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Contract meeting for Sessional GPs June 2013 Glasgow LMC Dr Patricia Moultrie Glasgow LMC Sessional GP Representative.

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Presentation on theme: "Contract meeting for Sessional GPs June 2013 Glasgow LMC Dr Patricia Moultrie Glasgow LMC Sessional GP Representative."— Presentation transcript:

1 Contract meeting for Sessional GPs June 2013 Glasgow LMC Dr Patricia Moultrie Glasgow LMC Sessional GP Representative

2 What is a Local Medical Committee? elected committee of local GPs elected committee of local GPs represents GPs in Glasgow and Clyde represents GPs in Glasgow and Clyde provides support and advice to GPs and practices provides support and advice to GPs and practices Glasgow LMC

3 Funding voluntary levy paid by all GPs, cost dependent upon list size voluntary levy paid by all GPs, cost dependent upon list size levy also finances the LMC’s contribution to the GP Defence Fund for national GP representation levy also finances the LMC’s contribution to the GP Defence Fund for national GP representation Glasgow LMC

4 Helping individual GPs The LMC provides help and advice to assist GPs steer through the NHS. Such help is available on all matters relevant to general practice including:The LMC provides help and advice to assist GPs steer through the NHS. Such help is available on all matters relevant to general practice including: –Workload issues –Coping with change –GPs’ remuneration –GPs’ terms and conditions of service –Complaints –Premises/Partnership affairs –Any disputes which may occur –Sick doctors and those with performance problems Glasgow LMC

5 National debate and policy setting Scottish and National Conferences of LMCs. Proposals from individual LMCs across the country are debated alongside those from the GPC. Scottish and National Conferences of LMCs. Proposals from individual LMCs across the country are debated alongside those from the GPC. The outcome of the debate determines the framework for the profession’s negotiations at both national and local levels. The outcome of the debate determines the framework for the profession’s negotiations at both national and local levels. Glasgow LMC

6 Glasgow LMC and Sessional GPs relationship relationship communication communication representation representation information information common interest common interest Glasgow LMC

7 Contact Glasgow LMC Dr Patricia Moultrie, Sessional GP Representative on Dr Patricia Moultrie, Sessional GP Representative on Mrs Mary Fingland, Office Secretary on Mrs Mary Fingland, Office Secretary on Glasgow LMC

8 Components of the Current GMS Contract Alastair Taylor Vice Chair Glasgow LMC

9 Funding Streams Global Sum & MPIGGlobal Sum & MPIG Quality and Outcomes FrameworkQuality and Outcomes Framework Enhanced ServicesEnhanced Services Health Board - administered funds, including seniorityHealth Board - administered funds, including seniority PremisesPremises IM&TIM&T Dispensing/personal administration of drugsDispensing/personal administration of drugs Glasgow LMC

10 Global Sum Calculated (Scottish Allocation Formula) to reflect: Calculated (Scottish Allocation Formula) to reflect: The age and sex structure of the practice population (demography) The age and sex structure of the practice population (demography) The additional need of the practice population (morbidity and deprivation) The additional need of the practice population (morbidity and deprivation) The rurality and remoteness of the practice population The rurality and remoteness of the practice population Creates a “Weighted List” to allocate the Global Sum Creates a “Weighted List” to allocate the Global Sum Glasgow LMC

11 Global Sum Covers: Essential ServicesEssential Services Additional ServicesAdditional Services Staff CostsStaff Costs Locum Reimbursements (for appraisal, career development and protected time)Locum Reimbursements (for appraisal, career development and protected time) The cost of GPs “employers superannuation” contributions for those funding allocations mapped across from the old red book contract.The cost of GPs “employers superannuation” contributions for those funding allocations mapped across from the old red book contract.

