1. Clinical Commissioning Forum November 2016 Programme Board Commissioning Intentions 2017-19

2. 2 Table of Contents Programme BoardNumber Primary Care Quality1 Long Term Conditions2 Planned Care3 Early Years – Maternity & Children’s4 Crisis Care – Integrated & Urgent Care5 Mental Health6 Prescribing7

3. Primary Care Quality Board (PCQB) 1

4. Three areas to consult on: 1)CCE Contract 2017-19: All ready consulted on minor changes Do we want to have a fresh look at referrals e.g. take a more longitudinal approach? Do we want to have a fresh look at A&E 2)GP forward view – (see PCQB Appendix 1) summary of what CCGs have to do - Plan to spend access money of £6 per head for London – need to offer 155 additional hours of care per week incorporating weekends and weekdays from 6.30-8.00 Practice transformation support – £3 per head – including high impact areas 3)Reconsider whether the CCG takes on level 2 or level 3 delegated commissioning of primary care (see PCQB Appendix 2) 4

5. Rationale as seen by NHS England: Critical to STP planning Supports the development of more coherent commissioning plans for healthcare systems Gives CCGs greater ability to transform primary care Gives CCHG greater insight into practice performance issues Gives greater opportunities to develop a more sustainable primary care workforce Helps strengthen the relationships between CCGs and practices Additionally for C&H: We have good primary care so why not take it on/we are practically already doing it so why not do it officially Benefits and risks of taking it on as seen by the CCG: Deal breaker for Devolution There still are unquantified financial risks about taking it on – e.g. need to make recurrent savings to the budget through a QUIPP – NHSE has made savings to date through changes to business rates and efficiencies in waste disposal Is there any real freedom to use primary care budget without reference back to NHS England NHSE support team is under-resourced - CCG would have to make an additional investments to plug this Change in fundamental relationship between the CCG and members if it takes on performance management Some flexibility open to the CCG re DESs and QOF Delegated commissioning of primary care 5

6. Long Term Conditions (LTC) 2

7. “Must Do’s” and the CCG IAF Learning Disabilities: Work in the “Transforming Care Partnership” to reduce specialist inpatient care Personal Health Budgets: Increase Prevention: National Diabetes Prevention Programme “At risk” registers and annual reviews; LTC contract Management: Focus on patients with diabetes not achieving the “triple target” and attending structured education Improve self-care and reduce demand: see next page 7

8. Supported self management and patient activation Peer support; Time to talk; Social prescribing National Diabetes Prevention Programme Structured education for people with diabetes What else should we be doing? GP confederation’s demand management project will be piloting e-consult; a patient app; group consultations and maximising the pharmacy offer via healthy living pharmacies 8

9. Virtual clinics How is the virtual CKD service working? Any thoughts on the next service we should consider? 9

10. Planned Care 3

11. Planned Care Headline Commissioning Intentions 2017-19 Community services: Implement a new model for gynaecology with HUH; including a tiered model of care with enhanced primary care, community and secondary care pathways under one lead service provider Develop a community-based DMARD monitoring pathway/service with HUH moving appropriate patients from rheumatology to primary care possibly via the GP confederation. Commission new audiology services for the community Review the community dermatology service and build on the pilot Teledermatology service for roll out across primary care Cancer: STP/NEL cancer commissioning board plans to reduce pathway delays and deliver the constitutional standards. Aiming towards 50% of patients diagnosed within 28 days by 2020. Plans to widen GP direct access to diagnostics such as CT and upper and lower GI, improve screening uptake. NEL cancer commissioning board plans to improve earlier diagnosis Misc: Implement a new model of community and primary care interpretation services replacing the current Bi- Lingual Advocacy Service. Continue to work with HUH to deliver a tier 3 weight management service Clinical Leadership Programme and demand management 11

12. Community Services Gynaecology - Redesign of services: A four tier gynaecology service delivered in: Tier 1: Primary Care - Ensure pathways are followed – all practices Tier 2: Enhanced Primary Care - Routine procedures and follow up – possibly hub model Tier 3: Community Service - Routine one stop diagnostic and treatment services Tier 4: Secondary Care - Complicated care services To provide a service that delivers the right care in the right environment, whilst supporting the education of clinicians and patients. Community and secondary care services provided by HUH to manage the clinical pathway. Tier 1 & 2 services provided by local GPs. Dermatology Following the pilot teledermatology (clinical photography/consultant review) service commencing in Feb 2017, we aim to expand this service across primary care by September 2017. Review community service and align with teledermatology and minor surgery services Commission teledermatology service- review and maximise current community GPSI services to deliver Improve access to allergy services including paediatrics Provide directed education to GPs 12

13. Community Services (Cont) Rheumatology Undertake audit to understand the reasons behind HUH’s high follow up rate in rheumatology Develop a rheumatology pathway that outlines future arrangements for: DMARD monitoring and the prescribing of Subcutaneous Methotrexate Evaluate options for providing support to primary care delivery as part of this new rheumatology pathway Commission primary care services and education to support this new way of working Audiology Review current service provision including the availability of: direct access and community locations Evaluate commissioning options to promote integration, including closer working with children’s services, One Stop Services for patients Implement new national framework model including the options of direct access and children's services Align the future audiology services with ENT services based in the community and HUH 13

14. Cancer Cancer: Overall direction for cancer is set by the National Strategy. STP/NEL cancer commissioning board plans to reduce pathway delays and deliver the constitutional standards. Aiming towards 50% of patients diagnosed within 28days by 2020. NEL cancer commissioning board plans to improve earlier diagnosis Improve screening uptake Public awareness campaign messages via Public Health Dissemination of best practice across STP footprint City and Hackney Cancer contract with the GP confederation to continue Bowel screening uptake Safety netting 2ww refs Plans to widen GP direct access to diagnostics such as CT chest and abdomen, upper GI and implement straight to test model for lower GI endoscopy. GP education (via clinical leads) using data from cancer practice profiles (including raising awareness of rates of patients diagnosed via A&E etc), increase use of decision support tools, SEAs etc Continue to support improvements to support survivorship and recovery and improve overall patient experience 14

15. Miscellaneous Misc: Tier 3 Weight Management – Redesign dietetic services to provide T3 pathway Bi-Lingual Advocacy Review – A total redesign aiming for an interpretation model that is more equitable and includes criteria for telephone, face to face and perhaps skype services where appropriate. Advocacy is focussed on a limited criteria for new patients and is time limited Paediatric ENT – review pathways following audit and provide service in the community service if appropriate Clinical Leadership Programme (with Homerton) - Developing pathways, Continue general demand management : Agreed shared pathways for outpatients Increasing e-Referral and email advice services Making better use of electronic systems more widely such as tQuest Introducing more technology such as virtual clinics, video appointments where appropriate. 15

