The professional voice of general practice in Islington Londonwide LMCs is the brand name of Londonwide Local Medical Committees Limited Registered and office address: Tavistock House North, Tavistock Square, London WC1H 9HX. T. 020 7387 2034/7418 F. 020 7383 7442 E. info@lmc.org.uk www.lmc.org.uk Registered in England No. 6391298. Londonwide Local Medical Committees Limited is registered as a Company Limited by Guarantee Chief Executive: Dr Michelle Drage

ISLINGTON LOCAL MEDICAL COMMITTEE MEETING

To be held from 3.00 pm to 4.30 pm on Wednesday 27 February 2013 at

Laycock Professional Development Centre, Laycock Street, London N1 1TH

PART 2 (OPEN)

3.00 to 4.30 pm

AGENDA

1.0 Apologies

2.0 Declarations of conflicts interest Members to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate

3.0 Minutes and matters arising not listed elsewhere on the agenda: 3.1 Minutes of LMC Part 2 meeting 19 December 2012 (pages 3-13) 3.1.1 POLCE (minute 5.3.1 refers) – to provide an update with regard to Dr Ruckert’s

concerns and to receive the NCL draft POLCE guidelines 3.2 Notes of interim meeting on 23 January 2013 (pages 14-16)

4.0 4.1 4.2

NCL issues: Draft and unconfirmed minutes of NCL Cluster and LMC Chairs meeting on 18 December 2012 (pages 17-25) Feedback from meeting on 26 February 2013

5.0 Islington Local issues 5.1

Report from Chief Officer or other representatives including: • Update on financial position

• Transition arrangements and payments to GPs

• Risk Sharing arrangements (paper to follow) 5.2 NCL Unscheduled Care Strategy

• NCL Urgent Care Centres • 111 update

• Out of hours update regarding City and Hackney GPs opting back in – Mr Cairns to report

5.3 5.3.1 5.3.2 5.3.3

Local Enhanced Services update including: Draft process map for CCG commissioning LES approval (paper to follow) Improving Access to primary care (pages 26-88) Referral Management Service

5.4 LESs and joint working with Public Health – verbal update 5.5 Impact of phasing out MPIG on Islington practices – CCG to provide feedback 5.6 New contract – impact of QOF changes on Islington practices – to note GPC update

(pages 89-92) 5.7 Premises including services charges and leases

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5.8 IM&T Strategy: verbal update 5.9 5.9.1

Public Health issues: Transfer of anonymised GP practice data to London Borough of Islington post-transition (pages 93-94)

5.9.2 Publishing Islington GP practice overview profiles on the new ‘Evidence Hub’ (pages 95-97)

5.10 Whittington Health – to receive an update from the CCG regarding the concerns raised at the last LMC meeting

6.0 Date of next meeting: 24 April 2013 7.0 Any other business

2

Minutes of the Islington LMC Part 2 meeting on 19 December 2012 from 3.00 - to 4.30 pm

Laycock Professional Development Centre, Laycock Street, London N1 1TH

PART TWO Present:

LMC members Dr Robbie Bunt

Ms Bernadette Edwards Ms Jenny Finch

Dr Paddy Glackin Dr Antonia Lile Dr Linden Ruckert Dr Catherine Steven Dr Clifton Woolf

Borough representatives Dr Eleanor Barry Dr Julie Billet

Ms Alison Blair Dr Gillian Greenhough Ms Avni Shah

Secretariat

Mr Greg Cairns Miss Nicola Rice Dr Julie Sharman

Item no.

Action

Organisation / person

responsible

1.0 Apologies Apologies for absence were received from Dr Sharon Bennett, Dr Cornel Fleming and Simon Hazelwood.

2.0 Declarations of conflicts of interest: Dr Bunt declared an interest in relation to item 4.2.2 below as he practised in PCT owned premises. Dr Greenhough noted that her surgery also operated from PCT owned premises.

3.0 Minutes and matters arising not listed elsewhere on the agenda:

3.1 Minutes of LMC part 2 meeting on 22 August 2012 The minutes of the meeting on 22 August 2012 were agreed as a correct record.

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3.2 Minutes of LMC Part meeting on 24 October 2012 The minutes of the meeting on 24 October 2012 were agreed as a correct record.

