Co-Commissioning Arrangements in Primary Care (GP practices) - Principles and Process for managing and Contracting 1. Purpose The CCG will have delegated authority to commission primary care (For clarity, this refers only to GP practices) from 1 April 2015. To ensure transparency and reduce ambiguity it is essential that the principles and process for managing these arrangements are clearly defined. 2. Introduction CCGs have a statutory duty to assist and support NHS England in securing continuous improvement in the quality of primary medical services. The CCG recognises that, under delegated commissioning arrangements, it will remain accountable for its pre-existing statutory functions, including in relation to quality assurance, but that these will need to be extended across the primary care contracts for which it will take on responsibility. The CCG has incorporated within the Terms of Reference of the Primary Care Sub-Committee the requirement for that Committee to provide assurance to the Governing Body regarding the quality, safety and contracting process of primary medical care services in Rotherham. 3. Process for developing quality assurance arrangements in South Yorkshire & Bassetlaw The CCG s Chief Nurse has participated in a group of representatives (nurses and doctors) across South Yorkshire & Bassetlaw which has sought agreement on the principles for managing quality and the quality assurance processes to be adopted in Primary Care taking into account the co-commissioning options in a safe and effective way. The approach outlined below was developed by this group, and was discussed at the Co-Commissioning Steering Group in November 2014. It summarises the agreed principles, to which Rotherham CCG is fully committed. The proposals include using the Responsible, Accountable Supporting, Consulted, Informed (RASCI) governance model to ensure clarity between commissioners where the accountability and responsibility for quality functions is not clear. 4. Assurance Principles 4.1 Current Position To support the quality processes within South Yorkshire and Bassetlaw the 5 CCGs and NHS England have adopted a collaborative approach via the Chief Nurses in respect of quality assurance for acute and community providers. All areas have adopted the Commissioning for Assurance and Improvement policy which uses an Appreciative Enquiry Approach to quality monitoring. All commissioners have adopted this policy which contains a 1 P a g e
Assurance Framework. This has been a very effective process which has proven to be a great example of collaborative working therefore the proposal attempts to adopt this principle in reference to quality assurance in Primary Care. 4.2 Assurance Framework in Primary Care Whilst the practice as the provider is accountable for the quality of services, NHS England and CCGs as commissioners have a shared responsibility for quality assurance. Rotherham CCG already has a statutory duty to assist and support NHS England with quality but will also have delegated authority for contracting of GP practices from 1 April 2015. The quality assurance framework describes our proposed approach to monitoring and assuring quality in all Primary Care commissioned services. The three domains of quality: patient safety, clinical effectiveness and patient experience will be monitored through routine internal contractual processes and clinical governance structures and external sources such as CQC, peer reviews, national surveys etc. GP practices as providers are required to have their own quality monitoring processes in place and through the duty of candour and the contractual relationship with commissioners they have to provide information and assurance to commissioners and engage in system wide approaches to improving quality. There should be consideration of the contractual process throughout the quality assurance process The following describes the process and escalation in relation to Assurance: Stage 1 Routine Monitoring for Primary Care: Routine Monitoring includes the following: Routine Metric Monitoring Patient Safety Indicators include: monitoring of HCAI, safeguarding vulnerable children and adults, reporting of patient safety incidents, workforce numbers, skills and training, Uptake of vaccinations and Immunisations Patient Experience Indicators include: complaints, Friends and Family test, Access to appointments/services Effectiveness Indicators include: Emergency admissions data, referral rates, and partnership working arrangements. Stage 1 Routine Assurance Visits / Arrangements for Primary Care Routine quality assurance (peer review) visits in Rotherham are now in their second year of a three year programme (whereby each practice is visited once every three years). There is an annual table top exercise with attendance from SCE GPs, Chief Nurse and Head of Medicines Management. The purpose of the table top is to review a suite of information including elective and non-elective benchmarking information, prescribing information and performance against CCG commissioned services. Those practices scheduled to be visited are looked at in 2 P a g e