16. 4 Early Years - Maternity & Children’s

17. Commissioning safe & effective maternity care There have been six maternal deaths at the Homerton between 2013 and 2016 and two CQC inspections requiring improvements to the Homerton maternity service. Most actions have now been implemented and embedded into clinical practice. Pregnant women continue to present with high levels of complexity (medical, obstetric, social and psychological) and in 2015/16 approximately 52% of deliveries at the Homerton fell under the category ‘with comorbidities and complications’. We will require the Homerton to deliver a number of actions and improvements to provide assurance that local maternity care is safe, effective and responsive to women’s needs: Audit of tariff coding to understand high levels of acuity in deliveries Staffing review to ensure staffing levels and skill mix (medical & nursing) reflect reported increase in acuity Increase the number of midwifery led births (home births and at the birth centre) and increase the proportion of women booking for care by 10 weeks of pregnancy Increase the numbers of women receiving continuity of care from their midwife and develop midwifery offer for women receiving obstetric led care We will continue to monitor progress against the joint CCG / HUH combined action plan to ensure all recommendations from CQC inspections and maternal deaths reviews have been implemented and have produced positive change. Ongoing items are centred on audit, training and staffing levels. We will also review local services against “Better Births” national maternity review, and develop a shared local plan that focuses on: Personalised care and care planning Improved postnatal care and perinatal mental health support Choice and continuity of carer Community hubs and care close to home We will continue to input into NEL maternity network demand and capacity work stream to ensure there is adequate local maternity provision that is women centred and needs led. 17

18. Reducing infant mortality The Infant mortality rate in C&H is 5.7, higher than national and London averages. In the period 2011-2013, 26 infants died before their first birthday. In the same period there were 79 stillbirths in C&H, a stillbirth rate of 5.8 stillbirths per 1,000 births. The London rate was 5.5, the national rate 4.9. We have committed in our STP to reducing the rate of infant deaths and stillbirths in line with national expectations (20% by 2020). We will task the services we commission to deliver the following initiatives and recommendations: Implement recommendations from Public Health review of recent stillbirths and neonatal deaths, identifying preventable deaths and areas for service development. Improve the quality and safety of care in pregnancy and labour by strengthening the monitoring and escalation of raised blood pressure & increasing prescription of aspirin to women identified at risk of pre-eclampsia Ensure recommendations from the joint Homerton & CCG diabetes audit are locally implemented to ensure local compliance with national standards and best practice management of diabetes in pregnancy. Ensure recommendations from national “Savings Babies Lives” care bundle continue to be locally embedded into clinical practice and are monitored for impact: CO screening & swift referral to cessation services to reduce numbers of women smoking in pregnancy (aiming to half numbers by 2021). Implementation of risk assessment and surveillance for fetal growth restriction, via London RCT study of GAP and GROW tools. Raising awareness with women of reduced fetal movement, by providing Mama Academy wallets to encourage women to take action when they experience reduced fetal movements. Effective fetal monitoring during labour - ensuring Homerton is committed to the continuation of the Cardiotocography (CTG) midwifery posts, who deliver training and on the spot support to staff to evaluate CTG results effectively and escalate accordingly. 18

19. Reducing health inequalities – vulnerable women It is estimated that of 5783 deliveries at Homerton Hospital in 2013, 19% were to women classed as socially vulnerable. This equates to around 1096 women and babies. A 2016 CHIMAT toolkit estimated that in C&H, 1,435 to 2,335 women will have a mild, moderate or severe mental health need in the perinatal period each year. Local rates of breastfeeding, while high at 92% a birth and 83% at 6-8 weeks, mask lower levels of exclusive breastfeeding for some groups including some groups of Black and Asian women. We also know that maternal and infant mortality and morbidity disproportionately affects women and babies from deprived backgrounds. Locally we will ensure that a variety of local health and voluntary sector providers deliver services that address and reduce health inequalities, by providing targeted and tailored support to vulnerable pregnant women: Define and strengthen the vulnerable women’s care pathway to ensure a clear service offer is in place and agree a “failsafe” process to flag up women who DNA appointments with either their GP or Midwife. Extend the provision of targeted and tailored support for women who may struggle to access mainstream services, and evaluate impact of services, including: Targeted antenatal classes Bump buddies peer support in pregnancy service Postnatal group support (bonding with baby) Review impact of the locally developed perinatal mental health kite mark. Implement the London perinatal mental health service specification with local acute, community and mental health providers. Monitor uptake of and access to perinatal mental health services including 6 week IAPT waits for pregnant women and new parents. Jointly commission breastfeeding peer support services with the LA to ensure best use of pooled resources and to target support to reach women with lowest rates of exclusive breastfeeding at 6-8 weeks. Develop a tariff for the tongue tie service and review impact of service on breastfeeding continuation (and potentially failure to thrive). 19

20. 40% of City and Hackney children live in poverty. 3.2% of 0-4 children are coded as vulnerable with 2.7% coded UPP. 659 children had a joint vulnerable child action plan in 15/16. 27% of 4-5 year olds are obese. The CCG is an outlier for high numbers of 0-4 years admitted to hospital with unintended and deliberate injuries, and for children under 1 with emergency admissions for lower respiratory tract infections. We will continue to focus on early identification of needs and joint management of risks through the Early Years contract, key components will continue to be:  Vulnerable children’s register, joint action planning and review, with HVs  Offer and deliver new patient checks to 5-17 year olds  Maintain a register of CYP who have a ‘carer’ role and refer for support  Promote offer of a 16 th Birthday health check New developments for discussion: Family organisation template (family tree) developed following learning from a serious case review; provides a mechanism to record all of the members of the household; enables assessment of available family support and assists in the identification of possible risk, therefore enhancing paediatric assessments  Care planning with school nurses referral to / communication with school nurses not included on the EMIS template currently, consider consistency in communication with SN team via the Early Years contract?  Social Care pathway continue developing better communication between GPs and Social services by providing detailed information about the cases and the outcomes. Involve GPs in decision making at the time of closure of the cases and finally create social care pathway Reducing health inequalities – vulnerable children 20