3.3 Notes of interim meeting on 21 November 2012 Ms Shah undertook to forward the notes of the interim meeting on 21 November 2012 to the LMC office.

AS

4.0 NCL issues:

4.1 Draft and unconfirmed minutes of NCL Cluster and LMC Chairs meeting on 30 October 2012 The minutes were received.

4.2

4.2.1

Feedback from NCL Cluster and LMC Chairs meeting on 18 December 2012 Dr Bunt noted that Ms Caroline Taylor had not attended the NCL Cluster/LMC Chairs Group the previous day which was disappointing. He explained that the issues which had been discussed included the primary care strategy money and leases for practices in PCT owned premises. Primary Care Strategy money: Mr Cairns reminded the Committee that the argument for implementing the primary care strategy had been that £47m would be made available to the five NCL boroughs over 3 years. He noted, however, that when he asked the NCL Cluster representatives how much money would be available, whether it was guaranteed and whether CCGs knew where it was, they could not provide answers. It would seem therefore that beyond April 2013 there were no guarantees that CCGs would have access to the primary care development money. Ms Blair advised that the CCG was concerned about this also as there were currently staff in place delivering the models. In addition she advised that Islington CCG had drawn down £1.8m to do the primary care development work this year. It was understood that there would be a 2% topslice of the CCG’s budget next year and the NCB had been asked if it would top slice 2% of the primary care development money also. Ms Blair explained that CCGs had received notification of their allocation for the following year the previous day which was less than anticipated and a lot of work needed to be done to understand the figures. However, the assumption was that the CCG would be able to draw on the money in the collaborative pot to carry on primary care development. Ms Blair also reported that NCL Cluster had been asked to draw up a financial risk share assessment. It was possible that CCGs could

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4.2.2

risk share in a smaller group if the five as a group did not work. Leases for practices in PCT-owned premises Dr Bunt advised Ms Amanda Challis had initially written to him as Chair of Islington LMC in June 2012 with a list of 10 practices which worked in PCT owned premises, the ownership of which would transfer to Whittington Health or PropCo in April 2013. The proposal was that these practices should have a lease in place by that date. Dr Bunt advised that a response was sent to that letter but nothing further was heard until Dr Bunt’s practice received Mr Andrew Ulyett’s letter of 7 December 2012 advising that service charges would be sought for 10/11 and 11/12. Dr Bunt expressed concern that no invoice had been attached to Mr Ulyett’s letter and there was no mention of any charges in respect of 12/13. Dr Bunt advised that the LMC had initially requested that a cap should be put on outstanding payments and despite inviting Mr Martyn Hill the NCL premises LEAD to at least two of the NCL Cluster/LMC Chairs meetings to discuss this he had not attended. He wondered what Whittington Health would feel about taking on this unsolved issue. He further understood that initially there had been agreement that there would be a Once for London generic lease and service charge schedule but this had been replaced by a national solution. It had transpired subsequently, however, that this would not now happen and that it would be up to Clusters to negotiate leases and service charges at a local level. Dr Greenhough noted that Mr Phil Orwin had been adamant that all service charges would be collected by the end of March 2012 as part of the reconciliation of Whittington Health’s bills. Dr Bunt advised that his practice had not received any such letter although it did receive a letter in June 2012 with a spreadsheet showing a first draft of what the PCT thought was owed. Dr Bunt considered that there was a huge risk to the practices in Islington affected by this and it was not clear who would negotiate the leases, what would happen in relation to the back charges and what would happen in relation to the stamp duty and Land Registry costs. He explained that it had been agreed at the NCL Cluster/LMC Chairs meeting the previous day that a meeting would be arranged for January 2013 but the deadline against which things were supposed to have happened was perilously close. Ms Blair noted that the first time she had seen the tabled letter was when it had been shared by the LMC office and expressed concern as the letter indicated that she and Ms Shah could be contacted for any advice. Ms Shah confirmed that she had been copied into Ms Challis original email in June 2012 and was aware that not much had happened since then and confirmed that there had been no discussions about capping back charges. Mr Cairns advised that part of the Once for London agreement reached was that retrospective charges would be limited to one year and noted that debts could not be transferred to PropCo or Whittington Health but that they could be transferred to the CCG.

