1. Everyone Counts: Planning for Patients (Focus on changes regarding ≥75yrs and those with complex needs) 1

2. Key contractual changes for practices 2 The government has determined that there will be a specific focus during 14/15 on those patients aged ≥75 yrs and those with complex needs All patients aged ≥75 yrs to have an accountable GP. For those that need it to have a comprehensive and co-ordinated package of care.

3. New enhanced service (national) There will be a new enhanced service to improve services for patients with complex health and care needs and to help reduce avoidable emergency admissions. This will replace the QOF QP domain and the current enhanced service for risk profiling and care management and will be funded from the resources released from these two current schemes. 3

4. New enhanced service (continued) The key features of the scheme will be for GP practices to: –Improve practice availability, including same-day telephone consultations, for all patients at risk of unplanned hospital admission –Ensure that other clinicians and providers (eg A&E clinicians, ambulance services) can easily contact the GP practice by telephone to support decisions relating to hospital transfers or admissions –Carry out regular risk profiling, with a view to identifying at least two per cent of adult patients – and any children with complex needs – who are at high risk of emergency admissions and who will benefit from more proactive care management –Provide proactive care and support for at-risk patients through developing, sharing and regularly reviewing personalised care plans and by ensuring they have a named accountable GP and care coordinator –Work with hospitals to review and improve discharge processes; –Undertake internal reviews of unplanned admissions/readmissions 4

5. Key requirements for CCGs 5 To support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. To provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patient aged 75 and over. pg14, paragraph 36, Everyone Counts: Planning for Patients 2014/15 to 2018/19

6. 6 Practice Area Team Accountable GP Comprehensive package of care New DES to support practices to implement changes CCG £5/pt investment Care Homes LES MDT LES Risk stratification tool Reduce avoidable admissions

7. 7 £5/pt investment provides opportunity for innovation in primary care to help improve quality and deliver efficiencies (CCG QIPP target 14/15 circa £15m on total budget circa £400m).

8. How does the £5/pt investment fit with existing programmes? Practice plans to improve quality of care for older people Reduce admissions £5/pt CCG Care Homes contract (LES) CCG MDT contract (LES) CCG funded Community Geriatricians 8 National Risk stratification DES New CCG multi-agency falls work CCG winter planning work Admission prevention network Dementia services New trust 7 day working

9. How could the £5/pt investment be used to reduce admissions? 9 Regular review of housebound/socially isolated patients? Link with other practices to offer a new service? Group together in localities and increase opening hours? Local/practice further development of care homes service

10. 10 Increased use of risk stratification tool – identify “at risk” groups? Tool live from June/July Rapid review of falls patients not needing admission? What are your ideas? Time to innovate….. What could £5/pt investment be used… (continued) ? Self care - education? Review patients on complex drug regimes?

11. What might outcomes look like? 11 Reduce avoidable admissions? Improved patient experience? Reduce exception reporting in COPD Evidence of clinical interventions made? A unified approach or a practice specific approach?

12. How can the CCG support your practice Meet with practices or locality to talk through these changes and help develop an action plan. Create template for action plan. Facilitate training and education. IT solutions. What else? 12

13. Payment mechanisms Payments will be based on list size as of 1 st April 14. Practices will receive 50% of payment in April 14 upon submission of their action plan. ?% will be based on practice achievement? ?% will be based on locality achievement? ?% if all localities achieve target? For discussion 13

14. Timescale By end of February CCG to create a template action plan and circulate to practices. February – mid March Meetings between practices and CCG representatives will take place over the next four weeks to help support practices. Schedule in a March locality meeting, discuss draft plans. By 31 st March Practices to submit plans into the CCG by 31 st March 14. 14

15. Tea Break Break into localities for further discussion 15

16. Purpose of locality discussions 1. Discuss how we can improve the quality of care for our patients aged 75yrs and over using the £5/pt investment. Generate ideas. 2.Discuss together what outcomes might look like. 3. What support practices need the CCG to provide. 16

17. Facilitation of locality discussion Focus on £5/pt first, other business at the end. CIA - KB and Lois T SBS – MS and Claire P Ipswich – IQ, David B DHG – PK, Louise H 17