1. PROPOSED PCE 18\19 28 FEBRUARY
On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG
11/11/2018

2. Understand what’s being proposed Notify LMC of comments\concerns
Aims Today
Understand what’s being proposed
Notify LMC of comments\concerns
Group dynamic – peer review where learning from and supporting each other
11/11/2018

3. Discussions to Date 7 February PCE Clinical Leads 8 February
Documents shared with LMC
LMC shared documents with Committee members
13 February
Gov Body Chairs
CIG re follow ups
22 February
LMC review
11/11/2018

4. PCE 18\19 - Aims Build on the success of PCE 17\18
Reduce variation to deliver improved health outcomes
Investment to support release of capacity in & sustainability of general practice
Investment proportionate to increased workload
Must align to strategic direction – improving heath outcomes, working at scale, integration and FRP delivery
Enable the paradigm shift needed to create a more integrated way of working, led by strong primary care teams based around General Practice
Continue to allow flexibility in focus and delivery of actions
Be more specific where appropriate and more light touch where appropriate
11/11/2018

5. Reflection on 17\18 THANK YOU – KEEP GOING!
Clinical peer review at group level
Releasing clinical capacity
Reducing spend
14% at month 10 reduction in referrals
35% reduction in formulary prescribing savings at month 8
Inconsistency between groups BUT
THANK YOU – KEEP GOING!
Group dynamic – peer review where learning from and supporting each other
11/11/2018

6. PCE 18\19 INVESTMENT £11 per head Funding
2 year contract – Variable elements (eg levels of reduction in variation)
It’s a Gamble
No 0.5% Reserve
EMIS v actual activity -need to understand this and see stepped change 18\19
BUT PRACTICES DELIVER
£101k PER AVERAGE PRACTICE
11/11/2018

7. Bridging the £1.3m Gap – South Worcs
£x PMS Premium will be vired to Local Enhanced Services budget
£200K Locality Commissioning Funds
Recycle Engagement Monies
Leaves £300K – Exploring options – may need to cover gap from Improving Access to GP Services allocation and reduced service expectation
11/11/2018

8. CCG Financial Recovery Targets 18\19
Savings areas supported through PCE
Full year benefit from 17/18 £m
Addition target for 18/19
Total
Outpatients - referral variation
£0.4m
£0.8m
£1.2m
Prescribing – including formulary; variation; repeats & self care
£1.9m
£3.6m
£5.5m
Emergency admission reducing variation
£2.9m
Outpatients – follow-ups
£1.8m
TOTAL
£2.3m
£9.1m
£11.4m
17\18 benefit will be delivered with no further action by practices
11/11/2018

9. PCE 18\19-OVERVIEW One Contract £11 per patient B\F PCE1-3 elements
Best Practice, Education & Development (IQSP, Study Days, LTCs, Audits,
Referrals – Maintain or Improve (+ 2% growth)
Prescribing – Maintain or Improve (+4% growth)
Repeat Waste – More specific than 17\18
NEW:
Best Practice: Mental Health
Follow ups
Emergency admission avoidance via Neighbourhood Teams
Removal of Asthma & COPD indicators for South Worcs Practices
On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG
11/11/2018

10. INVESTMENT
This new contract represents the biggest investment so far in general practice. We recognise that practices cannot achieve the requirements in isolation and will require support from each other, working collectively and with others, and from the CCG
Eg CCG account managers, neighbourhood team managers
11/11/2018

11. Where’s the Money coming from
PCE Funding Sources /19
R&B SW WF
Total
£'000
Year 3 PMS Premium Available
512
1,951
622
3,085
Medicines Optimisation - Funded as 17/18 outside PMS ex ESLIS
377
699
265
1,341
Medicines Waste funded as 17/18 outside PMS from CCG resources
251
466
177
894
Additional resources to be invested (engagement) as 17/18
141
Co- Commissioning Overall GAP
(46)
(1,314)
(301)
(1,661)
CCG Recurrent Support
214
502
193
909
Other CCG Support
240 86
326
EOL LES 88 52
140
Extended Access - Balance of Funding
290
Use of CCG Transformation Reserve
305
584
203
1,015
Year 2 CCG Funded Sustainability & Transformation
2,092
3,885
1,474
7,452
11/11/2018