21. Improving pregnancy outcomes There are just over 8,000 women aged 20-45 years with one long-term condition (LTC), 1,200 with two or more and around 350 pregnant women with one or more LTC. Rising levels of obesity are impacting on maternal health and pregnancy outcomes: in 2014/15 17% of women delivering at HUH had a BMI >30 and 3% had a BMI >40. Local uptake of maternal flu and pertussis immunisations is low at 32.6% compared with the national average of 39.8% and London average of 35.9%. Locally we will commission enhanced services for pregnant women with additional medical or social needs from primary care and acute services, and specifically we will: Review performance & learning from the GP Confederation early years preconception and pregnancy contract, with a focus on evidencing: Efficacy and uptake of preconception care for women with LTCs Better management of pregnant women’s LTCs. Earlier identification of women with social & psychological needs and risks, and increase the number of referrals to local support services (perinatal mental health, bump buddies, targeted antenatal classes) Increased local uptake of folic acid, aspirin and healthy start vitamins Ensure a clear local pathway and services are available for women with a high BMI and implement recommendations from Public Health review of maternal obesity Review the success of the NHSE & Homerton immunisation in pregnancy SLA, ensuring there has been a significant increase in the number of women who receive Pertussis and Flu jabs during their pregnancy. Ensure pregnant women, partners and parents have the opportunity to provide feedback on their experience of using maternity services and are kept informed on what steps have been taken to improve services. 21

22. In 15/16 practices coded the following numbers of children: asthma -1895; epilepsy -166; diabetes -102 Focus of 17/18 LTC contract will be: asthma, diabetes, epilepsy and sickle cell. Purpose across all areas is: - oversight of management; regardless of where the CYP receives their care; proactive follow up as needed - check that there are no gaps in / poor experience of care - check that care is coordinated, and CYP have personalised care plans Sickle Cell - Establish register, deliver annual review - Deliver transition discussion jointly with HUHT community specialist Nurse (supports transition to adult services and promotes repatriation to HUHT service where clinically appropriate) Asthma - A Single, personalised care plan, used across HUHT and primary care - Annual review, more often as required - Follow up post unplanned care attendance - Assessment of ‘at risk’ of asthma - what is GP feedback on how this is working this year? Developments  Need agreed approach to sharing clinical information across care providers to support local oversight of care / promote transfer of care to local providers where clinically appropriate Improving children’s outcomes (LTCs) 22

23. Special Educational Needs and Disabilities (SEND) Education and Health Care Plans (EHCPs) have replaced statements for CYP 0 to 25 years. Personalised, outcome based plans, that identify the needs an individual has that are impacting on their learning. Education, health, and social care work together to identify and meet these needs.  What is the role of the GP in supporting CYP with disabilities?  How much do GPs understand about the change from statements to Education and Health Care Plans (EHCPs?)  Are health pathways clear for GPs and for families? Specific priorities: - LD health checks – what other input do GPs have/ what do families ask of you? - Supporting health input to EHCPs for 18 to 25 year olds; a pathway needs to be agreed so that health information informs the plan Community paediatrics /therapy teams / CAMHS lead on this for children only 23

24. Spotlight on Community Paediatrics  Would further information / education session about community paediatrics be helpful?  Is it clear when / how to refer?  Do you receive care plans ? Developments  Children with disabilities needs assessment being undertaken in Q3 16/17  We know it will highlight lack of local health data  Consider roll out of consistent, simple coding of (disability) conditions in 17/18, across HUHT and primary care  If you had a practice based children with disabilities register would this enable you to provide more support to families / help identify training needs? 24

25. Community Paediatrics- scope of service Clinics based at Hackney Ark Neuro developmental clinics (1 per children’s centre area) School age neuro developmental (complex) Complex communication clinic (linked to ASD pathway) Social Communication Assessment Clinic (autism diagnosis for 5-14yr olds) Physical AssessmentInfant Neonatal Development clinic Health in Care Clinic (LAC)Child Protection Medicals Education and Health Care Plan (EHCP) School medical clinicLEAP (MDT specialist obesity clinic) Audiology Tier 2 Based at Hackney Ark but provided by Moorfields: Children’s vision clinic Clinics delivered from other sites Special advisory clinics -3 clinics, covering the North, Central and South regions of Hackney Paediatric Continence service – based in 2 health centres and toileting advisory clinic at the Ark Child Health clinics - trainees support these clinics as part of their training Provision at special schools in Hackney Multidisciplinary assessment clinic at Ickburgh special school Paediatric clinic at the Garden special school Medicals at Stormont special school 25

26. Joint prevention priorities with LbH and City Immunisations  Priority to achieve 95% herd immunity for Childhood Immunisations within 2 years  Non-recurrent funding secured, contracting options being explored  Significantly increase uptake by pregnant women of flu and pertussis immunisations Healthy start vitamins  Increase uptake of healthy start vitamins for all pregnant women and mothers up to 1 year post birth and babies from 4 weeks to 4 years through enhanced promotion (including via GPs as part of Early Years contract) Obesity  Proposal to decommission the community paediatrics component of the LEAP MDT from April 2017; currently this is a one off medical assessment without follow up  Consider whether a primary care pathway could replace this medical input  The CCG and LBH / City need to consider a joint strategy, recognising the CCG responsibility for Tier 3  Lack of evidence around Tier 3 services; CCG to consider an enhanced psychology based /MDT offer  Clarity on referral pathways for GPs (for women planning a baby, pregnant, postnatally and for children) and opportunity to train primary care staff in motivational interviewing / brief interventions / how to raise the issue. Smoking  Midwifery, Health Visiting and Primary Care focus on identifying parents who smoke and referring them for support to quit. Implementation of CO screening in Health visiting. 26

27. Activity in urgent care – children Increasing Activity  Increase in paediatric A&E attendances of 658 in months 1-5 in 2015/16 compared with 2016/17  The increase in the 0-4 years cohort accounts for 457 of these additional attendances; the 5-9 year cohort account for a further 191  Analysis of the data shows that 61% of cases are discharged and do not require any follow-up treatment  PUCC data indicates a 39% predicted reduction in activity in 2016/17 compared with 2015/16. This is attributed to reduced staffing and increasing acuity What can we do? Current A&E and frequent attenders audit work will inform the ideas below  Is there a new model for winter baby clinics in Primary care to cater specifically for infants under 1 with acute breathing related illness? How we can we work with the community paeds trainees?  Targeted health promotion with OJ community around accident prevention and home safety  Develop pathway for management of minor head injuries in primary care  Promote use of duty doctor / alternatives to going to A&E - Are children prioritised? - Shall we consult with users ?  Develop promotional materials with PH and Children’s centres regarding appropriate access to health services  Develop and define pathways for children with long-term conditions  Develop and define pathways and support for vulnerable families  Investigate capacity / access issues in Primary care. 27

