Practice Based Commissioning

KIRKLEES

PRACTICE BASED COMMISSIONING

FINANCIAL INCENTIVE SCHEME

FOR 2010-11

Version Control

Version no / Date / Time / Author / Role / Comment
V1 / 5.2.2010 10.26am / JG/AD / First version
V2 / 10.2.2010 8.52AM / JG/AD / Revision of many indicators based on initial feedback received
V3 / 16.2.2010
14.30pm / JG/AD / Revision of peer review and meetings indicators and finance indicators following discussion at CommissioningCollege
V4 / 16.3.2010
09.00AM / JG/AD / Revision of care planning indicator. Inclusion of templates as appendices
V5 / 23.3.2010 / JG/AD / Revision of care planning, A and E and predictive risk indicators
V6 / 31.3.10 / JG/AD / Revision of care planning and finance indicators, some very minor wording changes to medicines management

Since 2006 the Department of Health (DH) has required PCTs to put in place a local financial incentive scheme (FIS) for Practice Based Commissioning (PBC). Uptake of this Financial Incentive Scheme is assessed through the MORI survey, via a questionnaire sent to practices from the DH.

The DH best practice guidance of March 2009 “Clinical Commissioning: Our Vision for Practice Based Commissioning” sets out that “every PCT should agree PBC incentive schemes that promote better health, better care and better value in specific areas”.

Principles

The principles agreed in designing the financial incentive scheme for 2010/11 are:

Base on “Quality, Innovation, Productivity and Prevention” (QIPP):

All indicators can demonstrate clear QIPP outcomes and effectiveness

Include Identified Priorities:

Includes targets from “vital signs” where appropriate and not already covered by QOF or enhanced services

Encourage participation:

Provides a scheme that is attractive to practices

Have appropriate targets:

Indicators are specific, measurable, achievable, realistic and time bound

Be equitable:

Is fair and consistent across the PCT area

Support learning and development:

Includes indicators for peer review and attendance at plenary/ forum meetings

Offer some local flexibility:

Enables some indicators to be locally determined so that issues that are of particular relevance to specific consortia can be addressed

Payment reflects workload

Where the work involved is proportionate to list size then a payment per patient is appropriate. Where workload is similar regardless of list size then a flat payment is appropriate

Provide feedback to practices

Each indicator has a clearly identified method and timeline for provision of feedback to practices about the difference the indicator has made

The eleven indicators within the incentive scheme are:

Care planning

Use of A and E

Predictive risk

Medicines management better care better value (two indicators)

Finance

Diabetic retinal screening registers

Peer review

Plenary attendance

Local indicators (two indicators)

The majority of indicators have standard and stretch levels.

CARE PLANNING

Description of the Indicator

Undertake care planning with patients with diabetes and provide detail of types of goals agreed through diabetes care planning consultations. To review the patient and record progress against the chosen goal.

Collate information to include:

Description of goal agreed:

E.g.: To exercise more to help reduce weight

Goal Category [NHS Referral / Self Care Approach / Other]:

E.g.: Self Care Approach – walking

Goal Type [Maintenance/Improvement]

E.g.: Improvement (due to weight loss)

Any Unmet Needs identified [YES/NO]:

E.g.: Join Salsa Class – no classes available locally

Progress against goals

E.g.: Goal achieved – walking 30 minutes daily, lost 1 stone

Provide a return to the PCT.

Why has this indicator been included?

Care Planning is a target within the Vital Signs of the Operating Framework. Personalised care planning in general practice can ensure better outcomes for patients, reduced exacerbations of long term conditions, increased patient satisfaction and financial savings. Department of Health research and localevidence indicates the benefits of care planning include:

Reduced emergency attendances and inpatient days
Quality-of-life improvements
Greater patient knowledge and confidence in being able to cope with their
condition(s)
Better use of medication
Reduced costs
Overall improved quality of care.

This is an extension to the previous Care Planning indicator in the 2009/10 FIS. Including Care Planning in the FIS for 2010/2011 will complement the care planning training to be delivered from April onwards and help embed care planning into normal diabetes care.

What does the practice need to do to achieve this indicator?

Training:

Diabetes clinicians within each practice (GP and/or Practice Nurse[s] who will be undertaking Care Planning reviews) to attend a local Care Planning Training event of 1.5 days.

This training is available during 2010. Practices who attended this training during April/May 2009 are exempt from this condition.

Reviews:

Undertake an initial care planning review with 25% of patients on the diabetes register setting goals, with a further follow up 6 months later to review and record their progress against goals.

Complete the excel spreadsheet, providing 1 x return [March 2011] detailing the goals agreed for the relevant percentage of care planning consultations and their review outcome.

This is a new 25% with effect 1st April 2010 and reviews undertaken previous to this date cannot be counted towards the 25%.

How and when will feedback be given to practices?

Feedback will be given Spring 2011 following analysis of data received via the PCT’s PBC newsletter and also at PBC Plenary and Forum meetings.

Who should practices contact for support?

