A meeting of Bromley CCG Primary Care Commissioning Committee 22 March 2018 ENCLOSURE 7 PROPOSAL FOR ENHANCED MEDICAL SUPPORT TO BROMLEY CARE HOMES SUMMARY: Bromley CCG gained agreement at the CCG Clinical Executive Group on 26 th October 2017 to develop a proposal for an enhanced medical support service into Bromley s care homes. The service was agreed to be procured under an APMS contract so that it can register nursing home residents, residential home residents and extra care housing tenants as patients and provide them with core General Medical Services as well as an enhanced service specification for medical support as care home patients. The service will cover 43 care homes with a capacity of around 1,811 beds (snapshot from January 2018) which provide care for people with a range of healthcare needs. This service is only available for residents of care homes within the geographical boundary of London Borough of Bromley. Following a full review of the VMO scheme, scoping of best practice and clinical and care home engagement, this paper asks the Primary Care Commissioning Committee to consent to a Chair s action for a decision about procurement of an APMS contract to provide enhanced medical care for all care home residents. The chair s action will be required following the conclusion of the robust engagement strategy and subsequent finalisation of the service specification. A draft of the specification for the proposed services is included as appendix B of this paper. This has been developed in collaboration with clinical and managerial colleagues within the CCG, as well as significant feedback from the council, general practices, Bromley LMC, care home managers and other stakeholders. The proposals include additional investment into the enhanced services including from the Better Care Fund, increasing the total budget from 168,000 to approximately 445,000. Potential savings based on other test sites for enhanced support to care homes services suggest up to 1 million of urgent care and prescribing savings, as well as significant benefits for patient quality of life. The Primary Care Steering Group reviewed the paper and draft service specification on the 8 th March and requested the following actions be undertaken: The paper to be submitted to the PCCC on the 22 nd March for information, discussion and Chair s action for a decision about procurement The CCG Clinical Directors and lay members to undertake a final review and comment on the draft service specification Finance approval of the spend and budgets for the new service Clinical Chair: Dr Andrew Parson 1 Chief Officer: Dr Angela Bhan
Background A Care Homes Programme Board (CHPB) has been established jointly with the London Borough of Bromley to develop and enable the creation and implementation of an integrated health and care strategy for care homes in Bromley. The review of the VMO service specification and proposals for enhanced medical support forms part of the Health and Care Offer work stream within the Care Homes Programme Board. This work stream is tasked with developing and implementing a model of integrated health and care services in support of care homes based upon the Bromley Multi- Disciplinary Team (MDT)/Integrated Care Network (ICN) model and including self-care, dementia support, and end of life care. In 2017, Bromley CCG conducted an analysis of Bromley s care homes which identified significant variation across care homes in the quality and quantity of medical support received from General Practitioners and other healthcare professionals. This is due to a range of factors, most notably to a variation in the nature of contractual arrangements for GP cover and the low level of funding available under the VMO scheme comparative to the potential workload of caring for high needs patients. Also, some care homes contract directly with GPs under a retainer arrangement. The analysis also identified significant acute hospital related activity from care homes for conditions which may have been prevented if good case management, appropriate nursing skills, medicines management and adequate policies, systems and protocols were in place. Alongside this, the varying level of care home staff competency, experience and motivation as well as the care home management ability to provide leadership and retain staff are considered to be the key determinants of good quality care for residents in care homes. See appendix A for feedback from GP practice visits and VMOs, care homes, patients and colleagues/others that has been completed as part of this proposal development. Note, feedback from the three March cluster meetings saw the proposals met with unanimous support from the GP commissioners in attendance, complemented by a variety of discussion and feedback that has been directly incorporated into the service specification. Proposal Following a full review of the VMO scheme, scoping of best practice and clinical and care home engagement, this paper proposes to establish an APMS GP contract to provide enhanced medical care for all care home residents. The APMS contract will offer continuity of care for each home against specific, measurable KPIs enabling Bromley CCG to measure the success of this contract against baseline information. Care home residents will have the option to opt out and remain with their existing GP if they wish, respecting patient choice. Existing VMOs will be provided with a six month notice period to allow a carefully managed transition period to the provider of the new service. Specification A final draft of the service specification for the proposed services is included as appendix B of this paper. This has been developed in collaboration with clinical and managerial colleagues within the CCG, as well as significant feedback from the council, general practices, Bromley LMC, care home managers and other stakeholders. The service provider will be required to participate in a multidisciplinary approach to proactive case management, pharmaceutical care and reactive urgent care. Clinical Chair: Dr Andrew Parson 2 Chief Officer: Dr Angela Bhan