28. Appendix 1 NEL 5 year STP: Maternity (draft) 28

29. Early Years: Key Questions 1. How is the universal and targeted preconception work going? What is appetite for support from women? 2. How confident do GPs feel referring women to services such as perinatal mental health, voluntary sector services, support around breastfeeding etc? 3. How can we best promote choice in maternity care to women? (e.g. what hospital women book with and where they have their baby) 4. Would a school nursing pathway support better communication around transition to school and school health plans? 5. Do GPs receive sufficient clinical information about their children managed at Trusts other than HUHT? What are the gaps / pathways we should prioritise? 6. What do GPs see their role to be in supporting children with SEND (special education needs and disabilities)? 7. How can GPs support women and children to achieve a healthy weight? Are GPs interested in delivering medical reviews for obese children? 8. Can we better use the various primary care contracts to help children avoid hospital use (CHUHSE, Duty Doc, Extended Hours, PUCC)? 29

30. 5 Crisis Care - Urgent and Integrated Care

31. Overview In 2017/18 the CCG is intending to adopt an integrated approach to commissioning crisis services across local service providers. There are three component parts to our approach: Introduction of a local single point of coordination to co-ordinate crisis services 24/7 across health and social care Develop and strengthen the quadrant model for provision of integrated community services Improving discharge and delayed transfers of care Alongside this work, we are part of the North East London Urgent and Emergency Care Network. We are commissioning a new 111 service in collaboration with 7 CCGs across North East London, due to go live in February 2018. To support patients in crisis and ensure that care is co-ordinated around patient needs, Coordinate My Care (CMC) will be used for urgent care planning across as many care settings as possible to improve patient care. As well as frail elderly and end of life care patients, in 2017/18 CMC will be used for care planning with the top 2% of patients at risk of admission (AUA DES register). This will support decision-making across the system for high-risk and frail elderly groups. 31

32. Single Point of Co-ordination (SPOC) Implement a single point of coordination for all crises calls, taking referrals from the health and care professionals and interfacing with the local integrated urgent care service (111) for patient-facing referrals. Delivered via an alliance of providers who will have collective responsibility for delivering outcomes. key Features - 24 hours 7 days a week - Centralised call centre for triage and initial assessments - Range of clinicians/services, including integrated pathway with social care and mental health crisis - Arrangements in place to ensure access to care plans (CMC) in the call centre and community Key Benefits - Provide better response for urgent care needs - Be easier to navigate - Give confidence to service users - Prevent people not falling between services Timescales The local Single Point of Co-ordination will be developed through a series of gateways over the course of November to March 2017, with fully operational capabilities established by April 2017 to receive referrals from the London Ambulance Service and health and social care professionals. 32

33. Quadrant Working Our intention is to develop quadrant working and integrated community services that will ensure high- risk patients receive integrated health and social care, with proactive care plans electronically shared via co-ordinate my care. This will be achieved through a range of multidisciplinary services integrating with each other, with GP practices and with the single point of coordination/crisis services, working to common goals. Key features are: - Strong assessment and care planning with care planning discussions at practice level - A range of services from keeping well to more intense support and specialist teams, including voluntary sector services - One named professional to take lead for patients - GPs kept informed about actions and progress Services will be geared to strong community working alongside primary care in a way that will reduce hospital admissions and enable patients to stay at home, concentrating on patients most at risk of admission/those on the FHV list, and minimise hospital stays. We will apply lessons learnt from One Hackney and City to shape the operational model, including: - Clearer quadrant leadership and quadrant team structure - Clear objectives, metrics and accountability - Consistent documentation and information sharing processes across professionals 33

34. Discharge/DTOC We are working jointly with the London Borough of Hackney and the Trust to improve discharge processes and address Delayed Transfers of Care (DToCs). Discharge planning will be supported by inpatient teams viewing care plans agreed with patients prior to admission, with long-term plans and wishes clearly identified. Earlier discharge will be enabled across 7 days through quadrant teams with enhanced capabilities, undertaking assessments previously confined to a hospital setting. A plan to develop a local discharge to assess model will be established as part of a wider programme of quadrant development. Comprehensively embed the trusted assessor model across the acute and community. Support patients’ choices to avoid long hospital stays and ensure that families are fully involved in planning. 34

35. Demand Management Managing Demand in Primary Care Urgent care demand will continue to be managed in primary care 24/7, with patients accessing consistent and responsive GP telephone triage in and out of hours. The sickest patients will be visited at home or referred to secondary care, with onward referral to multi-disciplinary teams supporting patients at home where possible. The Frail Home Visiting, Duty Doctor and Paradoc service will be commissioned from recurrent funding from 2017/18 The current contract for Enhanced Access will expire on the 31 st March 2017 CHUHSE are contracted to deliver the Out of Hours contract until 1 st December 2017 Acute-based Demand Management Acute-based ambulatory care will ensure that patients with ambulatory-case sensitive conditions receive outpatient-based care rather than acute admissions. 35

36. Ring Fenced Budget A ‘ring fence’ financial framework for crisis care for 2017/18 within an integrated care alliance: In 2017/18 the contractual arrangements would remain largely as they are now - i.e. PBR and other current payment arrangements unless new national guidance emerges or the providers want to propose a different mechanism. The total budget for the services will be ring fenced and the providers will be wrapped together by an agreement which will establish a collective responsibility for the achievement of financial balance within the ring fenced budget and the achievement of KPIs. The CCG will enter a 2 year service contracts on 1 April 2017 on this basis linked to delivery of the shared/collective metrics. This will be renewable after 2 years to a total 4 year arrangement in the light of satisfactory performance. The wrapper contract will be signed by every provider which has a contract for services which are deemed to be funded from the ring fenced budget. The performance and activity of the services within the ring fenced budget will be overseen by a Crisis Service Management Board and which will be chaired by a provider who will be responsible for service integration. 36

37. 6 Mental Health

38. Summary of Mental Health Programme Board’s Commissioning Intentions 2017/18 Mental Health Alliances will be closely aligned to the Integrated Commissioning chapters with each alliance contributing to the planning work of workstream area. CAMHS: new funding will improve eating disorders, perinatal and autism pathways, provide 24/7 crisis support and transform services to improve links with schools, children’s social care, youth justice and continue to address early intervention and family support Primary care mental health: monitor MH screening, reviews/physical health checks, referrals and targets using the Primary Care MH Dashboard. Improve medication reviews with physical health checks for SMI patients focusing on those where diagnosis appear not to match medication. Increase engagement of HCAs to take time pressure off GP. IAPT services: we will continue to hit our access target by working with voluntary sector providers, improve access for BME groups through co-locating therapists in community organisations and will continue work on improving recovery. Dementia: continue to achieve the diagnosis targets and improve support for people with dementia and their carers. The dementia alliance will work towards more integrated care planning and care navigation pathways, identify ways to reduce excess bed days for people with dementia in acute hospital settings, acute psychiatric wards and rehabilitation/continuing care wards. Review crisis pathways and crisis line access and improve carers assessment and support. Crisis and urgent care: we will make more efficient use of combined inpatient beds across all three boroughs (CH, NH, TH), invest in a fully funded CORE psychiatric liaison service and compliant EIP service (aim to expand EIP), build on our innovative pre crisis initiatives: SUN Project, Crisis Café and pilot virtual street triage as part of the Crisis Line. We will review the case for bringing mental health urgent care under the umbrella of a new urgent care alliance, improve access to substance misuse services for inpatient wards and pilot ‘Open Dialogue’ 38