Julie Wood

Diabetes and Renal Programme Manager

Tel: 07720 463 006

ACCIDENT AND EMERGENCY

Description of the Indicator

This indicator is designed to identify patients who attend A & E in surgery opening hours and could appropriately have attended the practice or another primary care resource. Collate information about avoidable attendances (defined as those not requiring either an admission or any hospitalfollow up or any treatment that can only be carried out in a hospital setting), describe why the attendance was inappropriate, take action to advise, educate and inform the patient on alternative(s) and provide a quarterly return to the PCT.

Why has this indicator been included?

A&E attendances continue to increase; this indicator will help to identify patients who might otherwise have sought treatment from an alternative, community or primary care resource. It supports current drivers i.e. better care, better value; care closer to home; patient choice. It also ensures that patients are educated upon and directed to the most appropriate service (GP practice, 8-8 centre, self care etc).This is an area where financial savings may be apparent that will help practices to achieve the savings levels in the Finance Indicator.

What does the practice need to do to achieve stretch level?

To achieve stretch level the practice needs to note on the supplied proforma;

The patients name (to be removed prior to submission)
The complaint with which the patient attended A&E
The date and time of the attendance
If, in the opinion of the person completing the proforma, the A&E attendance was appropriate or inappropriate and why (e.g. on-going health problem and could have been seen in surgery). This is a subjective decision and will be based on local knowledge i.e. of the patient, their circumstances, family circumstances, other health conditions etc.
What alternative service (8-8 centre; visit to pharmacist etc) may have been appropriate.
Any action taken.
The practice will decide on the appropriate action (no action for a ‘first offence’ may be an acceptable decision)
The practice may take a variety of actions dependant upon the patient and his/her circumstances e.g. write a letter, send information, invite into the surgery, refer to Community Matrons etc.

What does the practice need to do to achieve standard level?

1-5 above

How and when will feedback be given to practices?

Feedback will be given at Consortia executive meetings and Plenaries/forums in Autumn 2010.

Feedback will also be in the PCT’s PBC newsletter on a six monthly basis.

Who should practices contact for support?

Designated PBC Facilitator and/orPat Andrewartha, Programme Manager for Urgent Care.

PREDICTIVE RISK

Description of the Indicator;

Evidence shows that improvements in both efficiency and quality of care can be made by providing care locally instead of admitting patients to hospital.

NHS Kirklees as part of the Predictive Risk Programme has purchased on behalf of GPs the Integrated Care Manager. This Tool is currently being made available to all GPs (wave 1 data available April 2010 and wave 2 data available June 2010) and will sit on a practice machine.

Why has this indicator been included?

Reducing length of stay along with managing and reducing emergency admissions is a key indicator in Better Care Better Value and the Vital signs indicators. The NHS operating Framework for 2010 -11, highlights the importance of achieving care closer to home, fewer acute beds, more standardised pathways, early and more upstream intervention and individuals taking greater ownership for their health.

The Integrated Care Manager provides us with Predictive Risk scores for each patient in the practice indicating those most likely to require secondary care utilisation in the coming 12 months. This data when used as part of a case management process will help us achieve reduced admissions to secondary care. The process described therefore starts with a focus on those patients most at risk of future hospital admission.

What does the practice need to do to achieve this indicator?

Practices need to complete all actions detailed below to fulfil this indicator and achieve payment.

From April 2010 – August 2010

A Practices need to sign up for the Predictive risk program and send the lead GP for predictive risk plus a Practice manager (or equivalent) on the training program (4 hours) before end August 2010.

Between April 2010 – March 2011 (once training complete)

GP’s will then use the Integrated Care Manager on a monthly basis to identify their patients with a high risk of inpatient admission in the coming year and case manage these.

B Run report from the Integrated Care Manager and validate the top 0.5% of the practice population – these are the patients that evidence shows you are likely to be working with already. Take any appropriate action you believe necessary.

C Using the “0.5 to 5%” category run a report and conduct at least 7 monthly review meetings during which you review a minimum of 5 patients.

Meetings must include a GP, Practice manager and/or Practice Nurse and should be Multidisciplinary, ideally including a Community Matron, District Nurse or other significant members of the MDT team. If you hold existing clinical meetings you may want to synchronise this meeting with your existing ones.

The patient review should consider

Any current key care plans in place
Next steps – eg possible referral to community teams or other potential interventions felt to be appropriate.
Lists to be updated monthly so that the 5 new patients reviewed are those with the highest risk flag, not reviewed previously.

Evidence the above will be demonstrated by completion of a practice action plan (you will be provided with a specific practice link to this form)

Complete the simple practice electronic record each month for a minimum of 7 months between April 2010 and March 2011.(i.e. a minimum of 35 patient reviews across the period). Practices can see the data they have previously submitted on their electronic forms by using the additional link provided.

Please note that a link to the simple practice electronic record and your practice specific log on will be provided to you in due course by the Long Terms Conditions Development Facilitator.