5

Dr Greenhough advised that the CCG could not accrue debts and noted her unhappiness with Mr Andrew Ulyett’s letter, particularly the reference to the 7.5% management fee about which practices had previously been unaware. Ms Blair confirmed that the CCG would make its own representations to Mr Hill about this particularly in relation to the impact on practices and the possibility of debts being passed to the CCG. It was agreed that it would be helpful for the LMC and CCG to keep in close contact regarding this issue.

AB

5.0 Islington local issues:

5.1 Report from Chief Officer Ms Blair reported the following:

• Islington CCG had been formally authorised with one condition that it collaborate with other CCGs so all looked to be in order for 1 April 2013.

• the CCG was in the process of developing a draft Operating

Plan which should be completed by the end of January 2013 and finalised by the end of March 2013 and it was noted that the CCG would want the LMC’s views about this.

• The CCG’s first performance management meeting with

NCB had taken place recently and it had gone well.

• Mr Neil Roberts had been appointed as the Primary Care Lead for North Central and North East London.

• The CCGs would be meeting in January 2013 to talk about how they might link in with primary care contracting and to identify where some of the boundaries were. There would also be a need to talk about specialist commissioning and how the contract rounds should be approached.

• A new set of Clinical leads had been appointed and Ms Blair was pleased to note that there had been a good response. The CCG was in the process of setting up development programmes for them in their new roles.

Dr Bunt advised that LLMCs was considering how it and the LMCs would work in the new structures.

5.2 CCG update Dr Greenhough reported that Dr Mo Akmal, Chief of Trauma & Orthopaedic Surgery at Imperial College Healthcare NHS Trust, had been appointed as the secondary care lead on the CCG Board.

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5.3 Primary Care Development Group:

5.3.1 Referral Management Service Ms Shah advised that proposals for a referral management service had been taken to the pan Islington meeting in November for the CCG to get a sense of what GPs wanted to do in relation to peer review of referrals. Information had subsequently been sent to all practices to obtain a further focus in terms of retrospective review and the deadline for receiving feedback was the end of this week. Ms Shah anticipated that this would be commissioned as a LES. Dr Ruckert queried where POLCE would sit in the new world and noted that she had continued to experience problems with regard to POLCE in that she never received a timely response in relation to any emails sent. Dr Ruckert further noted that she had never received a substantive response to the email she sent to Mr Orwin earlier in the year and which Mr Sinden undertook to respond to. Ms Blair confirmed that his would be followed up. Ms Shah confirmed that both she and Mr Sinden had received examples of concerns regarding POLCE and that the POLCE policy had been revised and the Service Improvement Group would be discussing the process at a forthcoming meeting. In addition Mr Sinden was looking at the IFR aspect of the policy. Dr Ruckert reiterated that in the meantime it would be helpful if practices could be provided with the name of a contact who they could contact with any queries who would respond. Dr Greenhough noted that a complaint had been made that despite there being 8 telephone numbers listed in the policy nobody answered when they were called. There had apparently been a problem with the telephone system and this was being looked into. Ms Shah confirmed that she would look into Dr Ruckert’s concerns.

AB/AS

AS

5.3.2 Improving access to primary care Ms Shah noted that the business case for an access Les had included two options; that a Doctor First LES be commissioned which would be different to the previous NCL version or that access could be facilitated through the Primary Care Foundation. Ms Shah advised that this was still a discussion paper and was open for review and it had input from Dr Bunt and Mr Cairns via the Primary Care Development Group. Ms Shah explained that this was due to be discussed further at the Service Improvement Group the following day and the paper would be brought back to the Primary Care Development Group meeting and the LMC. Ms Blair clarified that he proposal would be put to the FRQ in February 2013 and anticipated that it could be published within a week or two after that meeting.

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5.4 Local Enhanced Services:

5.4.1 LES funding/spend to date and committed spend Ms Shah tabled an overview of Islington NESs and LESs being commissioned from GP practices. She explained that the CCG was currently working through the projected spend for 12/13 to see what the budgets would be for 13/14. Dr Bunt observed that the Closing the Prevalence Gap and Diabetes LESs had not been agreed and asked whether it was likely that there would be a spend against these in the current year. Ms Shah considered that this would be possible as it was hoped that they would be launched in February 2013 and would involve a 50% upfront payment to practices. Ms Blair reported that these LESs were to be considered by the FRQ this week. Mr Cairns noted that at the NCL Cluster/LMC chairs meeting the previous day the issue of delays in getting things approved by the FRQ was discussed. Ms Blair noted that everything that Islington CCG had taken to the FRQ had been approved so far. Ms Shah explained that in terms of the new schemes for closing the prevalence gap and diabetes 4-6 months had been needed to develop them. Dr Billett further advised that the money for these LESs were for the life of the LESs so would be available for 18-24 months even if the implementation was delayed. In response to Dr Sharman’s query as to whether the local authority had committed itself to fund this for 2 years Dr Billett advised that the local authority would be legally obliged to ensure that any LESs transferred were commissioned for a year under the transfer arrangements. Dr Billet noted, however that there was no intention to decommission LESs at that point although the local authority might wish to monitor them. Dr Billett noted that there was recognition that general practice was a key deliverable for many of the projects. Dr Billett acknowledged that there was a question around how non NHS bodies commissioning services could contract with practices and so for the first year the local authority might ask the CCG to commission services on its behalf. Dr Greenhough noted that previously consideration would be given as to whether targets set out in enhanced services were realistic or not but explained that going forward the CCG would need to make sure that no matter where a patient resided in Islington they should have access to similar services and there was a risk was that not all practices did this. Dr Bunt noted that another risk was that practices could be overwhelmed by all the LESs and he suggested that the CCG needed to take an overview of all the things which practices were being asked to do and cope with such as CQC and changes to QOF and IT systems.

8

Dr Bunt noted that the Referral Management and enhanced access LESs had not been included on the overview. Ms Shah confirmed that the overview would be updated to include these LESs and would be continually updated.

5.4.2 Closing the Prevalence Gap LES and Diabetes LES Dr Bunt confirmed that the LMC supported the LESs. Dr Billett confirmed that the launch date for both would be mid January 2013.

5.4.3 NHS Health Checks for over 75s Dr Billett explained that this LES fell out of the Closing the Prevalence Gap LES and involved a more holistic and integrated approach to the care of older patients. It related to the universal offer of a health check to every patient over 75 years including housebound patients. Dr Glackin queried the level of payment made for a GP to do a home visit and suggested that the payment should be raised to £100 or that the visit could be done by a nurse to make it more viable for practices. Ms Edwards queried why a GP had to do the home visit when nurses were able to do more and were more likely to have the time. Dr Ruckert also noted that some of the checks required were already done by members of the multidisciplinary team and noted that things like blood pressure checks would not be realistic with the services available and considered that the Whittington Health laboratory would not be too happy doing lots of Vitamin D tests in respect of all these patients. Dr Billett advised that it was not intended that this be a blanket approach to health checks and that there could be an element of judgement as to what tests needed to be done. Although the Committee considered that it was broadly speaking a good idea the specification needed to be amended and it was agreed that the next version would be considered at the next Primary Care Development Group meeting.

JB/AS

5.4.4 NHS Health Checks Call and Recall system Dr Billett explained that it was proposed that there be a centralised call and recall system for health checks which was modelled around the cervical screening call and recall system. Dr Billett noted that this would be done by the Exeter team. It would look as though the letter had come from a practice and the intention was to relieve practices in having to do this work. Dr Billett explained that she wished to obtain the LMC’s agreement to undertake a pilot and advised that 17 practices had already expressed an interest. The LMC supported this proposal.

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5.4.5 Co-ordinate my care Dr Sharman explained that the LMC was proposing that the CCG commission a LES to reimburse practice staff attending CMC training and to pay for their time in inputting the data as this had to be done manually. In addition she explained that using CMC should not be mandatory. It was agreed that this would be taken forward at the next Primary Care Development Group meeting.

AS/GC

5.5 Working with public health around LESs Dr Bunt advised that the LMC would welcome being involved in the development of LESs at an early stage. It was agreed that Dr Julie Billett be invited to attend the Islington LMC Part 2 meetings on a regular basis.

NR

5.6 List deflation/ONS data It was noted that the LMC and the CCG did not agree on the interpretation of the 2011 census figures which had recently become available in that the LMC considered that they reflected the true list size and that practices lists were not inflated and so the current list validation round was not required. Ms Blair advised that the NCB would take on the responsibility of looking at list sizes but agreed that there were a number of unregistered patients which needed to be addressed and explained that Mr Tony Hoolaghan was leading on some work to look at social marketing to reach such people. It was noted that this would be discussed further at the next Primary Care Development meeting.