In summary, the specification will require the successful provider to: Establish a multidisciplinary team of GP/s, nurse/s and a clinical pharmacist as a minimum, plus adequate managerial and administrative capacity Register patients as part of an APMS contract to resolve questions about shared clinical responsibility and indemnity Provide a mix of proactive and reactive care o Planned ward rounds of care home patients o GP visits when residents first move into a home; when they come out of hospital; or if stable, a proactive visit at least once every three months o Medication review of all patients within first six months o Undertake normal GP practice duties, e.g. flu vaccinations, diabetes care, ECGs and BPM, LTC care planning, EoL care planning o Home visits and urgent visits when required no patients back at the surgery making it easier to do visits in the afternoons/evenings at short notice o GP practice without walls Actively forge relationships with care home managers and staff; including upskilling staff Actively forge relationships with St Christopher s, BHC and Discharge2 Assess GPs, and wider Bromley Integrated Care Networks (ICNs) Note, the new service is not proposed to register patients who reside in learning disability care homes in Bromley as LD people may often visit their GP (many are not housebound) and the clinical skillset for delivering enhanced care to LD patients is different from the frailty and geriatric focus of care in non-ld care homes and extra care housing. LD homes therefore fall outside the scope of this specification. Finance The current budget for providing the existing VMO service to care homes (including Learning Disability homes) for 2017/2018 is 168,000. The funding available to provide the new service is approximately 445,000. Sources of funding available for Bromley enhanced medical support to care homes are: 168,000 per annum from the Primary Care VMO Enhanced Service budget (existing funds) 245,000 per annum within the Better Care Fund Medical Support into Care Homes budget (new funding) 52,000 per annum within the Better Care Fund VMO support into Extra Care Housing budget (new funding) Existing funds for core general medical services on a per capita basis within the CCG delegated primary care budgets ( 97.61 per weighted patient) Total = 465,000 available not including delegated per capita budgets The cost of continuing to provide VMO services to 13 Learning Disability homes within the Borough needs to be deducted from the Finance available to sustain these arrangements; the estimated cost of continuing this service for 2018/2019 is 16,256. We will round this up to 20,000 to allow for contingency. Based on reviews of the Vanguard and other good practice models, potential future savings may be achievable. These are set out in the following table. Clinical Chair: Dr Andrew Parson 3 Chief Officer: Dr Angela Bhan
Figures based on average savings from Vanguard/Non Vanguard test sites 2016/2017 Bromley actual spend 2018/19 Bromley potential saving 10% reduction in A&E attendance 345,099.00 34,509.00 25% reduction in A&E admittance 2,357,707.00 589,426.00 10% reduction in drug spend See note below* 300,000.00 10% reduction in LAS call outs (based on Ealing results) 497,234.00 49,723.00 Potential total saving 973,658.00 * All Vanguard and Non Vanguard models are supporting similar savings of approximately 300,000 in drug costs alone. Medicines Management feel that a saving of 300,000 for circa 1,800 patients in Bromley s care homes is achievable. Further developments and enhancements The Care Homes Programme Board (CHPB) will continue to look at enhancing medical services available to care homes within the Borough after procurement of this contract, including access to community and voluntary sector services, care home staff and training and long term commissioning intentions for care home placements. The CHPB work programme is broken down into three main areas of activity Strategy, Health & Care Offer and Quality. Geriatrician input is provided to the Health & Care Offer task and finish group and will assist in shaping the MDT and supporting the GPs. The recommendation from PCSG regarding a geriatrician working as part of the MDT team on a rotational six month basis will be fed back to the Health & Care Offer task and finish group. Appendices A) Feedback from GP practice visits, care homes, patients and colleagues/others B) Draft service specification for enhanced medical support into care homes PROFESSIONAL INVOLVEMENT: Comments on the draft service specification have been received from the following: Dr Mandy Selby, End of Life Lead Dr Agnes Marossy, Consultant in Public Health Abigail Barry, Senior Prescribing Advisor, Interface Aileen Stamate, Strategy and Performance Manager, London Borough of Bromley Graham Mackenzie, Director for Transformation and Integration Jessica Arnold, Associate Director Primary Care Alex Humphrey, Senior Commissioning Manager Primary Care Dave Harris, Head of Finance Safeguarding Adults colleagues In addition, clinical support has been provided for this project by: Dr Chris Fatoyinbo, Care Homes Clinical Lead Dr Hamendra Patel, Bromley LMC nominated representative GP attendees of the March cluster meetings in Bromley, Orpington and Unity clusters Clinical Chair: Dr Andrew Parson 4 Chief Officer: Dr Angela Bhan