12 Global Sum Deductions For opting out e.gFor opting out e.g –Out of Hours 6.0% –Cervical Screening 1.1% Glasgow LMC

13 MPIG Minimum Practice Income GuaranteeMinimum Practice Income Guarantee MPIG = Global Sum via formula+ Correction FactorMPIG = Global Sum via formula+ Correction Factor Correction factor = How much greater Global Sum Equivalent was than Calculated Global SumCorrection factor = How much greater Global Sum Equivalent was than Calculated Global Sum Glasgow LMC

14 Quality Outcomes Framework QOF Clinical Areas: Clinical Areas: Atrial fibrillation, CHD, Heart failure, Hypertension, Peripheral arterial disease, Stroke and TIA, Diabetes mellitus, Hypothyroidism, Asthma, COPD, Dementia, Depression, Mental health, Cancer, Chronic kidney disease, Epilepsy, Learning disabilities, Osteoporosis, Rheumatoid arthritis, Palliative care, Cardiovascular disease - primary prevention, Obesity, Smoking, Cervical screening, Child health surveillance, Maternity, Sexual health Atrial fibrillation, CHD, Heart failure, Hypertension, Peripheral arterial disease, Stroke and TIA, Diabetes mellitus, Hypothyroidism, Asthma, COPD, Dementia, Depression, Mental health, Cancer, Chronic kidney disease, Epilepsy, Learning disabilities, Osteoporosis, Rheumatoid arthritis, Palliative care, Cardiovascular disease - primary prevention, Obesity, Smoking, Cervical screening, Child health surveillance, Maternity, Sexual health Glasgow LMC

15 QOF (2) Quality and productivity (QP) e.g. Referrals/ACPQuality and productivity (QP) e.g. Referrals/ACP Patient experience (PE) – 10 min appointmentsPatient experience (PE) – 10 min appointments Quality improvement (QI) – Trigger Tools/Patient Safety QuestionnaireQuality improvement (QI) – Trigger Tools/Patient Safety Questionnaire Medicines management (MM)Medicines management (MM) Public health (PH) “Blood pressure” in over 40sPublic health (PH) “Blood pressure” in over 40s Glasgow LMC

16 Enhanced Services Directed (DES)Directed (DES) –e.g. Childhood Immunisation, Flu jabs, Extended Hours Local (LES)Local (LES) –E.g. CDM Glasgow LMC

17 Other Streams Seniority:Seniority: –starts after 2 years in post (6 yrs reckonable) PremisesPremises –Cost Rent/Notional Rent IM&TIM&T –Hardware and Software supplied – to specification DispensingDispensing –Won’t discuss here

18 Any Questions for the Panel at the End? Glasgow LMC

19 Contributing to practices’ contract work 2013/14 Dr John Ip Glasgow LMC

20 Importance of QOF Significant funding for practicesSignificant funding for practices Increased levels of workIncreased levels of work More indicatorsMore indicators Higher thresholdsHigher thresholds Glasgow LMC

21 2013 QOF Changes- RA New Rheumatoid Arthritis domainNew Rheumatoid Arthritis domain 4 indicators total of 18 points4 indicators total of 18 points Glasgow LMC

22 2013 QOF Changes- RA Register (1 point)Register (1 point) Annual face to face Review (5 points)Annual face to face Review (5 points) Assess CVD Risk years using ASSIGN (7 points)Assess CVD Risk years using ASSIGN (7 points) Assess Fracture Risk years using FRAX (5 points)Assess Fracture Risk years using FRAX (5 points) Glasgow LMC

23 2013 QOF Changes DiabetesDiabetes –Annual dietician review (3) –New patients- referral to Structure Learning Programme (11) –ED screening, advice (4) & treatment (6) COPDCOPD –O 2 Sat for Grade 3 and above (5) Glasgow LMC

24 2013 QOF Changes DepressionDepression –Biopsychosocial assessment at time of new diagnosis –10-35 day review after diagnosis Primary Prevention CVDPrimary Prevention CVD –SCOT-PASQ for patients with HT diagnose after 1 April 2009 Glasgow LMC

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26 2013 QOF Changes All 15 month targets are now 12 monthsAll 15 month targets are now 12 months Some thresholds for full achievement increased ( 5-10% increase)Some thresholds for full achievement increased ( 5-10% increase) Glasgow LMC

