Agreement for the provision of ENHANCED services 2013/14

NHS HEALTH CHECKS FOR PATIENTS ON SEVERE MENTAL ILLNESS REGISTERS (SMI)

NHS DONCASTER CLINICAL COMMISSIONING GROUP

and

[Practice Name]

NHS DONCASTER CLINICAL COMMISSIONING GROUP (The Commissioner)

Signed:

Chris Stainforth

Chief Operating Officer (Designate)

NHS Doncaster Clinical Commissioning Group (CCG)

Dated:

[PRACTICE NAME ](The Provider)

Signed on behalf of Practice: (Practice Stamp)

(GP Principal)

Print Name

Dated:

Local Enhanced Service for Delivering Physical Health Checks for People on SMI Registers

Duration of agreement

The Agreement shall take effect on the 1 September 2013. The Commissioner or the Provider may terminate or vary this agreement by agreement with the other party at any time.

Introduction

All GP practices are expected to provide essential and those additional services that they are contracted to provide to all their patients in accordance with clause 32.1 nil detriment. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

Definition

The definition of SMI is and not limited to include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder. This definition shall be referred to in this document as (SMI)

Background

Severe mental illness such as schizophrenia and bipolar disorder is associated with high medical co-morbidity; mortality rates are approximately 50% higher than in the general population. The vulnerability of people with severe mental illness makes it essential that health providers offer them every opportunity to adopt healthy lifestyles and to access health services.

People with schizophrenia and bipolar disorder have:

  • A 4x higher chance of developing a respiratory disease
  • Up to 4x the chance of developing coronary heart disease (CHD)
  • 8x the chance of contracting hepatitis C
  • 15x the chance of contracting HIV
  • 5x the chance of developing diabetes

than the general population.

In addition to lifestyle factors, such as smoking, poor diet and lack of exercise, antipsychotic

drugs vary in their liability for metabolic side effects, such as weight gain, lipid abnormalities

and disturbance of glucose regulation. Specifically, they increase the risk of the metabolic

syndrome, a recognised cluster of features (hypertension, central obesity, glucose intolerance or insulin resistance and dyslipidaemia), which is a predictor of Type 2 diabetes and CHD

People with mental health problems have higher rates of:

  • Obesity
  • Smoking
  • Heart disease
  • Stroke
  • Hypertension
  • Respiratory disease
  • Diabetes
  • Breast cancer

Across the UK, people with a serious mental illness consult primary care practitioners more frequently and are in contact with primary care services for a longer cumulative time than people without mental health problems. Approximately 30% of people with a serious mental illness in the UK are now seen only in the primary care setting.

Shared Care of Patients – those on a dormant care plan

General practitioners are well placed to manage patients who are in the community and are generally well. There is a group of patients who have a history of psychotic symptoms and are currently controlled and are experiencing a sustained period of recovery. They are fully capable of full or near functioning. Their primary diagnosis is likely to include:

  • Schizophrenia
  • Schizotypal and delusional disorders
  • Manic episodes and
  • Bipolar affective disorders

Patient who are currently being discharged to primary care will normally have their anti-psychotic prescribing managed under a shared care arrangement. These patients can be transferred to primary care with support and guidance from the Mental Health Trust. While on a dormant care plan, the patient will require annual medication review plus/minus blood test where required.

The National Institute for Clinical Excellence (Nice 2009, 2006a) recommends that physical health checks should normally be provided within primary care and that ‘GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia at least once a year’.

A good physical health review should include advice about diet, exercise, smoking and substance and alcohol abuse; protection against influenza, plus regular preventative care.

GPs who have identified physical health for people on SMI as a QOF target, already provide the health checks in part, every 15 months. However, the average of the target group who are screened to meet the QOF indicator is 80%. It is proposed that 100% of the SMI registered population will be invited to participate in an annual health check in order to meet the Quality Premium target of 85%.

Target Population

Eligible population / 2,256 (SMI registered population)
Target offered 100% / 2,256
Target health checks delivered 85% / 1,917 received and recorded
  1. Proposed activity carried out for Physical Health Check and enhanced service aims.

