PRIMARY CARE COMMISSIONING COMMITTEE

PRIMARY CARE COMMISSIONING COMMITTEE 1. Date of Meeting: 2. Title of Report: Western Avenue Medical Centre Personal Medical Services (PMS) Reinvestment Report 3. Key Messages: The Personal Medical Services (PMS) funding was originally invested in Western Avenue Medical Centre to improve access and provide services to patients in order to reduce health inequalities and improve their life expectancy. 84% of patients registered at Western Avenue Medical Centre live in the most deprived areas (categorised as quintiles 1 and 2 by the Indices of Deprivation 2015) which is more than twice the national average. Therefore the PMS premium funding plays a vital role in supporting both clinical staff and services to meet the needs of this extremely deprived population. The practice has implemented a number of innovative services to help address and reduce health inequalities of Western Avenue Medical Centre patients. These include in-house pharmacists and direct access mental health. The latter has resulted in a reduction of referrals to the Primary Care Mental Health Team by over 30%. 4. Recommendations a. To note the work done to date between the Practice, the Primary Care Team and the Clinical Lead for Primary Care to understand the utilisation of the PMS premium funding with Western Avenue. b. Note the options that have been proposed in terms of ongoing funding for this practice. c. To agree whether or not Western Avenue Medical Centre should continue to receive the full PMS premium based on the evidence submitted. 5. Report Prepared By: Emma Cousens, Locality Project Manager, West Cheshire Clinical Commissioning Group

NHS WEST CHESHIRE CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE WESTERN AVENUE MEDICAL CENTRE PMS PREMIUM HIGHLIGHT AND REINVESTMENT REPORT PURPOSE 1. The purpose of this paper is to provide the Primary Care Commissioning Committee with the information required to make a decision regarding the Personal Medical Services (PMS) premium funding for Western Avenue Medical Centre. BACKGROUND 2. Personal Medical Services (PMS) agreements were locally agreed contracts between NHS England and a GP Practice. PMS contracts offered local flexibility compared to the nationally negotiated General Medical Services (GMS) contracts by offering variation in the range of services which were provided by the practice to meet the needs of the local population. 3. NHS England made a national commitment for PMS funding to be reviewed and funding aligned with that of GMS practices. The resulting PMS premium funding would then be reinvested back into General Practice on a more equitable basis. In November 2016 the Primary Care Operational Group agreed the recommendation to reinvest the majority of PMS funding equitably across all Practices through the Primary Care CQUIN in 2017/18. 4. The Clinical Commissioning Group has been working closely with Western Avenue Medical Centre to understand the current use of the PMS funding and impact a reduction in funding would have on their population s health outcomes and health inequalities. 5. Western Avenue Medical Centre currently receive circa 175k of additional funding as a PMS premium. This funding has not been reduced within year one due to evidence submitted before the commencement of the financial year 2016/17 to demonstrate a significant difference in population demographics and the risk of significant destabilisation at the Practice.

WESTERN AVENUE MEDICAL CENTRE DEMOGRAPHICS 6. Western Avenue Medical Centre and the Clinical Commissioning Group have looked at data obtained from Cheshire West and Chester Council which demonstrates the health inequalities within this population. 7. The Cheshire West and Chester Council Blacon ward snapshot below illustrates the health inequalities between Blacon residents and residents from other Cheshire West areas. Blacon Cheshire West Residents with bad or very bad health 8.4% 5.5% Day to day activities limited 22.9% 18.5% Life expectancy 75.1 Male 78.9 Female 79.1 Male 82.6 Female Obesity 27.9% 22.7% 8. Nationally 40% of patients registered at GP practices in England live in the most deprived areas (categorised as quintiles 1 and 2 by the Indices of Deprivation 2015). However, 84% of patients registered at Western Avenue Medical Centre live in quintiles 1 and 2, more than twice the national average. Therefore PMS premium funding plays a vital role in supporting both clinical staff and services which meet the needs of this extremely deprived population. 9. It is widely recognised that high deprivation equals poor health 1. As a result, patients have multifactorial needs and access GP practice services more than patients from less deprived areas. Western Avenue Medical Centre also has a large number of non English speaking patients which increases demand as they require double appointments. Evidence also suggests that there is a link between poverty and mental health, to meet the mental health needs of the patients the practice has implemented a direct access mental health service. All of these factors create high demand and put considerable pressure on the appointment system. 1 https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/inequalities-in-lifeexpectancy-kings-fund-aug15.pdf Kings Fund Inequalities in life expectancy August 2015

