey and action points agreed. Tanya Jefcoate-Malam, Deputy Head of Primary Care Sarah Murray, Head of Primary Care Kevin Carbery, Project Manager Jill Baker, Estates Project Manager October 2017
APPENDIX 1 CARE HOMES SPECIFICATION A. Service Specifications Service Specification No. 3 Service Commissioner Lead Provider Lead Executive Sponsor Locally Enhanced Scheme Primary Care provision Care Homes Lesley Hilton - Joint Commissioning Manager Vitoria Hough Clinical Lead Care Homes Laura Marsh - Director of Commissioning Period September 2017 Date of Review March 2018 1. Context and population need Currently within West Cheshire a Local Enhanced Service is provided for our patients in Nursing and Elderly Mentally Infirm or Dementia beds. Currently the vast majority of Nursing Homes within West Cheshire have a GP Practice that links directly to the care homes to deliver this enhanced service to patients who choose to register with their Practice. NHS England Enhanced Health in Care Homes (EHCH) sets out a clear framework and vision for providing joined up primary, community and secondary, social care to patients in care homes, via a range of in reach services. It contains seven key components and eighteen subcomponents which define the care homes model are put forward, with practical guidance explaining how organisations and providers can make the transition and implement the whole model. As part of Primary Care Redesign in West Cheshire the Local - Primary Care Commissioning for Quality and Innovation Scheme (CQUIN) 2017/18 progressed some important work for vulnerable patients within West Cheshire by risk stratifying those with frailty and allowing care for patients identified as at increased need to be co-ordinated, led by individualised goals and ensuring access to interventions that will improve health outcomes and including the key components of EHCH. The outcomes being seen from this approach have been beneficial and are helping to work towards the key ambitions of the West Cheshire Way: Improve self-care Supporting people within the community Working across boundaries Improving the management of complex and long-term conditions All GP practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The Primary Care CQUIN includes the assessment and coding of patients as frail and actions as appropriate are within the patient s records. The Practise will plan and implement care planning for all vulnerable patients. Providing proactive care in order to prevent deterioration where possible and coordinated reactive care for patients who have become acutely unwell, either to prevent a hospital admission or facilitate safe, timely and effective discharge from an Acute Trust.
Population: 1.1 Health and Care of Older People in England 2017 reports the numbers of older people aged eighty five and beyond are projected to grow exponentially in the next twenty years, doubling by 2036, so an important question that arises is the extent to which we are on the right path towards meeting these increasing needs and demands in future. 1.2. 2017 Age UK s analysis shows there are now nearly 1.2 million people (1,183,900) aged 65+ who don t receive the help they need with essential daily living activities. This represents a 17.9 per cent increase on last year and a 48 per cent increase since 2010. 1.3 Within West Cheshire there are currently 23 dual registered care homes; providing nursing and residential care with an approximate bed capacity of 1150. There are currently 21 residential registered care homes; providing residential care with an approximate bed capacity of 698. 1.4 Total residential capacity for people requiring varying levels of 24/7 care = 1848.For the purpose of this specification it would be of benefit to consider the whole care home sector population. 1.5 The majority of people at end of life would prefer to be cared for and die at home or in their usual place of residence (National End of Life Care Intelligence Network What we know now 2014, Public Health England June 2015). 2. Outcomes 2.1 The overall aim of the Enhanced Primary Care Service is to improve quality of care, through an enhanced clinical service to patients in care homes in West Cheshire. 2.2 It is noted that, whilst allowing and supporting patient choice, patients within a care home will be preferentially registered with the aligned GP practice with consent. Care homes will be encouraged to support the GP alignment and encourage new patients to register with the aligned practice in order to access the additional enhanced support. 2.3 Practices will be required to embed working relationships with their aligned care homes as well as providing enhanced proactive planned care arrangements to all their registered patients within the care home. 2.4 It is anticipated that Primary Care Services will work in coordination with the wider health and social care economy to provide proactive care for patients recognized as vulnerable. This includes patients in nursing, mixed nursing and residential and residential homes for the elderly and elderly mentally ill. The service outcomes are to; a) Provide the best Primary Care Model for good quality services for patients in care homes. b) Establish and manage an effective and efficient model of care within our community. c) Support the provision of community services in line with national and local commissioning intentions. d) Reduce the number of avoidable admissions to hospital e) Continue to review and evolve the service to best meet the needs of patients within resources available f) Deliver consistent responsive health care within the constraints of Primary Care. g) Work in partnership with health and social care colleagues to ensure the care model is inclusive and works across the boundaries of acute and community services. h) Promote and support a culture of openness about dying and provide support for patients, relatives and staff by ensuring patients who are palliative/ end of life have their diagnoses and wishes recorded on the Electronic Palliative Care and Coordination System (EPaCCS) i) Provide an equitable and individualised service to reduce variation in standards of patient care. j) Reflect the key components of EHCH by increased community involvement into care homes to reduce patients feelings of loneliness and isolation; improved care planning (physical, mental, emotional and social needs) with a focus on keeping patients in their normal place of residence; greater opportunity for patients to be involved in decisions