The local priority and emphasis is around achieving 85% for MH003, MH006 and MH007 of the QOF Criteria for Mental Health.

Locally the commissioner would like to take this priority measure a step further and incorporate some of the measures from the CCG outcomes indicator set (these are further measures for 13/14 but not all are live/ being collected yet including these) ie Measure C1.12 from the outcomes indicator set also includes:

  • Total cholesterol to high-density lipoprotein ratio
  • Fasting Blood glucose and
  • HbA1c for known diabetics not conducted within the health review during Diabetic check
  • Smoking status

Finally we would also like a local focus around reducing cardiovascular risk and it is expected then that not only are the checks done but any issues found are treated.

1a*NICE Guidance Physical Health Checks for people on SMI Registers.

Measurements
Body Mass Index
Waist circumference
Pulse rate (ECG)
Blood pressure / Blood tests
Lipids
Fasting Blood Glucose
Screening
Cervical cytology (unless patient declines)
Encouraging discussion and provide advice on self-examination (breast and testicular) –well woman/well man advice / Lifestyle Advice/management
Sleep
Smoking
Exercise
Alcohol
Diet
(inc referral for support)
Medication review
Antipsychotics – annual review
Mood stabilisers – annual review

GPs know their own patients well, are trusted by them and understand how best to make contact with their traditionally more hard to reach patients. Much work of a similar nature is already happening in general practice which allows patients, if necessary to move seamlessly from screening and diagnosis to management which is delivered under the standard GMS/PMS contract. Supporting staff to acquire the competencies required to deliver NHS Health Checks offers practices the opportunity to develop and broaden the skills and responsibilities of staff. It is for these reasons that general practice is considered the best place to deliver NHS Health Checks as a local enhanced service.

This service specification defines the outcomes required by NHS Doncaster CCG in relation to the delivery of physical health checks to all eligible individuals regardless of race, gender, disability, religion/belief or sexual orientation in line with Department of Health guidelines. This document will outline the key features of the program with the strategic aims of:

  • Reducing the incidence of vascular related conditions.
  • Reducing premature death from vascular related conditions.
  • Narrowing health inequalities

Service Aims

To provide a comprehensive and systematic annual health check and cardiovascular risk assessment for those who currently on the Severe and enduring Mental Illness register (SMI) and will build upon the existing QOF Criteria for Mental Health (MH).

Service outline –

It is expected that:

a)Eligible individuals from the practice SMI registered list will be offered a vascular risk health check which includes the measurements and blood tests detailed at point 1a.

b) Quality and clinical governance standards

The provider will ensure that patients receive a quality service whilst in their charge and will ensure the following quality standards are in place:

i)Ensure adherence to best practice and commitment to continually improving the service.

ii)Meet all clinical standards, legislative guidance and local procedures as required of the service.

iii)Meet all applicable statutory reporting requirements such as compliance against Care Quality Commission Quality and Safety regulations. The provider should provide evidence of compliance to the commissioner as and when requested to do so.

iv)Practices will be expected to adopt the Standard Operating Procedure attached herewith.

v)In addition the service will be expected to conform to relevant national and local guidance and NICE guidelines in particular.

vi)Providers should ensure that appropriate risk management and health and safety procedures are in place.

vii)Providers should ensure appropriate systems are in place to report Serious Incidents in line with national and local policy.

c) Risk communication

The results of the cardiovascular assessment will be communicated face to facewith the patient in a manner that the patient will understand and recorded on the practice clinical system.

The communication of risk and what it means for the individual is of paramount importance to the programme meeting its objective of helping people stay well for longer. Levels of risk need to be discussed alongside what each individual can do to reduce their risk, for example taking regular exercise, eating a healthy diet and stopping smoking. The NICE clinical guideline 67 (updated March 2010), provides some guidance on communication of risk in the context of cardiovascular risk assessment.

Treatment such as cholesterol lowering and antihypertensive medication may be offered where appropriate, in full discussion and agreement with the patient. Lifestyle advice and interventions such as stop smoking advice, referral to an accredited stop smoking advisor, dietary and alcohol advice, weight management and physical activity advice will be offered as appropriate to the individual’s needs.