10. Western Avenue Medical Centre continues to support West Cheshire Clinical Commissioning Group s strategic intentions by implementing their own transformation programme. The PMS premium funding supports a community with both a higher than average deprived population and mental health needs 2. The practice continues to take a proactive approach to managing the health inequalities within the community via high performance for relevant screening programmes and proactive follow up of inappropriate A&E attendances. In addition the practice offers innovative services such as in-house mental health support and in house pharmacist which have helped to reduce inequality and support health outcomes. 2 Poverty and Mental Health Mental Health Foundation and Joseph Rowntree Foundation August 2016 file:///c:/users/t-jefcoate-malam1/downloads/poverty%20and%20mental%20health.pdf

MULTIPLE DEPRIVATION IN CHESTER CITY 12. 70% of patients registered at Western Avenue Medical Centre live in quintile 1. This percentage rises to 84% when looking at patients registered at Western Avenue Medical Centre living in quintiles 1 and 2 more than twice the national average. This is significantly different from other practices in Chester City.

SERVICE DEVELOPMENT AND OUTCOMES 13. The Personal Medical Services (PMS) premium funding was originally invested in Western Avenue Medical Centre to improve access and provide services to patients in order to reduce health inequalities and improve their life expectancy. 14. In order to meet the Key Performance Indicators (KPI s) set out by the West Cheshire Clinical Commissioning Group; Western Avenue Medical Centre employed a salaried GP and a nurse practitioner. (Please see appendix 4 for more details). This has enabled the practice to increase access and also to develop innovative projects to help address health inequalities as detailed below. 15. Projects implemented include Direct Access to Mental Health Service, In-House Pharmacist, Inappropriate A&E Attendance reviews, appointments system change screening appointments, integrated working with the Children s Centre, one off educational sessions and supporting the CCG starting well team. The Direct Access Mental Health Service (DAMHS) 16. There is a link between deprivation and poor mental health. As such, a large number of GP appointment time is allocated to seeing patients with mental health conditions. When appropriate a GP will refer a patient into the Primary Care Mental Health Team (PCMHT) which has a 6 8 week waiting list. In the meantime patients often re-attend at the GP Practice or attend A&E which can lead to prescribing medication as an interim measure whilst waiting to be seen. 17. To address patient need Western Avenue Medical Centre has developed an in-house service called The Direct Access Mental Health Service (DAMHS). The service utilises a Mental Health Nurse and a Psychological Wellbeing Practitioner, both delivering 1.5 sessions per week each. 18. The Direct Access Mental Health Service (DAMHS) has reduced referrals into the Primary Care Mental Health Team (PCMHT). Between April 2015 and March 2016 the number of referrals into the PCMHT totalled 148. Between April 2016 and March 2017 the number of referrals into the PCMHT reduced to 54. For more information please see Appendix 1.

