Review of Local Enhanced Services 1. Background and context 1.1 CCGs are required to prepare for the phasing out of LESs by April 2014 by reviewing the existing LES portfolio and developing commissioning intentions for relevant community based services to be commissioned from April 2014 using the standard NHS contract. 1.2 The LES review timetable was externally set and driven by NHS England. The objective of this work was to ensure that the portfolio of local enhanced services commissioned by CL CCG is appropriately aligned with its strategic vision, as well as best quality of outcomes for patients. A working group was convened to review the specifications and make preliminary recommendations on future of interventions. 1.3 1.3 This paper does not, at this stage, include recommendations for contracting mechanisms for re-provisioning services going forward. However, it should be emphasised that investment released from the review of LES service will be re-invested in primary care services outlined in CL CCG s commissioning intentions for 2013/14. These services will include areas such as diagnosis in general practice of patients with deep vein thrombosis, Hepatitis C treatment in the community for homeless patients, Connecting Care for Children s health hubs in each locality pilot. 1.4 1.4 Chairs of the CCG have also met to discuss future commissioning principles. The following principles were discussed and are work in progress. The recommended approach will be discussed and agreed through the CCG governing body. Four categories of service commission from all practices, commission from providers within GP networks (wording to be agreed), compete, or incentive schemes. Common set of services to be commissioned across all CCGs. Aim to pay the same for the same service across all CCGs. Share resource across the 5 CCGs to enable the required investment to take place. Appendix one includes the suggested approach and Text for Commissioning Intentions document: Primary Care: 1.5 The CCGs in North West London are working together to deliver transformed primary care. At the heart of this work is the intention to improve the quality of general practice and reduce the known variation. Working with NHS England the CCGs in CWHHE and BHH will continue the work started in 2013/2014 to determine what good quality general practice is and what models of care could support this. 1
CCGs in CWHHE will undertake a piece of work to understand the variation in funding across general practice and will then work with NHS England to find a mechanism that enables us to move a fairer funding system during 2014/2015 and beyond. 2. Recommendations The table below summarises key information together with recommendations for future commissioning. Table one: Recommendations for CL CCG LES Services Local Enhanced Service Description DES/NES in place? Notice period Funding held by CCG Budget Recommend - - ation Funding held by NHS England* The 7 Day Access No 3 250,000 Continue Co-ordinate my care No 3 150,000 Continue Learning Disabilities Yes 3 No budget identified with CL CCG. Continue Psychological therapy in primary care The Homelessness Nurse Outreach LES No 6 No 3 668,371** Continue 100,000 Continue Flu Yes 6 Oral Anti-coagulation Yes 3 200,000 Evolve 125,219 Evolve 2
Local Enhanced Service Description DES/NES in place? Notice period Funding held by CCG Budget Recommend - - ation Funding held by NHS England* Phlebotomy No 6 117,000 Evolve Information Management and Technology (IM&T) No 6 111,000 Evolve Choose and Book No 6 The Locality Plan No 3 259,000 Evolve 200,000 Evolve The Extended Opening Hours Yes 3 593,000 Discontinue Minor Surgery Yes 6 141,383 Discontinue Care of the Homelessness Complementary therapies No 1 month 90,000 Discontinue N/a 1 month 147,000 Discontinue Total funding 2,002,371 1,149,602 * These budgets are an estimated based on 12/13 financial out-turn. Actual values to be returned to CL CCG are still to be agreed with NHS England. ** Includes original funding of 351,000 and additional funding of 317,370 agreed in September 2012 for supplementary service Details of each local enhanced specification is under appendix two. 2.2 Recommendations were based on the following rationale: Services to be continued - These services are those which have recently been developed and not yet/only recently been introduced and need sufficient time to demonstrate effectiveness. 3
Services to be evolved. This primarily relates to services designed to support the introduction of new IT systems which have now been embedded, or quality improvement programmes. Services to be discontinued. Primarily as they duplicate with DES services and/or have not demonstrated good patient outcomes. 3. Contractual arrangements with existing LES providers 3.1 There is considerable uncertainty surrounding NHS expectations regarding timetable and process for de-commissioning LES Services which will no longer be legal contracting mechanisms for April 2014. The CWHH collaborative will be writing to NHS England seeking clarification. 3.2 CL CCG will also need to serve notice on existing LES service for which notice periods vary from 1 6. 4. Communication These proposals for local enhanced services will be communicated to key audiences through the draft CL CCG Commissioning Intentions document. 4