39. Mental Health Strategic Priorities 2017- 2019 Reduce inequalities Improve the health of children and young people - in particular tackling childhood obesity and working with pregnant mothers and children under 5 to improve outcomes in early years Minimise the use of tobacco to reduce premature mortality Promote mental health, focusing on relieving depression and anxiety Caring for people with dementia and their carers Address social isolation Delivery the 5 Year Forward View Priorities in line with STP planning 39

40. Dementia Alliance Aligned to the Urgent Care and Prevention Integrated Commissioning Chapters Improving carer’s assessments Better integrated pathways, care planning and care navigation Reducing excess bed days Improved crisis pathways and crisis line access 40

41. CAMHS Alliance and CAMHS Transformation Programme Aligned to the Children and Early Years Integrated Commissioning Chapter Review the current crisis pathway and aim to provide 24/7 crisis resolution and liaison mental health services, which are appropriate for children and young people of City and Hackney. Increased integrated pathway to schools Better support for parenting Child to adult transition Improving the interface with Youth Justice Increased collaboration with wider CAMHS Alliance partners, namely City and Hackney schools, primary care, the youth justice system, maternity services and both local authorities. Ensure all current and future access and waiting time standards including the overarching 35% access rate are met including any sequential yearly targets. 41

42. Psychological Therapies Alliance Aligned to the Planned Care Integrated Commissioning Chapter Increasing access rates for psychological treatments Improving equity of access for BME groups Reducing waiting times and waiting lists for psychotherapy Improving return to work rates Improving information – creation of a clinical dashboard to better monitor waiting lists, waiting times, engagement and recovery across the alliance The application of a stepped care model with a greater use of Well Being intervention and guided self help through online therapy Improving outcomes and recovery 42

43. Primary Care Primary Care MH Dashboard to monitor MH: screening, reviews/physical health checks, referrals and targets Funding for primary care mental health reviews, physical health checks and screenings over and above QoF Improved medication reviews with physical health checks for SMI patients focusing on those where diagnosis appear not to match medication Primary Care Alliance (GP Confed, CEG, CCG, Family Action) co-ordinates and supports this programme Increasing engagement of HCAs to take time pressure off GP EPC - bi-monthly review and planning meetings with the GP Confederation, the CEG, ELFT and the CCG Closer working between ELFT Primary Care Liaison workers and GPs. 43

44. Urgent Care Aligned to the Unplanned Care Integrated Commissioning Chapter Support efficient inpatient bed availability across all three boroughs (CH, NH, TH) Fully funded CORE psychiatric liaison service and compliant EIP service (aim to expand EIP) Build on innovative pre crisis initiatives: SUN Project, Crisis Café Pilot virtual street triage as part of the Crisis Line Improve access to substance misuse services for inpatient wards Pilot ‘Open Dialogue’ Review case for bringing mental health urgent care under the umbrella of new urgent care alliance Ability to deliver 24/7 urgent home assessment 44

45. Prescribing 7

46. Prescribing Workstreams and the Five Year Forward Plan Framework Five Year Forward Plan Framework Workstream 17/18 PREVENTIONAcute Kidney Injury Project Heart Failure Respiratory Reviews PINCER Medicines Safety Tools Scriptswitch CCE Contract NEL STP Medicines Optimisation Group Medication Error Reporting Corticosteroid Use Reduction of Medicines Waste / Improve Prescribing Systems Biosimilars Drugs of Limited Clinical Evidence EARLY YEARSFuture adaptation of the successful respiratory project to focus on children CRISIS CAREAntibiotics Antidiabetic Drugs and agents PLANNED CAREManagement of High Cost Drugs Formulary Interface Domiciliary Medication Reviews Anticoagulation DMARDS Continence Care 46

47. Prescribing Incentive Scheme / CCE Contract 2017/18 – Prescribing elements Although benchmarking information for available prescribing indicators shows City & Hackney to perform well across a many prescribing indicators, there is still considerable scope for improvement. Also prescribing and utilisation of medicines is an evolving area requiring ongoing work including patient level reviews & audits to ensure standards remain high and the medicines that are made available in City and Hackney are cost efficient and the best for our patients There is a longstanding use of Prescribing Incentive Schemes across the country, as a tool to incentivise practices to remain within their prescribing budget allocation as well as improve quality of prescribing Recent NHS Policy documents such as NHS Five Year Forward View have highlighted that there is a greater need for medicines optimisation Over the last few years, there have been a number of tools introduced / expanded in C&H to support with the optimisation of medicines that our patients take and also to reduce medicines wastage. Submission of stipulated work is incentivised (for 2016/17, practices receive £0.60 per registered patient once all required work is submitted within required timelines). Practice feedback over the last 2 years led to PSPs taking on majority of work for CCE for 2016/17, though this has raised the standard of work submitted allowing for better CCG wide collation of results, there is possibility that for some practices, this has reduced potential practice learning. Why? 47

48. Prescribing Incentive Scheme / CCE Contract 2017/18 – Prescribing elements Practices are asked to:- A. To have a discussion as to whether to continue with practice prescribing work plans within an incentive scheme for practices OR whether the incentivised scheme is retired, with PSPs continuing to lead on prescribing work plans B. To agree role of PSP within a Practice Prescribing Incentive Scheme (if the Scheme continues) C. To agree the outline of proposed 2017/18 Prescribing Scheme Proposed Service Change Proposed 2017/18 Prescribing Incentive Scheme Prescribing Advisor Visits Annual prescribing visit + 4 follow up meetings with PSP(s) to discuss and agree prescribing work streams Audit to support:- Review of bi-annual prescribing data on dressings, hospital only/non-formulary drugs, specials Medication Error reporting and risk management eg opportunistic audits in response to Drug Safety Alerts Appropriate prescribing and medicines optimisation in patients with heart failure Preventing acute AKI and supporting patients with AKI Training – practices will be asked to participate in the following Specified e-learning related to AKI Prescribing Indicators –the practice will review their prescribing against the following indicators: Prescribing for UTI: ratio of the number of trimethoprim prescriptions vs. nitrofurantoin prescriptions [ ↓ ] Number of prescription items for trimethoprim for patients >70 years [ ↓ ] Antibacterial items per STAR PU [ ↓ ] Cephalosporins, Co-amoxiclav & Quinolones as % of all antibacterial items [ ↓ ] Least costly low/moderate dose ICS/LABA inhaler as a % of all low/moderate dose ICS/LABA inhalers[ ↑ ] Low and moderate dose ICS/LABA items as a % of all ICS/LABA [ ↑ ] Analogue insulins prescribed as a % of all long acting insulins [ ↓ ] Pregabalin Cost per ASTRO-PU[ ↓ ] Tramadol – Defined Daily Doses (DDDs) per 1000 patients [ ↓ ] Emollients Cost per 1,000 patients [ ↓ ] Proposed Implementation 48