AS

5.7

5.7.1

5.7.2

IM&T Strategy CSU IT contract/SLA Dr Bunt advised that the LMC would like to see a copy of the detailed contract/SLA between the CCG and CSU regarding IT services in order to ensure that things such as response times were appropriate. Ms Shah undertook to forward a copy of this to the LMC office. Emis web Dr Bunt expressed concern about the quality of the training his practice received from EMIS before going live. He advised that there was a lack of continuity in trainers and that there had been only one trainer which was not appropriate given the size of the practice. Dr Glackin further noted that some of the trainers did not understand how general practice worked and so were not able to help practice staff with the basic day to day things.

AS

10

Dr Greenhough responded to advise that GPs from practices where Emis web had been rolled out had been identified to offer support to those practices which were still to go through the process. Dr Bunt asked that lessons be learned from this in time for the roll out of Docman.

5.8 Changes to the NHS It was noted that this issue had been resolved.

5.9 Future working/relationships/communications with Whittington Health It was noted that the CCG had raised concerns about the MSK with Whittington Health through the contract discussions as it had become apparent from visits to practices that the waiting times had not reduced to 6 weeks as previously agreed.

5.10 Changes to the GMS contract 13/14 – Barbara Hakin letter of 23 October 2012 Dr Bunt drew attention to the tabled letter from Ms Barbara Hakin which set out proposals to phase out MPIG. Dr Bunt understood that most practices in Islington were hugely reliant on MPIG and the LMC was concerned about the impact of this. He noted that although the letter advised that the funding would be included in the global sum it was not clear what the mechanism for this would be and that deprivation might not be a factor. It was not clear if the GPC was negotiating with the government regarding this and he explained that he had asked the issue to be raised at the next LLMCs AGM and subsequent meeting with the GPC negotiators. Dr Greenhough agreed that there would be a need for the CCG and the LMC to work together on this and suggested that practices could be asked how much MPIG they received. Ms Shah advised that data about MPIG was already held and Dr Bunt suggested that it would be useful to see an anonymised list of practices showing the levels of MPIG. It was agreed that this would be discussed at the next interim meeting.

AS

PART THREE

6.0 Whittington Health Ms Carol Gillen and Dr Yong were welcomed to the meeting. Ms Gillen acknowledged that over the last 8 to 12 months there had been issues around the physio waiting times which had been due to many staff having left and the integration of 3 teams into one which would mean that the workforce could be used more flexibly. Ms Gillen also advised that much work had been done around skill mix and one of the big benefits had been integrating various IT systems into one version which meant that the capacity in the clinics

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could be seen at any one time. In addition to this there had been a lot of partnership working with leisure centres with the aim of normalising exercise and reduced membership rates. In relation to podiatry Ms Gillen explained that demand had exceeded capacity and Dr C Simpson a Darzi Fellow was leading on work around this. The work had included looking at efficiencies around triaging so patients could be seen within six weeks. Ms Gillen considered that Whittington Health was on target to ensuring that everybody could be seen within six weeks and noted, for example, that if urgent, a patient could be seen at Holloway the next day. Ms Gillen acknowledged that there was a need to find a better way to communicate with practices in relation to the capacity available in the 7 clinics. Dr Yong advised that the information which practices received regarding waiting times on RIO was not real time information. She noted that 500 appointments were sent out per week for MSK alone so if patients exercised their right to patient choice and chose the same clinic demand would go up. Dr Bunt noted that following either a GP or self referral patients often came back to the surgery with a letter from the service asking patients to phone it to make an appointment. He asked whether anybody from the service would ring a patient up to offer them an appointment the next day if there was one available. Dr Yong responded to advise that as MSK was a large volume service it initially had a lot of DNAs. Whittington Health was trying to offer a partial booking service by sending patients this opt in letter to try and alleviate the DNA rate. If people called at all times of the day it was difficult due to it being a high volume service. Dr Greenhough noted that there was a reality gap with those more senior in Whittington Health and those on the ground in relation to the waiting times. Dr Greenhough considered that there was a problem with the partial booking system and advised that the average wait seen by those on the ground was 14 weeks and that visits to practices had confirmed that patients did not get an appointment within six weeks. Dr Greenhough reminded Ms Gillen and Dr Yong that the CCG was promised in August 2012 that there would be a six week wait and suggested that everybody work together to resolve the issues. Dr Yong noted that Whittington Health had done an audit of 25 cases where people had been seen. Dr Bunt was of the view that this was not an appropriate audit as many people who had been referred did not make an appointment due to the waiting time. He suggested that a separate audit of 100 referrals made by GPs be undertaken to establish the waiting times. Ms Gillen and Dr Yong undertook to do this. Dr Bunt queried whether it would be possible to alter the booking system. He noted that the service would have the patients’ details