detail and there is a brief review of those practices which have been visited and are scheduled for the following year. The output from this meeting is the identification of key discussion points for each practice. The practices selected for visits in each year were selected at random by the LMC. These visits are clinically led by a member of the strategic clinical executive, with attendance from the Head of Primary Care and have been clearly distinguished from the contract meetings which (until 1 April 2015) are the responsibility of NHS England. Peer review visits are intended to be an informal way for practices to have an open discussion about areas of their practice. This is intended to be a supportive process and part of the on-going dialogue with practices and the CCG. Following the visit a summary of the key discussion points and actions for the practice and the CCG are sent to the practice. Action points are reviewed on a regular basis. Where the concerns are not addressed RCCG is able to invoke Stage 2. In significant, exceptional circumstances, the breach may be so severe that it may escalate the practice to Stage 3 as described in the Assurance Framework. Stage 2 Surveillance (Enhanced) This is the reactive element of the quality assurance framework. The provider is escalated to this level where increasing risk is identified. There is a need to undertake a quality assurance visit to gain assurance of the quality of provision and the safety for patients. It is triggered by a joint NHS England / CCG decision making process. There should be consideration at this point of the contractual process and recommendation to Surveillance Group (QSG) of the change in status. There should be a report produced which is shared with the provider as to areas of good practice as well as areas for improvement. The provider will be required to produce an action plan. This plan will be monitored through the governance arrangements in place when agreed. There will be a number of options available following this visit: Support should be put in place or signposted to enable the provider to deliver their action plan Stage 3 Risk Summit Should the identified risk remain or increased a Risk Summit will be considered. This would involve NHS England, the relevant CCG quality and contracting teams and the provider Chart 1 below shows the Assurance Framework in detail: 3 P a g e
Assurance Framework Local Assurance Patient Safety Incident reporting Safeguarding incidents SCR/IMR HCAI Vac & Imms uptake Medicines Management CAS alert compliance Workforce Section 11 audit QOF Patient Experience Complaints FFT Access to services Patient Surveys Effectiveness Emergency admissions A&E attendances Low Level Concerns Referral Rates Pathway compliance Clinical Governance arrangements NHS health check Partnership working Medicine Management arrangements Safeguarding visits/processes IP&C visits Proactive routine CCG quality visits Incident investigation support Maintaining high professional standards process Contract monitoring visits Enhanced Surveillance/Visits Increasing Risk and reducing assurance of quality Routine Monitoring Routine Assurance Visits/Arran gements Enhanced Surveillance Visit NHS England CCG and provider Risk Summit External Assurance Bodies CQC Registration/Inspection/Compliance CQC Monitoring Public Health England Local Authority Monitoring Professional Bodies Healthwatch LMC Deanery re placements QSG LPN DATA Health and Social Care Information Centre NHS England Dashboard National Reporting and Learning System (Safety Incidents) Central Alert system. Web Tool Risk Summit Enhanced Surveillance Routine Monitoring / Assurance 4 P a g e
5. Commissioning Principles The quality assurance framework above describes our proposed approach to contract monitoring arrangements for primary care (GP services). The contract monitoring process will work in conjunction with the quality assurance process and will consist, at minimum of the following key areas: Performance against core contract Review of performance against LIS,LES,DES,NES Performance against QOF Review of PMS/APMS key performance indicators Review of additional services The CCG is currently reviewing, with NHSE, the benefit and purpose of the PMS review process, this process is being led by NHSE. The Primary Care Commissioning team will liaise with practices to complete a declaration of self-assessment against relevant criteria on an annual basis with practice visits conducted as part of a three year cycle. In addition to this the CCG will conduct ad-hoc visits to validate data provided as part of the self-assessment process. If a practice is identified with performance concerns in respect of the contracting process the following action will be taken: Action plan to address the performance concern(s) including timescales; if the practice remains non-compliant Remedial action plan and planned review visit; if the practice remains non-compliant Application of contract sanctions In significant, exceptional circumstances, the breach may be so severe that it may escalate the requirement to escalate straight to a Risk Summit as described in the Assurance Framework and/or require counter fraud intervention. If the performance issues is of individual good medical practice, it remains NHSE s responsibility to investigate and take relevant actions in relation to the relevant practitioner. The CCG will utilise a series of metrics to inform the contracting process and reduce bureaucracy. Practice performance will be reported to the Primary Care Sub-Committee which is chaired by a Lay member of the CCG to ensure compliance with governance arrangements for GP commissioning. The CCG will contribute to work ongoing with NHS England to devise appropriate outcome measures to support the contracting and quality assurance process. The Primary Care Sub-Committee is responsible for the strategic direction and quality/performance management of primary care commissioning. 5 P a g e