Patient Story 19. Patient A had a long history of mental health issues which were managed by a previous practice with medication and regular telephone reviews. By the time Patient A was a patient at Western Avenue Medical Centre she was unable to work due to her mental health illness, was unable to care for her children and unable to leave the house. Date Referred To PHQ-9 score GAD-7 Score 18 Oct 2016 Seen by Psychological Wellbeing Practitioner (PWP),goals and plans discussed 18/27 15/21 25 Oct 2016 Appointment with PWP. Improvement noted N/A N/A 8 Nov 2016 Leaving home on a daily basis. Further targets discussed 22 Nov 2016 Attending Appointments alone 3 Jan 2017 Taking children to and from school. Looking for employment, discharged 5/27 11/21 5/27 5/21 2/27 3/21 In-House Pharmacist 20. It is recognised that high deprivation equals poor health. As a result, patients have multifactorial needs and a large number of patients are in receipt of multiple medications. The practice has employed a pharmacist to manage these patients, to reduce polypharmacy and take a focus on the risk of falls in the elderly. Outcomes from In-House Pharmacist 21. 14% reduction in medication reviews by the GP which has also resulted in improved patient access and patient journey. 22. The In-House Pharmacist works closely with the Medicines Manager to identify cost savings. Western Avenue Medical Centre has the highest percentage of cost savings within the City Medicines Managers. Data issued for February 2017 shows the percentage of saving of MM per annum is 351.3%, the next highest was 256.6%. 23. Reduced workload for admin team due to reduced number of repeat prescriptions. 24. Increase skill mix of Primary Care Team, leading to staffing efficiencies.

Inappropriate A&E Attendance Reviews 25. Since February 2016, Western Avenue Medical Centre have been proactively writing to patients who attend A&E inappropriately. Looking at the data collated by Western Avenue between June 2016 and June 2017; there were 845 recorded A&E attendances and 92 patients who were written to due to inappropriate attendance. For more information please see Appendix 1. A&E Attendances for Western Avenue 26. Western Avenue Medical Centre have achieved some positive results regarding their A&E attendance results. In June 2017 there was a 6.97% reduction in A&E attendances compared to that in the previous year. 27. For Western Avenue Medical Centre, Emergency readmission for the over 65s have reduced by 22.22% compared to the previous year. For more information please see Appendix 3. Screening & QOF 28. The Practice were identified as a Chlamydia testing champion for both 2016 and 2017 due to their increasing and high performance in offering and completing these tests for patients. 29. Western Avenue Medical Centre are high achievers for QOF, and continue to be within the top quartile of Practice performers for flu vaccination uptake in the over 65s and cervical screening. Most recently the Practice was recognised for their outstanding work at the Membership Council due to 85.1% of eligible patients taking up the flu vaccination. Starting Well 30. Please see more information in Appendix 1 regarding integrated work with the Children s Centre, one off education sessions and CCG starting well projects that the practice supports. Other demands on the practice due to population demographics 31. There are other demands on Western Avenue Medical Centre that are at variance to the workload of a practice in a less deprived area; including the number of safeguarding reports and meetings, patient requests for information and reports and registrations. Please see more information in Appendix 2.

PROPOSED DEVELOPMENTS Turning Point In-House Clinic 32. Western Avenue Medical Centre are currently looking at holding in house clinics in partnership with Turning Point. The active recovery service provides free support to those affected by drug and alcohol addiction. 33. Western Avenue Medical Centre report that their patients are reluctant to travel great distances to access services. Therefore they propose to offer Turning point space within the practice and offer the service out to all Blacon residents regardless of the practice they are registered with. Remploy and Stonham Housing Clinics 34. Western Avenue Medical Centre currently have Remploy and Stonham Housing housed within the Centre. If the PMS premium funding was confirmed these services will be available to all Blacon residents. SUMMARY 35. Western Avenue Medical Centre is one of only two practices within the whole area of West Cheshire that serve a population in which 84% of its population live within quintile 1 and 2 - the most deprived areas. 36. Investing PMS money into Western Avenue Medical Centre continues to be in line with the Clinical Commissioning Group s commissioning intentions of reducing health inequalities. The practice employ a number of clinicians who meet the needs of the local population, keeping them in primary care and therefore reducing the demand on secondary care. 37. Without PMS funding it is not financially viable to employ the extra clinicians which will result in reduced access and reduced services available for the patients. Without these additional services, the number of patients utilising secondary care will increase leading to longer waiting times for patients and an increased overall cost to the Clinical Commissioning Group. 38. Choosing to reinvest funds into Western Avenue Medical Centre which is twice as deprived as the average GP Practice in England will result in long term gains in both health inequalities and life expectancy.