about their health and care 3. NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term conditions Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring people have a positive experience of care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm 3.1. The NHS Outcomes Framework (NHS OF) is a set of indicators developed by the Department of Health to monitor the health outcomes of adults and children in England. The framework provides an overview of how the NHS is performing. 3.2. The NHS should be preventing people from dying prematurely by promoting good health and discouraging behaviours that put health at risk. Where people do develop a condition, the NHS has a responsibility to diagnose this as early as possible and manage it so that it does not deteriorate. 3.3. To promote safe discharge from hospital, any unsafe discharges will be reported as an incident and the Commissioners to ensure a full review is undertaken by the discharging hospital. 4. Local - Primary Care Commissioning for Quality and Innovation Scheme 2017/18.4.1 In order to support the requirement within the 2017/18 contract for GP Practices to assess and code patients as frail and action as appropriate, Practices are required to plan, implement and document care planning for all vulnerable patients. Practices are asked to focus specifically on patients who are vulnerable in their usual place of residence (including patients in residential and in their own homes)..4.2 Primary Care must ensure that any care planning is agreed jointly with the patient / family / carers / and including appropriate social care input. It should include plans for deterioration in the individual s condition. The plans should be coded into the patient s notes so that they are accessible by other care services e.g. GP Out of Hours 4.3 Practices to engage with the Clinical Commissioning Group to consider a new model of care to be developed and roll out to enable equitable and proactive care to all vulnerable patients irrespective of their place of residence. 5. Scope 5.1 All GP practices are already required to provide essential and some additional specified services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided to care home patients. 5.2 The enhanced service is designed to cover the enhanced aspects of clinical care of the patient, all of which are above and beyond the scope of essential services. 5.3 No part of this specification by commission, omission or implication defines or redefines essential or additional services. 5.4 The services referred to in this specification (essential, additional and enhanced) will be provided to vulnerable patients in nursing, mixed nursing/residential and residential homes for the elderly and elderly mentally ill. The model of care in to be introduced through a phased period 2017/18.
5.5 The practice will be commissioned to provide, to the home(s) within the practice boundary an enhanced level of medical care for all patients resident within that home, where patients are already or have agreed to register with the practice 6. Aims and objectives of service 6.1 The aims and objectives of the scheme are to: a) Ensure that patient s needs, their choices and what they want to achieve are identified, understood and reflected in the care and support they receive so that they have control of their lives. b) Ensure that choices and decisions made on behalf of patients who lack capacity follow the principals set out in law to demonstrate the decisions are made in the best interest of the person c) Ensure effective review of medicines, including supporting staff within the care home to reduce the number of medication errors that occur in care homes. d) Foster an environment of lifelong/ongoing learning and continuous strive for excellence in care homes by encouraging, implementing or sharing clinical education and training in relevant clinical areas, e.g. dementia. e) Support wider internal and external care home training initiatives. f) Make advanced provision in care planning for dying, death and bereavement g) Work together to reduce the number and severity of falls h) Promote good end of life care for patients i) Provide clinical support and advice through care planning to care home staff in relation to patients registered with the practice to enhance clinical care of the patient, particularly in relation to deteriorating conditions and potential admissions. 6.2 Improving the care of patients as outlined above should lead to a reduction in avoidable admissions. Admissions from care homes will be monitored by the Clinical Commissioning Groups and included within the practice quality dashboards. 7. Service description/care pathway 7.1 All new patients will receive a full initial assessment following admission to the care home and a multi-disciplinary care management plan developed. The care and support planning process is there to help decide the best way to meet the person s needs. The process must include the criteria for admission/non-admission to hospital, agreed with the patient/their family/best interest decision. 7.2 Scheduled ward round at the care home by clinical staff from the practice will take place (Minimum weekly in nursing homes and as required in residential homes) this will be to review the care of scheduled patients. The practice will be contactable by phone during inhours to answer queries as required. The practice and care home will agree how the consultation will be recorded at the home. 7.3 The enhanced service will include GP/relatives consultations which regularly occur during GP s ward rounds in the home. This will promote ongoing communication between GP, nurses, patients and their relatives, to alleviate anxiety. This will also ensure the feelings of inclusion in care and in the plan of care, which reduces uncertainty and avoidable hospital admissions 7.4 Patients will receive a full review of their medication including a review following any discharges from hospital following an unplanned admission. Current national advice suggests, that reviews for anti-psychotic medications, should take place every three months for patients with symptoms of dementia. The practice should work with their linked pharmacist/technician to support this process. The practice is to ensure all changes in medication are clear using care home and pharmacy agreed protocols with clear lines of communication to the relevant community pharmacy for both routine and urgent prescriptions.