49. Prescribing elements of 2017/18 CCE contract 2017/18 Medicines work stream of Clinical Commissioning and Engagement Contract Evidence to be submittedPayment Section A: Entry Level for CCE - Prescribing 1a. Practice to meet the prescribing advisor at least once during the year, by 30 th June 2017, to discuss Medicines Management: o Performance during previous 12 months o Action planning for 2017/18 and in particular to understand the basis of the required work including audits and QIPP Copy of Post-Visit Letter from Practice Pharmacist including agreed action points Part of the core CCE contract 1b. Practice will in addition to 1a, be asked to have three (3) subsequent meetings with Practice Pharmacist / Specialist Pharmacist during 2017/18 to include progress & feedback on: Prescribing Performance during previous 12 months Medication Review QIPP programme Audits ScriptSwitch Any Specialist Reviews e.g. Respiratory 1c. Practice to send to the MMT, at least bi-annually, a register outlining current prescribers / leavers & joiners to the medical and non-medical prescribers in the practice Practice’s submission of action points agreed at these 3 meetings 49

50. Prescribing elements of 2017/18 CCE contract Section B: Audit Levels for CCE - Prescribing 2017/18 Medicines work stream of Clinical Commissioning and Engagement Contract Evidence to be submittedPayment 2. Bi-annual submission of Reviews of Prescribing data on ‘Restricted Prescribing List’ Review data on:- Dressings Hospital only Non-Formulary Specials Each Practice to submit data outcomes forms, no later than 28 July 2017 (review of latest 3 month data) 31 January 2018 (review of latest 3 month data) Plus Dressings:- Q4 2017/18 ePACT data to show 95% reduction from baseline (Jan-Mar 2016) on costs of FP10 dressings (that are available via dressings store) Practice support pharmacist time provided by the CCG & incentive of 2p per registered patient for prompt submission of Practice’s Data Outcomes Forms and Prescribing achievement for dressings 50

51. Prescribing elements of 2015/16 CCE contract Section B: Audit Levels for CCE - Prescribing 3. Error reporting and risk management Responding to MHRA Drug Safety Alerts Medication Error Reporting Practice will be asked to:- utilise the PINCER audit tool which facilitates practice identification of pts potentially at risk of harm through prescribing errors/inadequate drug monitoring report medication related errors via the National Reporting and Learning Systems (NRLS). A summary of learning and action plan from the error should be submitted to MMT Action Drug Safety Alerts -record and submit reviews conducted in response to at least 75% of MHRA Drug Safety Alerts (those relevant to general practice) during 2017-18 Practice support pharmacist time provided by the CCG & incentive for prompt submission of Practice’s Learning & Action Points of 2p per registered patient per review 4. Clinical Audit 1 – Heart Failure – ensuring appropriate prescribing and medicines optimisation in patients with heart failure. Proposed that each Practice submits, a Summary report which outlines what the Learning from the Audit have been & the Practice’s Action Plan. Practice support pharmacist time provided by the CCG & incentive for prompt submission of Practice’s Learning & Action Points of 2p per registered patient per audit 5. Clinical Audit 2 – Clinical Audit & Training – preventing acute kidney injury (AKI) and supporting patients with AKI. Proposed that each Practice submits, a Summary report which outlines what the Learning from the Audit and AKI e-learning modules have been & the Practice’s Action Plan. E-learning needs to be completed by a specified deadline. AKI posters are to be displayed Provision of leaflets – confirmed by PSP Practice support pharmacist time provided by the CCG & incentive for prompt submission of Practice’s Learning & Action Points of 2p per registered patient per audit 51

52. Prescribing elements of 2015/16 CCE contract Practices that submit the Summary of Learning Points and Action Plan, by the due dates for the 2 audits will be incentivised with a payment of 10p per registered patient 6. Proposed that each Practice will actively engage in the Medicines QiPP Agenda & reach stipulated thresholds [threshold figures will be made available to practices shortly] MMT will: provide quarterly QIPP dashboard at least quarterly Practice will review prescribing against QIPP indicators, demonstrate improvements and reach the soon to be published thresholds for the 10 indicators below: Analogue insulins prescribed as a % of all long acting insulins [↓] Antibacterial items per STAR PU [↓] Cephalosporins, Co-amoxiclav & Quinolones as % of all antibacterial items [↓] Emollients Cost per 1,000 patients [↓] Least costly low/moderate dose ICS/LABA inhaler as a % of all low/moderate dose ICS/LABA inhalers[↑] Low and moderate dose ICS/LABA items as a % of all ICS/LABA [↑] Number of prescription items for trimethoprim for patients >70 years [↓] Pregabalin Cost per ASTRO-PU[↓] Tramadol – Defined Daily Doses (DDDs) per 1000 patients [↓] Volume of prescribing for UTI: ratio of the number of trimethoprim prescriptions vs. nitrofurantoin prescriptions [↓] Dashboard Quarter4 2017/18 Epact data Q4 2017/18 data will be available June 2018 Practices are encouraged to review, monthly, their current QIPP status on the secure site of the Prescribing site (as per monthly email to practices) Payment 5p per registered patient for achieving each of the 10 prioritised indicators on Action No5, so max total 50p per registered patient for achieving all 10 indicators 52