Appendix 1 Suggested Text for Commissioning Intentions Document: Primary Care: The CCGs in North West London are working together to deliver transformed primary care. At the heart of this work is the intention to improve the quality of general practice and reduce the known variation. Working with NHS England the CCGs in CWHHE and BHH will continue the work started in 2013/2014 to determine what good quality general practice is and what models of care could support this. CCGs in CWHHE will undertake a piece of work to understand the variation in funding across general practice and will then work with NHS England to find a mechanism that enables us to move a fairer funding system during 2014/2015 and beyond. Recommissioning of Local Enhanced Services From April 2014 CCGs will no longer have the ability to commission local enhanced services from primary care providers; instead CCGs will be required to commission any out of hospital services required using an appropriate and proportionate procurement process and the NHS Standard Contract as the contracting mechanism. As a consequence CCGs are reviewing all the local enhanced services that have been commissioned and are concluding which services that they wish to retain. The arrangements have not yet been finalised. However, we expect to apply the following principles in our decision making: High quality, financially sustainable primary care is vital to the strategic direction of all the CCGs, and so no financial savings will be sought through the review. Current levels of expenditure across the 5 CCGs will be at least maintained, and investment will be made in some areas All services are being considered from the perspective of the patient. We will therefore be seeking to integrate care and provide it as holistically and as close to home as possible where this is in the best interest of the patient and where value for money can be demonstrated. We will be ensuring that where appropriate, the integration of services for the patient will outweigh the fragmentation of service provision through procurement Services that are currently commissioned through LES will be either decommissioned; recommissioned in their current form using a standard NHS contract or recommissioned to a different service specification using a standard NHS contract The CCGs have developed a Commissioning Framework to support decision making for the recommissioning of Local Enhanced Services based on the draft guidance issued by Monitor. This will be subject to review as and when the Monitor guidance is finalised. The framework is included at Appendix three. Future models of primary care are currently being developed. All CCGs are currently exploring ways of working across networks of practices to best provide care for their patients, and this is likely to lead to many services that are currently provided through LES being provided in future by a network of practices providing services to their own patients or on behalf of other practices within the network. 5
We see this model as key to the delivery of whole systems integrated care and we will therefore identify a number of services where primary care is most capable and best able to deliver those services In line with this, where practices are commissioned to provide services at scale to patients from other practices within or across networks, the practice will be required to meet minimum quality standards before they will be able to do so All CCGs will be working towards commissioning a common bundle of services that will be provided by individual practices or by groups of practices across localities or networks. CCG will commission services using a service specification and pricing structure agreed across the five CCGs. CCGs will be working together to fund the required investment in primary care. Transitional funding arrangements will be considered for providers whose income is materially affected by the changes from LES, to enable them to manage the change and continue to provide safe services to patients. We expect to compete a small number of services that are currently commissioned using LES contracting mechanism. However we expect the list to be limited. The CCGs will look to commission services from all providers of general medical services but will work with NHS England to ensure that there is no duplication of service or payment in relation to PMS or APMS providers who deliver services above and beyond the requirements of the general medical services contract. The CCGs will aim to move to this commissioning arrangement as early as possible in 2014/2015. In order to ensure continuity of service provision the CCGs will transfer services currently commissioned as enhanced services on to standard NHS Contracts with effect from 1.4.14. The above intentions and table below are subject to further assessment and testing by CCGs and the CCGs may amend these as further work is undertaken. CCGs will issue decommissioning notices to providers for those enhanced services that they do not wish to commission in 2014/2015. The list of services that will be decommissioned for CL CCG is: Minor Surgery Out of hours Care for the Homeless Complementary Therapies. Sets out the framework that we are using to make decisions regarding the future provision of services currently commissioned via LES. 6