CG/FY

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and asked whether the service could call the patient and book an appointment with them there and then. Ms Gillen confirmed that a piece of work around this could be done. It was agreed that Ms Shah would liaise with Ms Gillen about this and any proposal would be shared with the LMC office at an early stage. Ms Gillen acknowledged the concerns which had been expressed by members of the Committee and undertook to look at ways in which GPs could see information about capacity in all the clinics. Dr Bunt asked whether it would be possible to make referrals to the service using Choose and Book which Dr Yong thought would be possible. Ms Edwards asked whether the high DNA rate was in relation to the follow up appointments. Dr Yong advised that this was the case although the service did sent text messages and called the patients. Ms Edwards considered that the DNA rate might be due to patients being dissatisfied with the service and although they had been seen and given an appointment they have decided not to attend. Dr Bunt understood that often people were just given a leaflet about exercise at some appointments. Dr Greenhough noted that there was a gap in expectations and considered that GPs needed to understand what services were being offered. Dr Yong explained that information about the services offered were provided in the GP Bulletin.

CG/AS

CG

7.0 Date of next meeting: 27 February 2013

8.0 Any other business There was no other business.

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Actions from Islington LMC meeting 23 January 2013

Item Action required

Completed

3.1 3.1.1

Matters arising from LMC Part 2 meeting on 19 December 2012 POLCE (minute 3.1.7 refers) A new draft policy has been issued but not widely circulated and is being reviewed by the CCG. The POLCE IFR process will be done by the CSU, there are issues regarding the split for specialist commissioning and the CCG. Sue Beecham is managing this. Ms Shah to check substantive response from Mr Sinden to Dr Ruckert’s letter An update will be considered in the SJLC in February. Dr Greenhough has enquired for a response in relation to dialling a single number and ensuring the call is answered. Dr Bunt confirmed it had been recorded in the minutes. Ms Blair would make enquiries regarding the policy for consideration by the Governing Body and to sign off responsibility and to delegate to the CSU. The draft policy will be sent to RB & GC

AS

AB

GG/AB

4.2 4.2.1

Feedback from NCL Cluster/LMC Chairs meeting on 18 December 2012: Leases for practices in GP owned premises Dr Bunt to hold meeting with Finance to consider payments. There is a potential risk for Practices relating to retrospective invoices for rent and service charges from the last 3 years. CCG will also look at this issue and Ms Blair will discuss with Ms Weyman as Chair of Finance and Performance Committee. To confirm whether the issue had been recorded as a risk for Primary Care

RB/AW

AB/AW

AB

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5.3.2 Improving Access to primary care There are two main concerns regarding the evidence from Milton Keynes. There was insufficient evidence of working in inner city areas and a number of patients leaving practices and registering with another practice. The decision was to pilot Dr First in a group of practices and to look at the impact and with practices and obtain patient feedback. The issue should be considered in Patient and Public Participation Working Groups and Practices for views, as this could impact on the disadvantaged and minority groups. Ms Blair to discuss with Ms Shah of the current position.

AB/AS

5.4.2 Closing the Gap Prevalence and Diabetes LESs Dr Bunt working well with Public Health and Ms Billet with some new LESs coming out. EOLC LES had some concerns regarding money and training. A suggestion of practice based training for the team and a proposal of payment regarding the time it took to input information.

AB/AS

IM&T Strategy Dr Bunt had not seen the GP IT SLA. Mr Cairn would check with the IT Sub Group and report back.

GC/AS

? Check minutes for action that AB was responsible for and had been missed?

AB

Transition to NHS NCB Ms Blair noted that the NCB were populating their structure. There are concerns are the risk of NCB specialist commissioning and IFR. An agreement had been made for the NCB will be part of the contract negotiations. It was still unclear who would be in Islington contact for Primary Care. A contingency was being worked on if the funding for the Primary Care strategy was not given by the NCB. Contract envelopes were being worked on for distribution.