The NHS numbers of patients should not be recorded on this form. You should keep a list of the patients you review each month for your records or in case they are required for audit, but these do not need to be submitted routinely. The suggested template (enclosed) may be used if you wish.

Seven monthly returns have been requested to allow time for GPs not trained until July/August to take part in the scheme and to make it equitable to all.

How and when will feedback be given to practices?

Feedback will be given at Consortia executive meetings and Plenary/Forums in autumn 2010. Practices can see the data they have previously submitted on their electronic forms.

Feedback will also be in the PCT’s PBC newsletter on a six monthly basis. This will include the outcomes of any audit of the scheme that have been undertaken.

Who should practices contact for support?

Designated PBC Facilitators, Performance Information Analysts and Murray Forrest, LTC Development Facilitator -

Please note – this is a separate indicator and is in addition to the peer review indicator, anylocal indicators developed by Consortia/Stand Alones or any other schemes where the Predictive Risk Tool may be used alongside other sources of information to support any activities undertaken.

MEDICINES MANAGEMENT

Better Care Better Value prescribing indicators (BCBV)

Description of the Indicator

Practices choose two of the BCBV indicators where they are not achieving the desired prescribing levels. The Medicines Management team will provide a “Red / Amber / Green” list for all three indicators. The practice may only choose to work on indicators that are showing as Red or Amber on the list.

Where a practice is showing Red or Amber on only one indicator, then the practice may work on the “Patient register & medication review (Care Homes)” reserve indicator as it’s second medicines management indicator. Where a practice achieves well against all three BCBV indicators, the medicines management team may agree an additional local indicator. Where it is not possible to work on two medicines management indicators, the PCT will agree an alternative indicator that is relevant to the practice.

The three Better Care Batter Value Indicators are:

Use of low cost Statins compared to all statin prescribing
Use of low cost Proton Pump Inhibitors (PPIs) compared to all PPI prescribing
Use of ACE inhibitors compared to all ACE/ARB prescribing.

The indicators will use the national BCBV prescribing indicator set to allow easy comparison with other PCTs and national prescribing levels.

Review prescribing of the drugs within the indicator/s selected, with support from the medicines management team. Assess which patients are suitable to change to alternative products within the same therapeutic class to improve the practice achievement vs the indicator/s (as per the individual BCBV indicator selected) and to improve prescribing cost efficiencies available.

The practice with assistance of the medicines management team will collate information on the number of patients who have had treatments reviewed / changed (to provide an estimate of cost efficiencies achieved).

Regular (3 monthly) update reports will be provided indicating where the practice is in relation to the national average and top quartile for each indicator.

Why has this indicator been included?

There are three Better Care Better Value prescribing indicators, one for low cost statin use, one for low cost proton pump Inhibitors, and one for ratio of ACE inhibitor use to all ACE/ARB prescribing. On all three national indicators, the PCT, and most practices within NHS Kirklees, are significantly below the national average, with NHS Kirklees being ranked between 110th and 128th out of 153 PCTs, giving considerable scope for efficiency savings through the prescribing of alternative drugs within the same therapeutic class, but with a lower acquisition cost.This is an area where financial savings may be apparent that will help practices to achieve the savings levels in the Finance Indicator

What does the practice need to do to achieve stretch level?

To achieve 2 points for each BCBV indicators worked on, the practice has to:

a.move to the top 25% of practices (compared to the national indicator level – i.e. in the top quartile) with a minimum improvement from baseline of:

1. statins 8%

2. PPI’s 8%

3. ACE/ARB 6%

(all these are absolute increases)

b.If practice still below top 25% or below average (at 2010-11 year end)- minimum improvement from baseline of at least:

1. statins 15%

2. PPI’s 15%

3. ACE/ARB 10% (all these are absolute increases)

The reason for the larger increase required if the practice is below average is that it will be very much easier to achieve than a practice who is at “average” levels or better.

Baseline data will be based on BCBV indicator reports for quarter ending December 2009, with assessment for payment being based on BCBV indicator reports for quarter ending March 2011 reports. Payment will be made at the end of the year when the Q/E March 2011 reports are available.

What does the practice need to do to achieve standard level?

a.The practice moves to average or better (compared to the national indicator set) – witha minimum improvement from baseline of:

1. statins 5%

2. PPI’s 5%

3. ACE/ARB 4%

(all these are absolute increases)

b.If practice still below average (at 2010-11 year end) – minimum improvement

from baseline of at least:

1. statins 10%

2. PPI’s 10%

3. ACE/ARB 7%

(all these are absolute increases)

The reason for the larger increase required if the practice is below average is that it will be very much easier to achieve than a practice who is at “average” levels or better.

How and when will feedback be given to practices?

Feedback will be provided at least quarterly, with regular feedback on progress with the Medicines Management Practice Support Team, and with quarterly prescribing reports to allow assessment of progress vs. targets.

Baseline data using Q/E December 2009 prescribing, with quarterly update reports. Final assessment based on Q/E March 2011 data.