12. 18\19 GP Funding 18\19 GMS Uplift ? PCE 18\19 £11 ppatient
17\18 GMS Global Sum £85 per patient*
18\19 GMS Uplift ?
PCE 18\19 £11 ppatient
Local Enhanced Services £ 8 ppatient
18\19 Transformation Funds £ pp
TOTAL £ pp
* 20 practices above national funding level
11/11/2018

13. Integration & Reducing Variation in Emergency Admissions Options
Include all requirements in PCE – Clinical view = all in PCE OR
Some tasks in PCE eg – peer review
3. Replace all or some QOF domains with focus on integration, MDT’s, local solutions within a collective framework Not Supported
11/11/2018

14. Contract Elements
11/11/2018

15. Best Practice Summary CCG IQSP, audits, 2 study days All 3 CCGs
LTC – improvement compared to March 18 :
Stroke –AF007 5% improvement – up to 95%
Hypertension –HYP006 5% improvement up to 87%
New approach to planned end of life care :
Hold a monthly MDT meeting using a template to discuss new patients added to the palliative care register, and those already on the register where needed
New patients added to register to have Advance Care Planning discussion to include preferred place of care\death & DNAR\Respect as appropriate
Review all deaths regardless of whether the patient was on the palliative care register or not
Nominate a lead admin person for end of life
Complete an audit annually  of the percentage of patients dying in their preferred place
Use of Mild Cognitive Impairment Read Code & Development of Register – Year 1
Rationale re AF/Hyp
January Performance AF007:
R&B: Range 82% - 100%, average 92%,
12 practices at 94% or above.
8 at 95%+
WF: Range 88% - 98%
2 practices above 97.8% in WF
SW: Range 81% -99%
4 practices above 97.8%
Perf Jan HYP006:
RB Range 77-90%
SW Range74-91%
WF Range 76-88%
End of Life based on recommendations from Dr Clare Marley, work in WF/RB via LES. SW no longer have COPD/Astma
11/11/2018

16. Reducing Variation – Referrals 18\19 Modelling
GP practices to reduce variation by coming in line with Worcestershire median for referrals (127 per 1000 weighted patients, range 76 to 191)
Top 20 specialities as in 2017/18 with the removal of diagnostics for cardiology and neurology
% reduction capped at 15%
All practices should contain 2% growth
The Worcestershire CCG median referral level is 127 per 1000 weighted patients
Cap of 15% is to make the target achievable for all groups and thus ensure continued engagement.
Range of reduction 49 fewer (Rurals) to 1,534 (Redditch Town)
11/11/2018

17. Reducing Variation – Prescribing 18\19 Modelling
GP practices to reduce variation by moving towards Worcestershire median for prescribing (£38,265 per 1000 ASTRO Pus, range £26,990 to £46,836)
Practices to reduce non-formulary prescribing
% reduction in variation capped at 6%
All practices should contain growth
CCG will address issues of secondary care non-compliance
11/11/2018

18. EPS & ERD
Increase use of electronic transfer of prescriptions (EPS) to a minimum of 50% of potential opportunity by March 2019
Practices above 45% at March 2018 must increase by at least 5% by March 2019
Practices above 70% at March 2018 must maintain this level
Increase use of e-Repeat Dispensing (eRD) to a minimum of 5% of EPS items by March 2019
Practices over 3% at March 2018 should increase by at least 2% by March 2019
Practices 25% at March 2018 should maintain this level
EPS current range (0 to 92%) based on potential EPS items (excludes those not allowed and all items for dispensing patients
Use of EPS delivers time savings for GPs and practice staff - an average practice (53.4% EPS, 10,920 patients per month) saves an average of 80 minutes of GP time every day by signing electronic repeat dispensing prescriptions versus paper. More info and the benefits of EPS can be found at:
eRD current range (0-39% of active users)
Use of eRD is included as it can help free GP and practice time in managing repeat processes. NHS Digital can provide practices with specific patient information as to which patients have not had a change in medication for a period of time and are therefore suitable for eRD. For further information:
11/11/2018