1.0 CLINICAL EXAMPLE SERVICES RATIONALE Initial Assessment of Commissioning Route 1.1 Enhancement of existing core service provided by General Practices Care planning / care management Enhanced access to routine primary care Co-ordinate my Care In line with whole systems strategy that puts GPs at the centre of coordinating patients care Post operative wound care Ambulatory blood pressure monitoring Requires clarity of accountability (which remains with GP Practice) or are list based services Service will need to be integrated with existing care / provide continuity along a pathway Signal in commissioning intentions that we expect to commission these services from individual practices and will look for 100% coverage from General Practice. Individual Practices may subcontract to other General Practices to enable CCG to get to deliver equity of access. 1.2 Additional service provider will need to demonstrate capability. Continuity of care and integration of service provision are seen as critical 7 day access to routine primary care Mental health primary care plus services Enhanced management of patients with long term conditions: Anti-coagulation services for stable patients Insulin initiation Methotrexate prescribing Services for homeless patients Violent patients Service will need to be integrated with existing care / provide continuity along a pathway Requires clarity of accountability (which remains with GP Practice) To provide best quality the service may need to make best use of scarce skills to serve a network of GP practices Or Service could give patients choice of provider Signal in commissioning intentions that CCGs expect to commission services across networks. CCGs will look to award to lead practices who can deliver services on behalf of patients within their network. To get coverage across networks subcontracting across networks would be allowed 7
1.0 CLINICAL EXAMPLE SERVICES RATIONALE Initial Assessment of Commissioning Route Service providers will need to utilise SystmOne, the shared patient record 1.3 Additional service multiple providers possible but location of service provision seen as important to ensure continuity of patient care Service best provided from within practice buildings unless VFM or other considerations make this impossible, at which point competition of providers may be sought. Phlebotomy Near patient testing Counselling Service will need to be integrated with existing care / provide continuity along a pathway Wider holistic benefits can be gained by providing services in a setting where the patient is also receiving other aspects of care at the same time Requirement for multiple locations reduces opportunity for VFM being achieved through a procurement and increases the administration costs associated with managing contracts Signal in commissioning intentions that CCGs expect to commission services from individual practices. Where practices decline to provide service, procurement or subcontracting across networks would be sought to ensure services are provided for all patients 1.4 Additional service provider will need to demonstrate enhanced skills requiring further training / accreditation Any Capable Provider Minor surgery Joint injections Psychological therapy in primary care (IAPT) Homeless nurse outreach Already other providers in the market and generally not provided by general practice itself Signal in commissioning intentions that the Contracts will be competed during 2014 but in the short term contracts may be migrated over to NHS Contracts as a holding position 8
Appendix Two Category One - Services to Be Retained Under New Re-provisioning Arrangements 1.0 The 7 Day Access LES The 7 Day Access LES supports two Quality Premium national measures: reducing potential years of life lost through amenable mortality, and reducing avoidable emergency admissions. It does so by increasing patient access to primary care and thereby reducing reliance on secondary care. The LES enables patients to 'walk-in' and see a doctor on the weekend without a pre-booked appointment, and requires participating practices to accept redirections from A&E and Urgent Care Centres where the patient can be seen safely in Primary Care. 1.2 Rationale This programme was introduced in 2013 following winter funding initiatives in 2011-12 and 2012-13 and represents a key element to reducing hospital admissions. It is also key to supporting the CCG strategy of increasing access to primary care. An interim evaluation of the service has indicated that the patients are using the service more for routine than urgent issues and consequently the programme does not seem to have affected avoidable hospital presentations. In response an education/communication programme is scheduled to address this and other measures will be considered as appropriate. It is important for this service to have sufficient time to be properly tested and supported. The overall effectiveness of the programme will be closely monitored and appropriate action taken in response to poor performance. 