Verbal and written information will be offered to the patient to communicate the risk and any interventions required. The British Heart Foundation (BHF) Cardiovascular Risk leaflets are recommended for use, available directly from the BHF.

d) Clinical interventions

Where clinical interventions are required:

i)The service will ensure appropriate standards for the prevention and controls of infection are in place. This will include;

  • Providing a clean, safe environment and appropriate hand washing facilities
  • Agreeing to undertake infection prevention audits when required.
  • Ensuring staff undertake infection prevention and control training.
  • All clinical procedures must be carried out in accordance with local and national guidance.
  • Decontamination of equipment/medical devices must be in accordance with local and national guidance.

Accreditation

A provider may be accepted for the provision of this LES if it has a commitment to working with the commissioner and other practices to ensure a commonality of approach, where appropriate, across Doncaster.

The provider of this service has a legal obligation to adhere to all equality legislation. If requested the provider must produce their policy relating to race, gender, disability, religion or belief, sexual orientation and age. This policy should include the reporting mechanism for any adverse events which would constitute a deviation.

The Provider should have a planned, regular programme of education, training and support in relation to the delivery of this service.

All staff involved in providing this service should be competent to do so.

Staff must be trained to an appropriate standard. Guidance can be obtained at:

A designated senior clinician in the practice will have overall responsibility for the service.

There will be identified staff time to deliver the service.

Reporting and payment

The commissioner, in agreeing to this enhanced service, in no way commit themselves to the capital expenditure or revenue consequences of the equipment necessary for particular procedures covered by this enhanced service.

The payment for each completed NHS Health Check will be:

£20.00 for each completed NHS Health Check (10 mins GP time)

£10.00 for each completed NHS Health Check following an achievement of 85% or more for MH003, MH006 and MH007 of the QOF Criteria for Mental Health.

This is a flat rate incentivised enhanced health check for SMI patients.

Payment will be made for one health check per eligible patient. There is a clinical code for SMI Health Check which will verify the claim retrospectively and a retrospective, electronic audit will be carried out by the commissioner to verify claims. The commissioner reserves the right to seek reimbursement of any monies identified as overpayments.

Practices will be expected to check payment figures and raise any disputes by the end of the month following the end of the month.

Required Coding

Practices requiring advice on appropriate Read/CTV3 codes may contact the Data Quality Team.

  • CTV Codes

Version 2 (non TPP)

Service Verification

The Provider should ensure:

  • Maintenance of accurate records, including record of invitations, interventions, reviews and outcomes.
  • Recording of procedures using recommended Read/CTV3 codes.
  • Maintenance of accurate disease registers and high risk of cardiovascular disease register.
  • Records of attendance and monitoring.
  • Capturing the data required to complete the quarterly financial claim.

Key Performance Indicators

COVERAGE (Required for the monthly or Quarterly CHECK Claim) – Information to be remitted with the quarterly payment claim:
Number of eligible people offered a NHS Health Check in the period
(only count an individual once, regardless of the total number of offers)
Number of eligible people who have received a NHS Health Check in the period
HEALTH INEQUALITIES (Required for the Quarterly Claim) – Information to be remitted with the quarterly claim:
Living in a deprived area NOT in a high risk, self-assigned ethnic category.
From a high risk, self-assigned ethnic group NOT living in a deprived area.
From a high risk, self-assigned ethnic group AND living in a deprived area.
Male
Female
OUTPUTS (following a Health Check) – Information to be remitted with the quarterly claim:
Offered a programme of weight management
Referred for investigation of possible CHD
Diagnosed with type II diabetes
Referred for investigation of possible PAD
Diagnosed with CKD (3-5)
Diagnosed with hypertension
Identified with impaired glucose regulation (either IGT or IFG)
Identified with 10-year CVD risk >20% (but not having CHD)
Started on statin therapy
Started on antihypertension therapy

Appendix 1 INSERT PRIMARY CARE TOOLKIT FOR PHYSICAL HEALTH CHECKS

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