1. Proposed changes to how practices are funded to manage people living with Long Term Health Conditions

2. A PRESENTATION FOR CPPEG

3. 3 There is strong evidence that early identification leads to better care Since Oct 2013 the CCG has funded practices to… Actively find people who are living with or at risk of any of the following conditions: Hypertension (persistently high blood pressure) Diabetes Chronic Kidney Disease Heart Failure Chronic Obstructive Pulmonary Disease (lung condition)

4. Working with the people of Camden to achieve the best health for all 4 And… Regularly review and monitor people who are most struggling to manage their condition People living with Heart Failure and COPD – review every 6 months People living with Diabetes – care plan every 12 months Embed treatment templates and protocols – ensuring high standards in all practices

5. “It’s a bit more thorough now. They talk about diabetes and all the aspects of my condition….”. We know that this is making a difference “It’s now a discussion between the two of you, which is how it should be.”

6. Prevalence 6

7. 7 £ To achieve targets for register sizes both individually and as a locality (promoting federated approach) Current Payment for GPs £ For each clinical review for defined groups of people £ For improvements in the number of people with high blood glucose levels

8. 3 8 Proposal for the next Phase (from April 2016) 1.Practices to deliver at population level - 50,000 patients plus 2.Practices come together to develop plans for how to deliver service 3.Upfront payment to give practices capacity to make sustainable changes Also: Include other diagnoses eg cancer, epilepsy Bring in contracts for Complex Care, Serious Mental Illness Minimum quality standards 3 year agreement

9. 9 What will this be like for Camden residents More people who have a Long Term Condition will be proactively reviewed and have a Care Plan Those living with a Long Term Condition will have better support to manage clinical indicators such as blood pressure, blood glucose and to quit smoking People living with epilepsy who are struggling to manage will be proactively contacted by their GP to discuss their condition GPs will be well equipped to identify the symptoms of cancer at an earlier stage

10. 10 Timeline. Sept - Nov Approval by Procurement Cttee Commissioning Cttee Governing Body Nov - Apr Practice develop plans collaboratively and start to put capacity in place Apr 16 New contract commences