7.5 Practice clinicians will work with other health and social care professionals as appropriate to ensure care planning is reviewed and updated as appropriate. This may include meetings with care home staff to discuss any problems/concerns experienced with the provision of the enhanced service. 7.6 The clinical staff and care home staff will ensure any patients that may require referral to hospital or for assessment by other agencies as clinically appropriate, such that clinical intervention is tailored to the needs of the individual. To ensure that referrals are timely to reduce the potential for any unplanned admissions. 7.7 The quality of the patient dying is as important as their quality of life. Enhancing someone s sense of self and dignity will offer openness about dying. Promoting the adherence to the choices or decisions the patient has made or for those lacking capacity deemed in their best interests. 7.8 The agreed care planning should be recorded in both the home and the practice record, to ensure access to appropriate and timely information. The record must include criteria for admission/non-admission to hospital agreed with the patient/their family. This information should also be communicated to the GP Out of Hours service and include information relevant to the ambulance service (e.g. DNACPR) and recorded on the Cheshire care Record and EPaCCS. 8.Exception and inclusion criteria and thresholds 8.1 Standard General Medical Cover GMS) All patients are entitled to registration with a GP Practice if patient within the Practice s boundary (and in some certain restricted situations, when outside of that boundary), enabling them to access essential services for patients who are; ill, with conditions from which recovery is generally expected; life limiting illness; or suffering from chronic disease, Such services will be delivered in the manner determined by the practice in discussion with the patient. The enhanced service outlined in this specification currently requires additional proactive care that would not generally be expected for patients within their own homes or who are able to get into the surgery 8.2 Patients whose clinical care is outside the expectations of the Standard General Medical Cover and the Practice are unable to provide the clinical expertise required. 8.3 The provider remains responsible to ensure appropriate medical cover over GMS is in place before accepting the patient as a patient. 9. Interdependence with other services/providers NHS West Cheshire Clinical Commissioning Group, Cheshire West and Chester Council, Countess of Chester Hospital NHS Foundation Trust and Cheshire & Wirral Partnership NHS Foundation Trust. Care Home providers within the footprint of NHS West Cheshire Clinical Commissioning Group And any specifically commissioned providers
10. Applicable Service Standards 10.1 NHS England Standard GP Contract 10.2 Local - Primary Care Commissioning for Quality and Innovation Scheme 2017/18 10.3 General Practice National Institute for Clinical Excellence (NICE) 10.4 Royal College Guidance Care Homes 11. Payment 11.1 The current CQUIN (2017/18) provides approximately 3m for urgent and intermediate care for the population of West Cheshire. This includes; Care Homes LES ( 432k across the Clinical Commissioning Group ) Intermediate Care LES ( 90k across the Clinical Commissioning Group but separate from Care Home LES) Primary Care Frailty CQUIN 2016/17( 2.5m across the Clinical Commissioning Group ) Total CQUIN funding = circa 3m 11.2 In 2017/18 the overall budget for the enhanced care home service specified has been maintained. Each practice contracted to provide this service will receive 30.00 per month, per nursing bed and 8.00 per residential bed. 11.3 Numbers of patients (including NHS numbers) in each care home are supplied by the practice every quarter to verify individual patients 11.4 Payment will be made to practices quarterly in arrears based on submission of a form supplied by the Clinical Commissioning Group. 11.5 During circumstances when a care home has restrictions placed upon it which causes a reduction in available beds; payment to the practice will remain as outlined above. However the practice will be expected to make available additional support to the care home until such time the restrictions have been removed. 12.Outcome Metrics 12.1 The general standards that the Clinical Commissioning Group would like West Cheshire Practices to meet for their vulnerable and frail population are set down in the Primary Care Commissioning for Quality and Innovation Scheme Specification 2017/18. This makes provision for vulnerable patients in any setting, and requires proactive care in order to prevent deterioration where possible and co-ordinated reactive care for patients who have become acutely unwell, either to prevent a hospital admission or facilitate safe, timely and effective discharge from an Acute Trust. 13 Key Performance Measures 13.1 The key performance standards required of practices specific to the delivery of the enhanced primary care service to care homes are set out in Appendix 1. Performance metrics will be reported to and monitored through the Primary Care Dashboard. 13.2 2017/18 will provide accurate indicators to review and set % improvement where needed for CQUIN 2018/19 Please Note - Payment is not currently linked to performance but this will be reviewed after year one of the scheme? Appendix 1 Performance Measures Outcome Requirement Threshold** (total patients in the home aligned to the GP practice) Domain 1: Preventing people dying prematurely Percentage of patients with up to date plans following care planning Method of Measurement How measure is reported
reviews. Percentage of advanced planning in place for end of life including review of resuscitation status. Domain 2: Enhancing the quality of life of people with long term conditions Number of inappropriate admissions to acute or mental health inpatient provider 2017/18 collection of accurate data A review of admissions from care homes and discussion/sea to determine inappropriate admissions Number of patients having full annual health and medication review. Percentage of patients, identified, diagnosed and registered on the dementia register. Percentage of patients who have had anti-psychotic medication review in line with expectations? Domain 3: Helping people to recover from episodes of ill-health or following injury Identification of themes causing avoidable admissions or contacts. Themes would be identified during discussions/sea Nursing Home quality returns. Percentage of patients reviewed that prevented avoidable admission. Percentage of patients who received acute treatment within the care home. Domain 4: Ensuring that people have a positive experience of care Percentage of patients registered with the GP practice delivering the enhanced service. QUERY = Consider Friends and family type measure Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Evidence of partnership agreements and shared practices. Evidence of meeting with care homes colleagues