53. Safer Care Culture – NRLS and Medication Safety Tools (Scriptswitch, PINCER) Why? Proposed Service Change It is anticipated that there are 1.8 million serious prescribing errors in primary care each year - evidence predicts 5% of general practice prescriptions are erroneous, of which 0.18% are serious Developing an open, learning and safer culture locally is a high priority in delivering the Forward View: NHS Planning guidance 2016/17 – 2020/21 NHS England published a Patient Safety Alert: Improving medication error incident reporting and learning in 2014 directing small healthcare providers including general practices, dental practices, community pharmacies and those in the independent sector to report medication error incidents to the National Reporting and Learning System (NRLS) Medication errors are the most commonly reported safety incidence from GP practices, which have a very low reporting rate. The NRLS GP eform has been designed to simplify GP reporting. ScriptSwitch is a tool that provides GPs with detailed, locally authored patient safety information messages, drug switch recommendations and dosage optimisation information right at the point of prescribing. PINCER describes an evidence based approach to patient safety in which it has been demonstrated that the intervention of a pharmacists in general practice using a GP computer systems to identify patients at risk, can substantially reduce medication errors. Not only will it be possible to target medicines management resource more effectively by improving the quality of care, but it will also make cost savings by reducing health-care use resulting from adverse drug events Utilisation of PINCER audit tool by all practices A local reporting and learning culture to be established by practices reporting medication related errors via the National Reporting and Learning Systems (NRLS). A summary of learning and action plan from the error should be submitted to MMT as advised. Practices are to review and act on Drug Safety Alerts and document action taken using templates provided by MMT. (Practice must record and submit reviews conducted in response to at least 75% of MHRA Drug Safety Alerts during 2017-18) Practices to continue to prescribe safely and effectively taking into account safety recommendations provided by Scriptswitch PINCER approach to patient safety to be practiced by Practice Support Pharmacists when conducting medication reviews 53

54. Acute Kidney Injury Why? Proposed Service Change In August 2016, a patient safety alert from NHS Improvement (NHSI) relating to resources to support the care of patients with acute kidney injury (AKI). The alert is further to one issued in June 2014 on standardising the early identification of AKI. Key facts regarding AKI include: One in five emergency admissions to hospital will have AKI. 60% of AKI starts in the community AKI is 100 times more deadly than MRSA infection Around 20 per cent of AKI cases are preventable Costs of AKI to the NHS are £434-620m per year Think Kidneys is an NHS campaign designed to improve the care of people at risk or with acute kidney injury. The objectives of the campaign are to: Develop and implement tools and interventions for prevention, detection, treatment and enhanced recovery Promote effective management of AKI Provide evidence-based education and training programmes Highlight importance of AKI to commissioners, health care professionals and managers The following activities are proposed: Each Practice will be asked to submit, a summary report which outlines what the Learning from the Audit and AKI e-learning modules have been & the Practice’s Action Plan E-learning would need to be completed by a specified deadline. AKI posters to be displayed in the practice Provision of leaflets – confirmed by PSP 54

55. Antibiotics Why ? To help coordinate AMR workstream, the CCG has become a member of the North East London Antimicrobial Resistance Group. A GP antimicrobial lead has been appointed to help coordinate these efforts. Primary care antimicrobial guidelines have been drafted in conjunction with HUHFT. Urology guidelines that clearly outline the need to prescribe nitrofurantoin over trimethoprim. Part A: Reducing gram negative BSI a ≥10% reduction in all E coli BSI based on 2015/16 performance- collection & reporting of a core primary care data set for all E coli collection and reporting of a core primary care data set for all E coli BSI. Part B: Reduction of inappropriate antibiotic prescribing for UTI in primary care. a ≥10% reduction in the Trimethoprim: Nitrofurantoin prescribing ratio based on CCG baseline data. a ≥10% reduction in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data. Part C: sustained reduction of inappropriate antibiotic prescribing in primary care Items per Specific Therapeutic group Age-sex Related Prescribing Unit(STAR-PU) must be equal to or below England 2013/14 mean performance value of 1.161 items per STAR-PU Similar tests will apply for 2018/19. Proposed Service change Quality Premiums (QP) Antibiotics are the cornerstone of modern medicine and need to be preserved. In recent decades antibiotic resistance has become a reality globally. Inappropriate and overuse of antibiotics are known drivers of resistance; reducing the amount of antibiotics consumed slows bacteria developing resistance to these vital drugs, and therefore helps prevent antibiotic resistant infections. Over the last few years antibiotic consumption has been included in the CCG’s Quality Premiums. The two measures were: Reduction in the number of antibiotics prescribed in primary care. Reduction in the proportion of broad spectrum antibiotics prescribed in primary care. In 2015/16 City and Hackney CCG did very well in both these indicators. Achieving greater reductions than the London average. Current prescribing data (June16) suggests that the CCG will also maintain this prescribing reduction for 16/17. From 2018 NHS England will be running a new 2-year Quality Premium scheme. Bloodstream infections will be a new mandated QP. This QP has three elements: Part A: Reducing gram negative blood stream infections (BSI) across the whole health economy. Part B: Reduction of inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care. Part C: Sustained reduction of inappropriate antibiotic prescribing in primary care. This QP will require joint working across the entire health economy. The CCG will also retain the previous QP (reduction in volume and broad spectrum antibiotics). 55

56. Medication Reviews GP Consortia meetings have highlighted some problems with medication use and hoarding of medicines. Feedback from practices currently providing domiciliary medication reviews via domiciliary medication review pharmacists and Practice Support Pharmacists (PSPs) has been positive Previous Patient Public Involvement (PPI) Committee meetings have highlighted that patients/public want more time to discuss their medicines and that this would also help to reduce medicines wastage. A recent medicines review survey found that 83% of patients said that there was a need for more support to help manage their medicines better. Why? To provide a CCG wide domiciliary medication review (DMR) service by clinical pharmacists, ensuring there is a clinical review using patient records, evidence based guidelines and assessments of how patients take their medicines. To provide medication review service by clinical pharmacists in care homes (including providing drug administration, prescribing & medicines management advice to patients, care home staff and GPs To extend this to practice based clinics for patients who are able to come to Practices To work with Practice Support Pharmacists in increasing the number of medication reviews Proposed Service Change Medication reviews involving DMR pharmacists, care home pharmacist & PSPs who will work closely with GPs to identify and provide support to the following high risk vulnerable patients: Patients who have frequent hospital admissions Patients on complicated medication regimens Patients on ‘high risk’ medicines (e.g. warfarin, digoxin, antipsychotics, opioids, antihypertensives, injectable or enteral medicines, medicines requiring TDM) Any recommendations made will be discussed with the patient and their GP. To ensure integrated care is received, other healthcare professionals will be contacted if needed (e.g. social care, specialist nurses, community pharmacists) with the patients consent. The Interim report for the DMR service pilot (Jan 16- April 16) showed that 500 interventions were made for 112 patients visited. The acceptance rate by practices for advice provided by the service was 84%. Positive feedback has been received from patients, practices and other health care professionals on the medication reviews undertaken by DMR pharmacist and nursing home pharmacist. Also improvements in the CQC report of one the care homes with regards to medicines management. Proposed Implementation 56

