1. PMS Premium Reinvestment
Wyre Forest CCG
6 September 2016
PMS Premium Reinvestment

2. To share feedback on discussions to-date
Aim Of Today
To share feedback on discussions to-date
To provide further opportunity to influence and shape the local contract, “Promoting Clinical Excellence”
To provide feedback and recommendation to the Primary Care Commissioning Committee

3. Co-commissioning primary care - why?
Deliver the best outcomes for our population
Support sustainable, high quality primary care – fund practices for new ways of working
Implement “Place-based Commissioning” – i.e. one budget for all health services in one community
Alignment of contracts and incentives = better, more integrated out-of-hospital care, QIPP
Paving way for 5-year forward view and general practice forward view
Use PMS premium to support our aims & PC Priorities

4. NHSE to approve proposals
PMS Premium – The Rules
CCGs to publish proposals for reinvesting PMS Premium in line with national principles & framework:
Reflects joint strategic plans for primary care
Secures services or outcomes that go beyond core contract
Helps reduce health inequalities
Equality of opportunity for GP practices
Consult with LMC
NHSE to approve proposals

5. Delegated Functions - Some of the Rules
“Where the CCG wishes to develop and offer a locally designed contract, it must ensure that it has consulted with its LMC in relation to the proposal and that it can demonstrate that the scheme will:
Improve outcomes
Reduce inequalities
Provide value for money
…”and avoids making any double payments under any Primary Medical Services Contracts”
NHS England role in approving CCG plans – end of July

6. LMC – agree principles, reward to reflect effort
Current Position
LMC – agree principles, reward to reflect effort
PCCC – agree priorities, principles
NHSE – concern re lack of service provision!

7. Timetable Wyre Forest Patient Group 6 Sept 2016
Proposal available on intranet 19 Sept – 7 Oct 2016
Frailty presentation by Dr Maggie Keeble
available on intranet 19 Sept – 31 Oct 2016
Survey monkey Sept – 7 Oct 2016
FAQs available on intranet 19 Sept – 31 Oct 2016
PC Commissioning Committee 12 Oct 2016
Contract Start Date 1 Nov 2016

8. Promoting Clinical Excellence Contract (Local Improvement Scheme) 2016/17 & 2017/18 A Proposal

9. What are the Wyre Forest Priorities?
Proactive Care for Older People living with Frailty – proactive care and co-ordinated care, personalised planning
Excellence in management of Long Term Conditions – high quality personalised care – e.g. Atrial Fibrillation
Effective Use of Resources-Best Practice – Making quality referrals
The Right Access – releasing capacity in general practice e.g. Care Navigation

10. Contracting Vehicles
GMS Contract = funding per patient plus DESs, QOF & LESs
Local Improvement Scheme
Frail elderly
Long Term Conditions – AF
Avoidable appointments/Release capacity
Best Practice
Right Access
Funding
£26,455 (16/17) and
£34,227 (17/18)
per average practice (10,416 patients) .
Participation is voluntary
Can be held by individual or groups of practices working collectively
A number of pre-requisites:
Engagement (including information requests, completion of surveys e.g. workforce)
Compliance with prescribing formulary
IQSP participation (funded)
Others TBA

11. Funding Available
17 month contract starting 1 November 2016

12. Funding Per Average Practice

13. Contract & Payment
PMS Premium ring-fenced for re-investment in primary care services
17 Month Local Improvement Scheme, added to GMS Contract, 1 Nov March Phase 2 -1 April March 2018
All or nothing sign up – i.e. no cherry picking.
Longer contract caveat – recycle funding to new indicator if ‘double funding’ arises in 2017/18 due to contract, ES or QOF change.
Payment for achievement of tasks & Key Performance Indicators (sliding scale where appropriate)
Some Payments prepaid in November (IQSP, Quality Referrals, Training)
Some payments based on achievement in May 2017 (e.g. “QOF Plus”)
Practices to complete Delivery Plan
Payments adjusted for list size
Clear Payment profile & schedule to be provided for all practices
Performance dashboard
No manual claims – automatic data extract from systems

14. Frailty Standards Older People living with Frailty
Clinical Frailty Score
Older People living with Frailty
Unplanned admissions Register 2%
MDTM review - DES
Combined Proactive Care Plan
(EMIS template) incorporating Advance Care Planning