2.0 Coordinate My Care LES The Co-ordinate My Care LES supports the Quality Premium local measure of 'coordinate my care'. Both the LES and the Quality Premium measure intend to enable patients to have choice in planning where they wish to die and support patients who wish to die at home. 2.1 Rationale This service is been designed and will be introduced in October 2013. It is designed to ensure that patients at the end of life are treated with dignity and respect. It is a key aspect of our of CCG s strategic direction, critical for reducing avoidable hospital admissions. It is however likely that the payment mechanism within the LES is reviewed in the future as it is inconsistent with other CCGs. 3.0 Primary care Psychological Therapy and Counseling Enhanced Service The LES provides a cost-effective, efficacious and primary care based psychological therapy and counseling service in a time limited way for patients with mild to moderate mental health problems, and to ensure an equitable service in primary care. A new supplementary service will be introduced in October designed to increase the availability of IAPT CBT based services. 3.1 Rationale The service provides an excellent opportunity to increase the availability of psychological therapies in primary care. Poor mental health associated with range of long term conditions and hospital attendance. 4.0 The Homelessness Nurse Outreach LES The Homelessness Nurse Outreach LES supports two Quality Premium national measures: reducing potential years of life lost through amenable mortality, and reducing avoidable emergency admissions. 9
It supports these measures by offering two models of nurse outreach care to homeless people, to improve the clinical condition of homeless patients and to reduce their dependence on secondary care. 4.1 Rationale There is a high level of people who are homeless or sleep rough with associated high rates of emergency admissions, re-admissions and A&E attendances. It is important for this service to have sufficient time to be properly tested and supported. The overall effectiveness of the programme will be closely monitored. 5.0 Phlebotomy The Phlebotomy LES: Targets all adult patients aged 14+ requiring phlebotomy in Westminster Offers appointments for routine phlebotomy where required within 3 working days for 90% of requests and urgent requests within 24 hours Provides choice to patients of appointments on two or more days of the weeks 5.1 Rationale There was strong support for this service among the working group. It was felt that good and accessible blood testing was critical to effective diagnosis and good patient care. There was also support for the view that this service should be delivered from a safe environment the patient can easily access and that patients anxious about having blood tests including those with mental health patients and learning difficulties would more readily take up testing in a practice where they are well known and where they trust and recognise the staff. 6.0 Learning Disabilities The Learning Disabilities LES focuses on the development of a health action plan including information and action on medication and side effects, dental and oral health, nutrition, continence, hearing and vision, emotional needs, fitness and mobility, lifestyle factors and details regarding health screening. The LES also provides adequate and flexile appointment times for patients and geared towards hospital avoidance. It also offers supplementary training for GPs including MH, communication, consent and best interests. 6.1 Rationale People with Learning Disabilities are a target group for health inequalities. The LES covers people with mild, moderate and severe learning difficulties. There is a DES in place but this only caters for people in the two latter categories. It was therefore felt that provision should be retained for this patient group. However it should be noted that the CCG has insufficient funding for this service and the details are still to be worked through the NHS England. Category Two Services to be Amalgamated/Evolved IT Services It is proposed that the following services should be dis-continued and a new IT focussed service designed and implemented. These services were designed to introduce new IT systems and practices which have now been embedded. 10