57. Practice Leavers & Joiners (Prescribers) NHS Business Services Authority (NHSBSA) sends various reports to the Medicines Management Team (MMT); these reports sometimes includes instances where prescribers in a City and Hackney GP practices have used codes of practices not within City & Hackney. These incidents arise from practices not notifying the appropriate NHS agencies of o prescribers that have not ‘joined’ to the City and Hackney practice o prescribers have left the City and Hackney practice These leads to significant work by the MMTs of C&H and prescribers new/ previous CCGs in an attempt to redress financial responsibility associated with this ‘miscoding’ and also puts C&H CCG at financial Why? As part of the 17/18 CCE, practices will be asked to provide – at least bi-annually, an up to date list of all prescribers that work in their practices to the MMT Proposed Service Change Practices will be asked to submit bi-annually to the medicines management team, listing showing: o Current up to date names of prescribers ( medical & non-medical) that work in the practice o Names of medical & non- medical prescribers who have left practice within that quarter o Names of medical & non-medical prescribers who have joined practice within that quarter Proposed Implementation 57

58. Local Formulary Agreements & Issues at the Interface Why ? Proposed Service change Issues at the interface NICE guidance on Medicines Optimisation highlights the imports of good communication at the interface. Concerns regarding poor communication relating to changes to medication when crossing healthcare settings has been raised by both patients and GPs nationally. Interface issues that are highlighted to the Joint Prescribing Group, can be escalated to senior management at HUHFT. Recently the JPG requested that the HUHFT electronic discharging system is placed on the Trust risk register due to the risk posed by sending out multiple discharge summaries. Local Formulary In order to ensure City and Hackney patients receive equitable treatment across the borough we aim that practices prescribe in line with the formulary. The proposal would be to continue to review the use of high cost none formulary items; In order to reduce the use of these medications. This will help GP practices to prescribe in a clinically appropriate and cost effective manner. Continuation of this programme will ensure GP practices receive support from PSPs who can facilitate the adoption of formulary choices with support from the CCG medicines management team. Issues at the interface The medicines management team will continue to monitor and record any primary care interface concerns. information will be collected by regular feedback with the PSPs Practices, GP leads and Programme Boards. The MMT continue to run a busy medicines information services, a large number of requests for this service are regarding prescribing issues at the interface. Local Formulary Review 2015/16 prescribing data to highlight high cost spending on none formulary items. high cost non-formulary drugs will then be reviewed with PSPs at a practice level to determine reasons for use This information gathering highlights the need for guidelines to be produced around formulary choices to aid prescribing. An example of this is the recently developed eczema guidelines. This document will help GPs when choosing preparations. A further work steam will be the North East London STP medicines optimisation group: reviewing medication across the footprint. The group have highlighted drugs of low clinical value. C&H MMT have taken a lead on this project. PSPs will provide targeted support to each of their allocated practices in the event of any specific issues related to none formulary prescribing. Information will then be shared in the monthly prescribing newsletters to support best practice and improve use of the formulary 58

59. Interface work - Biosimilars Why? Barriers to implementation Introduction of biosimilars is more complex then generic switches for pharmaceutical drugs. Patients established on a brand will require additional support during switching. Clinicians will also require education and training on new products. Overcoming Barriers The CCG and HUHFT have agreed to develop a working group to establish a work plan for the managed introduction of biosimilar medication. This work plan will involve an 18-24 month agreement between the CCG and the Trust. The trust will be provided with financial resource to help implement the safe up take of biosimilars into the health economy. Proposed Service change Biosimilars A biosimilar medicine is a biological medicine which is highly similar to another biological medicine already licensed for use. Biological medicines are those that are made by or derived from a biological source such as a bacterium / yeast. The continuing development of biological medicines, including biosimilar medicines, creates increased choice for patients and clinicians. Biologics are often expensive and used to treat long term conditions. Biosimilar medicines are cheaper then the originator therefore these medicines have the potential to offer the NHS considerable cost savings and widen the access to innovative medicines. Biosimilars also increase commercial competition & enhance value propositions. Potential savings of £347K to the local health economy have been identified if all infliximab & etanercept (charged from HUHFT & Barts Health only, to C&H CCG) during 2015/16 had been prescribed & supplied as an equivalent biosimilar. NICE has written guidance on the introduction of biosimilars into the health economy. NHSE monitors uptake of biosimilars – currently monitoring the % uptake of biosimilar infliximab by Acute Trust. Implementation and increased uptake of biosimilar medicines in acute trusts has been identified as a priority area by the Medicines Optimisation STP group. HUHFT previously agreed to work on an infliximab CQUIN to increase use. The trust has informed the CCG that they will not be agreeing to another biosimilar CQUIN as the trust did not reach threshold for CQUIN payment. London Procurement Partnership (LPP) have proposed a 50:50 gain share agreement to increase the uptake of etanercept across London. C&H CCG is reviewing alternative options to implementing biosimilar introduction as the CCG is not supportive of Gain Share agreements 59

60. Anticoagulation Why? Many patients taking warfarin in City & Hackney continue to receive routine care in secondary care and do not have equitable access to the community based warfarin services The current mechanism for warfarin service provision could be more cost effective No tenders were received following 2 open procurement tendering exercises for a new consultant led community warfarin service Why? Alternative options for a local warfarin service will need to be assessed; the primary focus will remain the safe transfer from secondary care into primary care – of initiation of warfarin and routine follow up of patients on warfarin Scoping feasibility of increasing / expanding current primary care provision Review paper – outlining alternative options is being prepared for submission of Nov2016 contracts committee Proposed Service Change 60

61. Disease - Modifying Anti-Rheumatic Drugs (DMARDs) Why? DMARDs are a group of medicines that are used to treat primarily rheumatoid arthritis but also used to treat other conditions such as chronic inflammatory skin or bowel disease. DMARDs require regular monitoring due to their side-effect profile patients are required to have regular tests There are increasing numbers of patients prescribed DMARDs and currently many patients continue to receive routine monitoring in the hospital. Regular monitoring of DMARDs should be in line with the shared care agreements for individual DMARDs. However, feedback from GPs has highlighted the following: Shared care agreements which provide information to manage patients safely are not always provided by the initiating hospital specialists to GPs Where monitoring is carried out by the Hospital, often blood test results are not received by GP practices in a seamless robust manner In addition, data on HUHFT follow up rates suggest very high rheumatology follow up rates, possibly driven by frequent hospital attendance for DMARD monitoring Why? Planned Care Board have agreement with HUHFT for audit in 2017 to establish drivers for high follow up rates Working group is currently being set up to involve key stakeholders across interface development of a a commissioning pathway which will identify which activities can be undertaken by different providers ensuring that pathology data is fully shared To review the options & feasibility for a community based DMARD monitoring service for clinically appropriate patients prescribed a DMARD who have been stabilised in secondary care The review will aim to look at the following: improved patient access offering a more convenient service, with care offered closer to home and with reduced waiting times strengthened integrated pathway of care Proposed Service Change

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