RECOMMENDATIONS The is asked to consider the following options. 39. Option 1 - Continue with the current level of funding Western Avenue Medical Centre continue to receive the current level of funding. This would enable the Centre to further develop services to address the health inequalities of the population and this would also continue to support the reduction in A&E attendances. In addition the Centre would be able to commit to services which help reduce the number of referrals to the Primary Care Mental Health Team through the Direct Access Mental Health Service. The patient journey would also to continue to be improved by the in-house pharmacist and polypharmacy and medicines wastage reduced. Benefits Current patient outcomes achieved will continue. Enhanced engagement from Western Avenue Medical Centre. CCG input and control over service developed within a population of deprivation. Disadvantages Inadequate funding across practices leading to disagreement. 40. Option 2 Share the total amount between 35 practices This would give each practice approximately an extra 5K a year to invest into the Primary Care CQUIN on a sliding scale up until the end of the four year transition period. Benefits Provides additional funding for all practices via the CQUIN. Provided equity across practices. Disadvantages Once distributed, funding is unlikely to create a large enough impact on an individual practice basis to improve outcomes. Western Avenue could be unstabilised. Patient outcomes at Western Avenue Medical Centre would decline and secondary care emergency activity increase.

APPENDIX 1 - Service development, outcomes and impact/risks SERVICE DEVELOPMENT Direct Access to Mental Health Services ADDITIONAL INFORMATION PMS funding funds majority of the service. CWP currently part fund the staff. In house service waiting time is only 2-3 weeks. FUNDING REQUIRMENTS PMS funds Mental Health Nurse and 1 Psychological Wellbeing Practitioner (PWP) OUTCOMES From 19 July to 2 December 2016 Mental Health Nurse = 47 appointments. (13 discharged/self help: 10 referrals to Psychological Wellbeing Practitioner (PWP) 17 PCMHT referrals). PWP = 69 apts. (15 discharged/self help: 10 step 2 session: 20 PCMHT referrals). IMPACT / RISKS If the funding ceases then the only referral route will be straight into PCMHT. Increased waiting times for patients. Potentially more intervention required due to waiting time and therefore increased cost to NHS system. Increased prescribing. In House Pharmacist Employed from November 2014 x 2 sessions a week Pharmacist 2 sessions a week Reduce polypharmacy. Improve patient journey and patient access. 14% reduction in medication review by GP s in 2016 compared to 2015. Increased pressure on GP s with more patients booking in for medication reviews. Screening appointments Flu, chlamydia, cervical Admin time Robust call and recall system Patients failing to attend screening appointment are sent personalised letter and ask them to rebook. Reduced number of screening appointments for patients. Recall system reduced. Reduced ability to carry out ECG s and spirometry.

SERVICE DEVELOPMENT Inappropriate A&E Attendance reviews ADDITIONAL INFORMATION Proactively writing to patients who attended A&E inappropriately FUNDING OUTCOMES REQUIRMENTS Admin time Started February 2016. Started coding June 2016. Data for 1 year = 845 recorded A&E attendances, 92 been written to regarding inappropriate attendance. IMPACT / RISKS Significant increases in A&E attendances due to reduced access to apts. Increase in admin time to process more A&E attendance reports. Current attendance undergo review by a clinician. Releasing a GP to carry out this function would be extremely difficult. Appointments system change Changed in August 2014 Due to the population needs approximately 50% of appointments are available on the day PMS funds 1 GP and 1 NP Majority of patients have on the day access. Reduced A&E Attendances 30% less appointments available = approx.417 GP apointments lost and 612 ANP apointments lost per month. Increases in A&E attendances. Increase in referrals due to loss of ability to refer internally. Increased workload for secondary care. Increased cost for