19. Reducing Outpatient Activity
The CCGs currently spend £26m per annum on follow-up outpatient activity - of which £18m is with Worcs Acute. Evidence from elsewhere indicates that a proportion of this activity does not add clinical benefit - and does not need to take place; and a proportion of activity that could be dealt with on an exception basis and/or via non face to face contact.
The CCGs believe that there is a step change opportunity to reduce follow-up activity in order to reprioritise clinical time. The objective is not to shift activity from acute and re-provide within primary care on a like for like basis - but to fundamentally review how patients can receive follow-up care,  where this is needed, and in the most efficient and effective way.
The purpose of this initiative is to support a reduction of 10% which roughly correlates to circa 9 patients per practice per week.
This is being developed with the full support of the WRH Trust management & clinicians
11/11/2018

20. Reducing Out Patient Follow Up Attendances
Quarter 1 – Phase 1 Follow Up Reduction
Review a sample of OP follow-up waiting list against a range of parameters to be determined by the CCG (under development)
Identify procedures\conditions where routine follow up appts could cease or be followed up remotely by telephone (example) with appropriate secondary care support / communication
Share results at PCE Meeting, amend if appropriate
Share results with CCG Elective Care Clinical Leads (Richard Davies, Nikki Burger) via a template of additional opportunities to reduce follow up activity
11/11/2018

21. Reducing O\P Follow Up Attendances
Quarter 2 – Phase 2 Coproduction
Elective Care Clinical Leads review templates to test hypotheses and determine:
Specialties where there is greatest potential for reduction in follow-up activity and liaise with secondary care to agree rapid access where this may be required
Role of Secondary Care
Potential role of general practice to be undertaken within £11 per head investment
Identify opportunities where invest to save business case is necessary
Practices (eg PCE clinical lead) to participate in co-production conversations through
NB Work is underway to gain support from secondary care to simultaneously instigate peer review of variation in numbers of follow-up appointments between clinicians.
11/11/2018

22. Integrated Working\Neighbourhood Teams
Aim
Stabilise & Support general practice
Reducing variation in emergency admissions
Key Requirements
Leadership (Neighbourhood Team & MDTs)
Engagement across all practices
Develop & Implement a Plan
11/11/2018

23. Neighbourhood Team & Multidisciplinary Team Lead(s)
Neighbourhood level actions
Identify a GP lead (neighbourhood Team lead) taking overall responsibility for delivery of the neighbourhood plan, represent practices from the neighbourhood on the Alliance Board and participate in 2/3 county wide leadership team development events per year, lead an annual review of progress, identifying achievements and lesson learned to be shared with Alliance Board
Develop and implement a neighbourhood plan, addressing priorities identified within the Neighbourhood team profile , including the delivery of an agreed reduction in variation of emergency admission rates Take corrective action when plan not delivering required outcomes
Identify a lead from within General practice* who will be responsible for developing and implementing a locally agreed MDT approach for the neighbourhood. The lead will be responsible for:
Reviewing current MDT arrangements across the neighbourhood
Ensuring the agreed MDT approach is adequately resourced and chaired, including the provision of administrative support
Seeking out and sharing good practice and learning
Establishing and leading a neighbourhood level forum for sharing learning and best practice from practice based discussions And ensuring actions/learning is reflected in delivery plan
MDT Focus must include:
patients who are frequent attenders in primary care, acute services and WMAS.
Patients with complex needs who would benefit from Multi Disciplinary care planning
Review of patients on the frailty register who are current inpatients, facilitating timely discharge.
Reflective review of patients on the frailty register following an acute emergency admission, to establish why they were admitted and any additional interventions captured on an action plan to prevent future readmission.
* Can be same individual
11/11/2018