27 Other Contract Work Medicines ManagementMedicines Management ScriptSwitchScriptSwitch Anticipatory Care Pathways & eKISAnticipatory Care Pathways & eKIS Polypharmacy ReviewsPolypharmacy Reviews Glasgow LMC

28 Tips for EMIS

29 Correct Coding Using TemplatesUsing Templates Values e.g. BP, BMIValues e.g. BP, BMI Medication ReviewsMedication Reviews Smoking Status & adviceSmoking Status & advice Glasgow LMC

30 Reviews of Patient LARC advice for ContraceptivesLARC advice for Contraceptives Dementia reviewDementia review Glasgow LMC

31 Population Manager The Pop up boxesThe Pop up boxes What do they mean?What do they mean? Glasgow LMC

32 Other Tips Searching in consultationsSearching in consultations Audit trail for medicinesAudit trail for medicines Glasgow LMC

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51 Questions?

52 Anticipatory Care Planning, Poly-pharmacy and KIS 24th June John Nugent Clinical Director 52

53 Anticipatory Care Planning, Poly- pharmacy Improving Care for Patients at High Risk of Emergency Admission ‘…appropriate ACP can improve the quality of care, reduce the risk of medication harm and either (or both) the number of future admissions and lengths of stay…’ ‘As poly-pharmacy can significantly increase the risks (of admission/harm)…it has been agreed as appropriate to include’ 53

54 What is/the point of an ACP? Improving the quality of care; ‘Anticipatory care planning encourages people to adopt a ‘thinking ahead’ approach and to have greater control and choice by planning for what their preferred support and care interventions would be in the event of a future flare-up or deterioration in their condition, or a carer crisis.’ 54

55 QOF QP Identifying patients for ACP and Poly-pharmacy Reviews Using a SPARRA risk threshold of between 40% (20%) and 60% will generate a cohort of around 5% of patients in the practice to fulfil the QP006 indicator Working down from an ‘upper ceiling’ of those with a 60% risk score will enable the practice to improve outcomes for people most likely to benefit from an Anticipatory Care Plan and a poly-pharmacy review. This will complement other local ACP initiatives that target cohorts with greater than 60% SPARRA risk 55

56 Rationale Patients < 60% SPARRA risk more likely to be engaged with the practice team than active on the community nursing caseload i.e. mobile Interventions < 60% represent earlier intervention likely to reduce escalation of dependency and to optimise adherence to medicines. 56

57 Guidance Scope to apply clinical judgement to what constitutes 'at risk of emergency admission' ; may be patients who would benefit from an ACP but do not have a risk score within the risk thresholds specified The Key Information Summary (KIS); tool by which practices create and share (with consent) ACPs Summary of medical history/patient wishes, replaces paper based faxing between GPs and OOH More generic version of the electronic Palliative Care Summary (ePCS). 57

58 Guidance Current ePCS patient information will transfer automatically to KIS but needs checked once KIS is switched on (ePCS patients that transfer automatically to KIS will not count as part of the cohort required for QP006 and QP007) NHS24, SAS, A&E, OOH and Acute Admission Areas already have access to KIS Access in other acute areas/departments depends on Board PMS systems and clinical portal developments 58

59 Poly-pharmacy 50% drugs not taken as prescribed 5-17% admissions due to adverse reactions If on multiple medications more side effects Potential harm of drug may outweigh benefit

60 QOF QP; QP004(S), 7 points QP004(S). The contractor meets internally to review data on emergency admissions, for patients on the contractor's registered list, provided by the NHS Board and the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S) Template for reporting will be agreed nationally 60

61 QOF QP; QP005(S), 17 points QP005(S). The contractor participates in an external peer review with either a group of local practices, or practices from within the board area, to compare its data on emergency admissions and to share the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S), and proposes areas for internal practice improvement and service design improvements for the NHS Board. 61

62 QOF QP; QP006(S), 5 points QP006(S). The contractor produces a list of 5 per cent of patients in the practice, who are predicted to be at significant risk of emergency admission or unscheduled care. This list can be produced using a risk profiling tool accessible to practices e.g. SPARRA, or where this is not available/required (by local agreement), alternative arrangements can be agreed between the NHS Board and LMC. 62