COMMITTEE INVOLVEMENT: Primary Care Steering Group 8 th March 2018 CCG Clinical Executive Group 26 th October 2017 Care Homes Programme Board (ongoing) Previous CEG meetings, Primary Care Programme Boards and Community Based Care Boards in 2016/17 PUBLIC AND USER INVOLVEMENT: Five practices engaged through face to face visits Five care homes engaged through face to face visits Two patients engaged through face to face visits An online survey has been sent out to the Patient Advisory Group MANAGEMENT OF CONFLICTS OF INTEREST GP Clinical Directors may lose funding from the cessation of the existing VMO scheme; and/or may benefit from removing one of the most vulnerable cohorts of patients that require intensive care from their patient lists. OUTCOME OF IMPACT ASSESSMENTS COMPLETED Equality Impact Assessment and Data Protection Impact Assessment are currently being worked on with the Quality team and the CSU. These will be completed prior to commencing procurement. RECOMMENDATIONS: The Primary Care Commissioning Committee is asked to: i. Comment and input into the proposals for procuring an APMS contract for the general medical care and enhanced medical care for care home residents. ii. Discuss and consent to taking of Chair s action for a decision about the final specification and move to procurement of these services ACRONYMS VMO Visiting Medical Officer CHPB Care Homes Programme Board APMS Alternative Provider Medical Services Contract PAG Patient Advisory Group CSU Commissioning Support Unit DIRECTOR RESPONSIBLE Graham Mackenzie Director of Integrated Commissioning MDT Multi-Disciplinary Team ICN Integrated Care Network PCSG Primary Care Steering Group LD Learning Disability BHC Bromley Health Care AUTHOR Helen Copeland Commissioning Project Manager CLINICAL LEAD: Dr Chris Fatoyinbo, Clinical Lead for community based care Clinical Chair: Dr Andrew Parson 5 Chief Officer: Dr Angela Bhan
Appendix A: Clinician, care home, patient and colleague engagement Engagement with practices Engagement took place with five GP practices providing the existing VMO service. The engagement took place between September 2017 and January 2018. A questionnaire was completed at each of the meetings to ensure consistency of responses from each of the GPs. Concerns raised were: Volume of patients to be seen within the timeframe available Patients are complex with multiple comorbidities Volume of telephone contact made by homes with GPs for unnecessary patient queries Duplication of document completion care home files require updating and EMIS needs updating once GP returns to surgery Turnover of care home staff Lack of structure to GP visits by care home Advantages identified were: Continuity of care for patients Good working relationship with home Allocated time to see patients Engagement with care homes Face to face engagement took place with five care homes using the existing VMO service. The engagement took place between December 2017 and January 2018. A questionnaire was completed at each of the meetings to ensure consistency of responses from each of the care homes. Concerns raised were: No set visits by GP, feeling like they have to push for a GP to come out Delays in getting prescriptions, especially for mental health issues Podiatrists will not come out to care homes as they do not meet the criteria Mental health support required who holds responsibility for mental health of the patient Referrals process who can refer, how to refer and speed of referrals some dermatology referral are taking up to five months Speed of access to a GP Parkinson s Nurse Advantages identified were: GP having an interest in the elderly GP very responsive to queries, speaks in a language the family and staff can understand Caring GPs who are accessible Consistency of GP visiting who has a knowledge of the patients Additional services both GPs and care homes would like to see linked directly to homes: A GP led multi-disciplinary team Physiotherapy, Podiatry, Diabetes Nurse, Elderly Care Physician, Psychiatry (for dementia patients), Advanced Nurse Practitioner, Clinical Prescribing Adviser, Quality Nurse, Pharmacist to audit the home and carry out training, Audiologist Clinical Chair: Dr Andrew Parson 6 Chief Officer: Dr Angela Bhan
One respondent also requested that consideration was given to offering flexible working for some of these services rather than during core hours of 9-5 Patient Engagement Patient engagement has been carried out at one home with two residents. The VMO experience by both patients was seen to be a positive one. The challenge with patient engagement event for this cohort is the number of patients suffering from dementia. An online survey has been sent out to the Patient Advisory Group to obtain feedback from family members of care home residents; one response has been received at the time of writing. Supplier events A Prior Information Notice (PIN) will be issued to the market as part of the procurement process to gauge interest from suppliers in bidding for this contract. South East London collaboration The Care Homes Programme Board is making contact with SEL to make them aware of our programme. NHS England requirements There are no specific NHS England requirements to commission these services. CCGs are being encouraged to review their existing medical provision to care homes. A reference document called The framework for Enhanced Health in Care Homes has been produced by NHSE to support this. Vanguards have been trialing various elements from this framework and reporting back their progress to date. Clinical Chair: Dr Andrew Parson 7 Chief Officer: Dr Angela Bhan