24. Practice Responsibilities
Identify a practice lead GP* to participate in monthly meetings with neighbourhood health and social care leads, supporting the development and implementation of the out of hospital based care model, including engagement in the development and delivery of the neighbourhood team plan
Review practice level data, supporting the development & implementation of neighbourhood plan specifically focussing on actions which deliver the agreed reduction in variation of emergency admission rates
Take corrective action when plan not delivering required outcomes
Identify a practice lead* responsible for supporting the locally agreed MDT approach by:
Identifying patients/issues for discussion
Sharing information in a timely way to allow for meaningful discussion at the meeting
Attending Multidisciplinary Team meetings, where appropriate
Ensuring the primary care actions following the MDTs are completed, i.e. uploading recommendations onto EMIS
Disseminating actions and learning as appropriate with practice team
Identify common themes and share best practice at neighbourhood level
Contribution of the evaluation of the MDTs by providing feedback and conducting patient surveys, as required
11/11/2018

25. CCG Staff will support groups in development\completion
Summary
Clinical Peer Review individual practice & PCE group
Releasing clinical capacity
Develop & implement Plans
reduce variation-Referrals/prescribing
Completion of Reducing Outpatient Follow Ups Template
Neighbourhood Team Plan setting out how variation in number of emergency admissions will be reduced
CCG Staff will support groups in development\completion
Medicines Commissioning team will lead development of prescribing plan
11/11/2018

26. TIMESCALES Referrals\Prescribing
Plan
Deadline
Panel Members
Referrals\Prescribing
As soon as possible, no later than 27th April 2018
Drs Gemma Moore, Roy Williams, George Henry and Jonathan Leach
Follow up template
Within two weeks of data being received & on-going
Elective Care Clinical Leads
Emergency Admissions
27th April 2018
Tim Tebbs & Simon Trickett with Alliance Board Chairs
Integrated Care Partnership Board

27. CONTRACT TERMS HEADLINES
11/11/2018

28. Commissioning Policies, Templates & Surveys
As per 2017\18
New developments to be discussed with LMC before inclusion (Clause 4.4)
Quarterly Workforce Survey
Completion of Resilience Tool\Questionnaire?”
11/11/2018

29. Monitoring What does “Light Touch” mean?
Referral Plan refresh if achieving or over-achieving (6 Month 10)
Less Reporting if achieving or over-achieving
Earned autonomy in year
11/11/2018

30. Payment Top slicing for leadership roles:
PCE Clinical Lead(Referrals & Prescribing)
PCE Pharmacist Lead
Neighbourhood Team Lead*
Multidisciplinary Meetings Lead*
NOTE – value of Top Slice will vary depending on the size of the group.
Smaller groups will be ‘losing’ more, and larger groups contributing less.
The argument in support of this approach is that we have tried to encourage larger scale working but were petitioned to accept smaller groups;
This differential cost is a consequence of working at a smaller scale.
MINIMUM RATES
*Could be one individual
** Top slicing will impact more on smaller groups
11/11/2018

31. Payment Mechanism (previously Section 7, PCE 17\18)
Frontloading:
April – 25% of £11
Leadership payment as soon as arrangements confirmed
Plans to CCG by 11 May
Review plans by 18th May
Jun 1st – 50% less leadership amount (paid to practices with nominated leads)
25% post Jan 2019*
* Final payment reconciled to amount due based on delivery of plans and actions or claw back applied to areas not delivered
11/11/2018

32. NO CHANGE to 17\18 CLAUSES Section 9 – Clinically Led Review
Section 10 – Breach of Contract
Section 11 – Witholding or Deducting Monies
Section 12 – Disputes
Section 13 – Contract Notice
11/11/2018

33. Engagement & Consultation
28 February
28 Feb-15 Mar
By 16 March
19 March
FRP sign off Business Case
Discussions at Localities
Practices send comments to LMC
LMC send final comments to CCG
14 March
PCCC decision to invest
21 March
23 March
29 March
Launch of contract/study day
CCG to issue contracts to practices
Practices to return signed Contract
1 April
New contract starts
Future Practice Communication & Engagement
Quarterly Strategic Commissioning meetings with Exec Leadership Team (and annually with Gov Body)
Huddle
IQSP
PCE Study Days
11/11/2018

34. QUESTION & ANSWER SESSION
11/11/2018