63 QOF QP; QP007(S), 30 points QP007(S). The contractor identifies a minimum of 15 per cent (in 2014/15, 30 per cent) of those patients from the list produced in indicator QP006(S) who would most benefit from an Anticipatory Care Plan (the ACP must include a poly-pharmacy review), be shared with the local out of hours service and has an appropriate review date. The frequency of each patient’s review should be determined in the light of their clinical and care needs. The contractor will be responsible for ensuring that an appropriate system is in place for monitoring and reviewing the patients identified in this cohort. 63

64 QOF QP; QP008(S), 10 points QP008(S). The contractor holds at least 4 meetings during the year to review the needs of the relevant patients in the practice ACP cohort, to agree any required changes in the patient management and to share learning/ identify learning needs. These meetings should be open to multi-disciplinary professionals who support the practice’s patients 64

65 QOF QP; QP009(S), 10 points QP009(S). The contractor produces and submits a report to the Board before 15 March 2014 on internal practice and wider NHS Board system changes that may benefit patients with Anticipatory Care Plans (ACPs). The report should include Significant Events Reviews (SERs) on 1/1000, to a maximum of 3 patients per practice, of patients with ACPs from the cohort in QP007(S), who were admitted during the QOF year, after their ACP had been created. If less than the required number of patients with ACPs were admitted during the QOF year then the practice should write SERs of the care of an equivalent number of these patients who remained in the community. 65

66 Summary Patient centred care; closer to home, reduced harm Carers; communication, support Practices; supports review, professionally satisfying, reduces ‘chaos’ (use) Boards; reduced admissions/lengths of stay Improves interface working Not about keeping anyone out of hospital who needs hospital 66

67 Issues - now SPARRA; ‘push not pull’ Review and decide who would most benefit See in surgery/home KIS; EMIS now, VISION 2 weeks MDTs; membership, review Poly-pharmacy review; overlap with LES ‘Face-to-face’ 67

68 Poly-pharmacy; overlap with LES Practices should generally only make one claim for payment for a poly-pharmacy medication review, per patient, during 2013/14 Exceptional cases may arise when an ACP/PP should be developed after a Poly-pharmacy LES review has occurred or vice versa Payment can only be claimed on behalf of the same patient for a Poly-pharmacy LES and a ACP poly-pharmacy medication review during 2013/14 if; a. there are 2 distinct reviews recorded in the patient’s record b. there is clear clinical justification to demonstrate the need for a repeat review for the same patient during the lifetime of the 2013/14 Poly-pharmacy LES

69 Clinical Justification The clinical justification would include a change in a patient`s clinical status due to one or more of the following occurring; 1.Hospital admission at least 1 month after the first poly- pharmacy review (ACP/PP or PP LES) had taken place 2. New clinical diagnosis 3. Deterioration in existing clinical condition requiring 3 or more either changes to drug or drug dose (oral or parenteral medication only) 4. Patient needing to go onto the palliative care register

70 Issues - later Role of DN/PN/Pharmacy support? Learning? Board support? 70

71 Information held on KIS Significant Diagnoses and PMH Prognosis Medication and allergies Current Care Needs Help at home (e.g. Social Services / Care Packages) Legal Issues (e.g. AWIA, Power of Attorney) Preferred Place Care End of Life Care wishes DNA-CPR information Free-text Anticipatory Care Plan

72 Example of a KIS which has been developed over a period of time?

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78 Summary of main issues

79 Plan of action in event of a deterioration

80 Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN

81 Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN Details of other professionals involved in care

82 Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN Details of other professionals involved in care Contact details of family member

83 Information available on KIS

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87 Patient Safety Indicators Sessional GPs Dr Paul Ryan, Clinical Director, NE Sector

88 SPSP in PC Aim is to reduce the number of events which could cause avoidable harm from healthcare delivered in any primary care setting “All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016”