15. Frailty Standards
Assess current 2% DES register for Frailty using recommended tool (Rockwood Frailty Scale) – payment of £150 per patient (same as SW) for all appropriate frail patients assessed and plan developed (cap at 2% of practice population).
2016/17
Identify Clinical Lead
Score and code severity accordingly
Attend Study Day & cascade knowledge internally
2017/18
Continue to score & code severity
Use of EMIS template for comprehensive Proactive Care Assessment and Plan for those patients coded as severely frail (up to 50% of the total DES register).
In-depth medication review with pharmacist or using STOPP-START tool.
Clinical lead attend Study Days x 2 & cascade learning internally

16. Payment Element for Frailty
2016/17 payments based upon 3 components:-
£12,500 per average practice (£60 per patient on DES register) identified and coded as being frail
£1,400 per practice for a lead GP and practice education
2017/18 payment:-
£18,764 per average practice (£90 per patient on DES register) for comprehensive assessment INCLUDING medication review
If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently
We need a whole new model of care based around a Proactive Patient Centred approach

17. Payment Element for Frailty
If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently
We need a whole new model of care based around a Proactive Patient Centred approach

18. Long Term Conditions
QOF PLUS

19. Scheme to reduce the incidence of stroke
Atrial Fibrillation
Scheme to reduce the incidence of stroke
Increase detection via Improving Quality Supporting Practices
Increase percentage with AF receiving OAC

20. Atrial Fibrillation (AF007) – Current Achievement
Definition: In those patients with atrial fibrillation with a record of a CHAD2DSC-VASc score of 2 or more the percentage of patients who are treated with anticoagulation drug therapy
An incentive payment is payable if a practice achieves anti-coagulation rates. The payment is adjusted for list size.
Rates are after exception reporting. Outliers are identified as exceeding mean plus one standard deviation.
WF has slightly lower anti-coagulation rates than SW.

21. Anti-Coagulation – Exception Reporting
But WF has lower exception reporting rates and less variation between practices.

22. AF Proposal Set same targets for WF as for SW.
Exception reporting outlier to be based on 2016/17 mean + 1 SD
This works out as

23. Right Access Releasing Capacity

25. Implement Avoidable Appointments Audit (£691) Share Results
Releasing Capacity
Implement Avoidable Appointments Audit (£691)
Share Results
Preparation for 2017
Identify Key Areas of Focus
There is funding available in 2017/18 which can be used to support the findings of the avoidable appointments audit e.g. introduce Care Navigator role.

26. Effective Use of Resources
Making Quality Referrals - Best Practice

27. Making Quality Referrals
Funded time to do skills register, top tips, utilize advice and guidance and time to review referral before it leaves the building. - £7,636
Review method (desktop, face-to-face etc.) decided by practice.
Practices identify a lead for 2-3 specialities - £250
Practices use inter-practice referrals, e-referrals, advice and guidance.
Agreed training - £1,000
16/17 no coding to ‘Referral for further care’ - £750 (If non-compliance occurs the practice will be invited to re-code the relevant items. Once this has been done satisfactorily full payment will be made). Decision later re 17/18
If we are going to cope with the demands of an ever increasing population of older people living with complex comorbidity and meet their needs whilst avoiding our secondary care services being swamped we need to manage this population very differently
We need a whole new model of care based around a Proactive Patient Centred approach

28. Tools – PCE Dashboard

29. Is contract spanning two financial years better for practices?
Questions
Is contract spanning two financial years better for practices?
Longer contract caveat – recycle funding to new indicator if ‘double funding’ arises in 2017/18 due to changes in priorities, GMS contract, Enhanced Services, QOF
Multiple Contracts – only frailty & IQSP spanning two years?

30. What Outcomes do we expect to see as a result of re-investment?
Proactive, co-ordinated and high quality care for older adults with severe frailty
Better advanced care planning
Better management of long term conditions – improved quality of life
Reduced morbidity and mortality – Stroke
Reduction in inappropriate hospital admissions
Fewer exacerbations leading to acute emergency admissions
Re-investment of funds in general practice to support sustainability, improve standards of care
More accurate coding of referrals
Release of capacity within general practice

31. Timetable Wyre Forest Patient Group 6 Sept 2016
Proposal available on intranet 19 Sept – 7 Oct 2016
Frailty presentation by Dr Maggie Keeble
available on intranet 19 Sept – 31 Oct 2016
Survey monkey Sept – 7 Oct 2016
FAQs available on intranet 19 Sept – 31 Oct 2016
PC Commissioning Committee 12 Oct 2016
Contract Start Date 1 Nov 2016