SERVICE DEVELOPMENT Starting Well ADDITIONAL INFORMATION Practice supports the starting well team in the CCG FUNDING REQUIRMENTS PMS pays for backfill for GP attend meetings. OUTCOMES Involved in development meetings and pilot new pathways. Piloting paediatric clinic out in the community. IMPACT / RISKS No time to support development in meetings or pilot new pathways. One off educational sessions with GP s Educational sessions led by clinicians for the patient population. PMS funding pays for clinician backfill to facilitate sessions. In an effort to reduce attendances by parents with young children into out of hours and A&E Educational sessions are held with GP s. These cover the most common conditions and discussing red flag warning signs and when to contact a GP or other healthcare service. Basic paediatric life support training will also be provided. No time to prepare or facilitate educational sessions for the patient population and wider Blacon. Children s Centre Opportunity to build relationship and look at joined up working with Children s Centre. PMS funding required to attend meetings and support facilitation on sessions to community. Greater integration between Western Avenue Medical Centre, Children s Centre and health visitors. Due to the large number of safeguarding cases relating to patients registered at the practice, it is not possible to discuss at MDT. Additional 2 hour monthly meeting between GP, admin person and Health visitor would no longer take place.

APPENDIX 2 - Other demands on Western Avenue Medical Centre due to population demographic OTHER DEMANDS ADDITONAL INFORMATION NUMBER PER MONTH Safeguarding Reports 271 patients (nearly 7% of the Meetings 16 per and Meetings population) with a annum safeguarding alert* TIME TAKES PER MONTH GP 2/3 hours a month Admin 12 hours a month Patient requests for information and reports Registrations Data for January May 2017 Reports for forms such as ESA, Universal Credit and PIP Due high level social housing there are a large number of new patient registrations and deductions. 24% (approx. 960 patients) of the practice populations changes per annum. Average 48 a month Registrations 37 average per month Deductions 35 average per month GP 5 hours per month Admin 18 hours a month Clinical 12 hours 20 mins a month Admin 6 hours 10 mins a month Admin 5 hours 50 mins a month *safeguarding alert (Child in need, TAF, looked after child, victim of domestic abuse, interim care order, MARAC report, victim of child sexual exploitation)

APPENDIX 3 - A&E attendances for Western Avenue Dashboard data to show reduction in A&E attendances and Emergency readmission s for over 65 s. Dashboard rate per 1,000 pop Actual Month Data A&E Attendance WA A&E Attendance Change from last year Emergency Readmission WA over 65's Emergency Readmission WA Change from last year Oct-16 Aug-16 152.09-4.82% 3.33 44.44% Nov-16 Sep-16 175.87-6.78% 50 57.14% Dec-16 Oct-16 205.01-4.98% 43.18 18.75% Jan-17 Nov-16 232.11-5.22% 45.45 11.11% Feb-17 Dec-16 32.21 0.80% 45.45-13.04% Mar-17 Jan-17 292.63-3.38% 53.57-14.29% Apr-17 Feb-17 318.98-4.40% 71.43 3.32% May-17 Mar-17 355.46-3.77% 66.96-14.29% Jun-17 Apr-17 360.27-1.32% 66.96-14.29% Jul-17 May-17 351.11-3.34% 68.13-11.43% Aug-17 Jun-17 340.75-6.97% 61.54-22.22%

APPENDIX 4 - STAFF COSTS CORE STAFF Job Title No. Sessions / Hours Costs PA (includes on costs) GP Partner Other Information 12 sessions per week N/A This information has not been disclosed Practice Nurse and HCA Admin Team including Practice Manager -PM 47.5 hours per week 43,100 289.5 hours per month 146,089 Structure of Admin: Full Time PM, 2 x Receptionists, 1 Data Quality / IT Manager. Part Time Office Manager, secretary, data input clerk, medicines manager. STAFF EMPLOYED WITH PMS FUNDING Job Title GP Salaried Advanced Nurse Practitioner No. sessions / Hours 9 sessions per week Costs PA (includes on costs) 8 sessions per week 48,900 Other Information 102,583 Currently not replaced 4 salaried GP sessions due to threat of PMS review. Paediatric Advanced Nurse Practitioner. In House Clinical Pharmacist 2 sessions per week 7,000 Started November 2014 Mental Health Nurse 1.5 sessions per week 9,000 Psychological Wellbeing Practitioner (PWP) 1.5 sessions per week 6,000 TOTAL 173,483.00