89 Three key workstreams Leadership and culture improving patient safety through the use of trigger tools (structured case note reviews) and safety climate surveysLeadership and culture Safer medicines: including the prescribing and monitoring of high risk medications, such as warfarin and disease-modifying anti-rheumatic drugs (DMARDs) and developing reliable systems for medication reconciliation in the communitySafer medicines Safe and effective patient care across the interface by focusing on developing reliable systems for handling written and electronic communication and implementing measures to ensure reliable care for patientsSafe and effective patient care across the interface

90 GG&C plans for SPSP in PC implementation Leadership and Culture: covered by QOF. 11 points to undertake safety climate survey and trigger tool review High risk area we are concentrating on is “Safer medicines: developing reliable systems for medication reconciliation in the community”

91 Guidance Patient Safety Indicators IndicatorPoints PS 1 The practice conducts two case note reviews, using a validated tool, to detect patient safety incidents, meets to discuss the results, and shares a reflective report on actions and themes that arise from this with the Health Board 6 PS 2 The practice conducts a safety climate survey with all staff, clinical and non-clinical, using a validated tool, meets to discuss the results, and shares a reflective report on actions that arise from this with the Health Board 5

92 Adverse Event Causation Accident Causation Technical Factors Human Factors Safety Culture Operator Behaviour =+ (30-20%) (70-80%)

93 Positive Safety Culture Safety a Priority Eliminate “shame and blame” Accept staff will make errors Build systems to make care safer Foster a culture where people can speak up Team training Organizational learning from errors and near-misses

94 Why is a strong Safety Culture Important? A strong safety culture essential to safe reliable care in any workplace

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96 Francis Report and Culture There was an atmosphere of fear of adverse repercussions There was a lack of openness It did not listen sufficiently to its patients and staff or correct deficiencies highlighted Above all it failed to tackle an insidious negative culture involving tolerance of poor standards

97 Francis Report Recommendations Openness – enabling concerns to be raised and disclosed freely without fear Transparency – allowing information about performance and outcomes to be shared Candour – ensuring that patients harmed by healthcare are informed Replace culture of fear with culture of openness honesty and transparency Real involvement of patients in all that is done.

98 Safety Climate Survey On line Practice centred Measurement Diagnosis Catalyst for change

99 How does the SafeQuest Safety Climate Survey work in practice?

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103 Trigger Review Reviewing your clinical records is the oldest form of audit! Looking for evidence of (undetected) safety incidents/latent risks Help you direct safety-related learning and improvement Quick and Structured versus Slow and Open Clinical triggers help you to navigate your records quickly Links with SEA and Quality Improvement Evidence for QOF, Appraisal and GPST etc. Random sample of 25 patients – high risk groups (e.g. >75 years, multiple morbidity/poly pharmacy) Review the last 12-week period only (x2 3mths apart for QOF) Takes between 90 minutes to 3-hours Tested with large groups of GPs, Practice Nurses and GP Trainees

104 “Triggers” in Clinical Records ‘‘Triggers’’ are defined as easily identifiable flags, occurrences or prompts in patient records that alert reviewers to actual or potential safety incidents (undetected) Sections in GP RecordsTriggers Clinical encounters (documented consultations) ≥3 consultations in 7 consecutive days Medication-related (acute and chronic prescribing) Repeat medication item stopped Clinical read codes High, medium, low, allergies New ‘high’ priority or allergy read code Correspondence Section Secondary care, other providers OOH / A&E attendance / Hospital admission Investigations Requests and results eGFR reduce 5.0

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107 Medicines Reconciliation

108 Care Bundles A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.” The steps must all be completed to succeed The “all or none” feature is the source of the bundle’s power Pass/fail

109 Medicines Reconciliation – care bundle measures Has the Immediate Discharge Document (IDD) been workflowed on the day of receipt? Has medicines reconciliation occurred within 2 working days of the IDD being workflowed to the GP? Is it documented that any changes to the medication have been acted on? Is it documented that any changes to the medication have been discussed with the patient or their representative within 7 days of receipt? Have all the above measures been met?

110 Knowledge Page hhtp://www.knowlegde.scot.nhs.uk/spsp-ps.aspx


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