7.0 Information Management and Technology (IM&T) The service was designed to reward practices who prepare successfully for the adoption of NHS Connecting for Health (CfH) IT systems and processes. Practices were required to implement the key national initiatives within the NHS: Connecting for Health (CfH) Programme including Electronic Transfer of Prescriptions (ETP); provide adequate training for new methods and systems; resource the successful installation and implementation of new technologies including paper-light (electronic record keeping). 8.0 The Choose and Book system was designed to achieve two things: to ensure that patients are offered a "choice" of provider for consultant-led first outpatient appointments where appropriate to their care, at the point of contact with their GP; and to ensure that patients can "book" their appointment at a time that is most convenient to them. Quality Improvement Services 9.0 The Locality Plan. This supports two Quality Premium national measures: reducing potential years of life lost through amenable mortality, and reducing avoidable emergency admissions. One key objective of the LES is to deliver a reduction in activity and deliver overall savings in individual practice combined A&E attendances, outpatient first attendances and non-elective admissions. 9.1 Rationale The service is a quality improvement programme for which responsibility has now transferred to NHS England. However, it may be useful to evolve this service and more directly align it with the out of hospital strategy, including exploring incentives to encourage practices to use the PRS. It is essential that the CCG supports the locality working which this LES has embedded and also encourages the practices to work together to deliver the QIPP programme. 10.0 Flu 10.1 This LES gives incentives to GPs to provide a proactive and preventative approach by adopting robust call and reminder systems for the patients on their list in all at-risk groups to receive immunisation. GP practices should review previous performance to identify areas for improvement and consider how to actively increase uptake rates. 10.2 There is a DES in place for flu immunisations and funding has been transferred to NHS England However, flu immunisation is a key priority for the CCG and it proposed that the CCG does not offer payments for immunisations completed but incentive payments are received for reaching certain thresholds. 11.0 Oral Anti-coagulation 11.1 The service is defined as the taking of bloods, determination of INR and dosing of warfarin provided to all patients during a single clinic attendance and at a frequency appropriate to clinical need. The scope of the LES includes initiation, monitoring and cessation of therapy when and if clinically appropriate. 11.2 There is a DES in place for oral anti-coagulation. However, this is an important service (and Anti-coagulation is a speciality area for PRS QIPP). It is proposed that we consider expanding provision in primary care and link to DVT. The funding for this service should also be reviewed as currently costs are more expensive than the acutes (with the exception of Imperial). 11
Category Three Services to be Discontinued These services duplicate existing Directly Enhanced Services. The specifications for these services are not clearly developed and their effectiveness on patient outcomes has not been clearly demonstrated. 12.0 The Extended Opening Hours LES 12.1 The LES enables patients to book appointments with GPs and nurses outside of core hours. There is a DES in place which provides an identical service and, therefore, it is difficult to justify continuation of this service. 13.0 Minor Surgery LES 13.1 The aim of this enhanced service is to implement a system wide approach to the redesign of Minor Surgery dealing with the high volume, low priority minor surgical cases across Westminster. This enhanced service aims to deliver high quality, accessible, care closer to home, by optimising existing resource and skill utilisation. Provision covers Section A: Invasive procedures, including incisions and excisions Section B: Injections of muscles tendons and joints 13.2 There is a DES in place which provides an identical service and, therefore, it is difficult to justify continuation of this service. 14.0 Complementary Therapies 14.1 The service covers osteopathy (400 care packages) massage (100 care packages) acupuncture (200 care packages) and Stress Management (8 courses). Although there was some support for this service within the working group, it was felt that this was not equitable to provide this service to a only a proportion of CL CCG patients (only 2 practices are signed up for this service) there are reported waiting times of several and there are some issues around underpinning evidence and clinical governance. 15.0 Care for the Homeless The Homelessness LES seeks to improve access to primary health care by targeting health services on the most difficult to engage homeless people. The service provides flexible walk in surgeries, /longer appointment times and appropriate and regular screening. However, It is felt that two CL CCG practices already delivered services for homeless people and a separate LES was unnecessary. There is also a NES service for the homeless and therefore the possibility of duplication. 15.1 A new Hep C specialist service is also under development and this element of provision will be integrated within this. 12