Payments for CCG Work Dr Bunt noted the details were still unclear regarding the remittance advice. Ms Shah is dealing with issues of payment

AB/AS

15

AOB SJLC agenda would consider Whittington Health and what is the position Dr Sauvage to give an NHS 111 update and Ms Blair would check the timing. Primary Care team to discuss Urgent Care in two meetings time. Check date of next Finance and Performance meeting.

GG/AB

AB/JS

LMC

DA

F&P Group meeting 27th March at 12.30-2.00pm

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Minutes of the NCL Cluster and LMC Chairs Group on 18 December 2012 at

1.30 pm in Room 6LM1 Stephenson House, 75 Hampstead Road, London NW1 2PL

Present: LMC Chairs Dr Robbie Bunt Dr Martin Harris Londonwide LMCs Mrs Jane Betts Mr Greg Cairns Dr Tony Grewal Miss Nicola Rice Dr Julie Sharman

NCL Cluster Mr Robert Evans (in the Chair) Ms Trish Galloway Mr Michael Hepworth Dr Angela Lennox Ms Suzanne Novak Mr David Thomas

Item no.

Action Organisation/person

responsible 1.0 Apologies

Apologies were received from Dr Claire Chalmers-Watson, Mr Martyn Hill, Dr Henrietta Hughes, Dr Manish Kumar, Dr Martin Lindsay, Dr Yvette Saldanha and Ms Caroline Taylor.

2.0 Declarations of conflicts of interest Dr Robbie Bunt declared an interest in relation to item 5.3.3 as he practised in one of the practices in a PCT-owned premise.

3.0 Minutes and matters arising:

3.1 Minutes of the NCL Chairs and Cluster Group meeting on 30 October 2012 The minutes were agreed as a correct record subject to the following amendment requested by Dr Henrietta Hughes: Minute 5.3 – Appraisals Paragraph 5, fifth line to be amended to replace ‘have appraisals done’ with ‘be recommended for revalidation’.

N Rice

3.1.1 Procurement of GP practices (minute 3.2.2 refers) Mr Evans undertook to provide an update on the procurement processes underway in Camden, Enfield and Haringey for sharing with the relevant LMCs.

R Evans

3.1.2 CMC (minute 3.2.3 refers) Mr Evans reported that Mr Hoolaghan had contacted NHS 111 regarding

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the LMC’s concerns about CMC but had not received a response.

3.1.3 Appraisals (minute 5.3 refers) Dr Grewal confirmed that Dr Alison Hill would be the LMC representative on the group which Dr Hughes was setting up to consider appraisals and revalidation.

3.1.4 Appraisal payments for Haringey PMS practices (minute 5.3 refers) Mr Evans noted that the Cluster maintained that the payments had been included in the PMS baseline and confirmed that Ms Suzanne Novak would be picking this up in her work as part of the PMS review. Dr Grewal requested that this message be conveyed to Dr Martin Lindsay which Mr Evans undertook to arrange.

R Evans

3.1.5 PALS conciliation (minute 5.6 refers) Dr Bunt understood that the relevant complaints policy which was available on NCL website had not been amended to remove the phrase ‘in exceptional circumstances’ following the agreement at the last meeting that the Cluster would pay for conciliation services. Ms Galloway undertook to ensure the policy was amended including the version on the website.

T Galloway

3.1.6 Christmas and New Year’s Even opening times (minute 8.2 refers) Dr Grewal expressed his thanks for the revised letter which had been sent to practices following the last meeting and was pleased to note that common sense had prevailed.

4.0 Strategic issues:

4.1

4.1.1

4.2.2

Chief Executive update Finance Mr Evans advised that the five PCTs would hit the control totals but that this position had only been possible in Barnet, Enfield and Haringey as money had come from elsewhere. It was not anticipated therefore that they would all be in a run rate balance by the end of the year. Dr Grewal asked what debt or surplus would be carried over to the CCGs in the next financial year. Mr Evans undertook to take this back and clarify the position. Transition Mr Evans reported that Mr Neil Roberts had been appointed as Head of Primary Care for the North East North Central LAT. Mr Grewal advised that the three Heads of Primary Care across London had suggested a meeting with the Medical Directors at LLMCs to look at ways of working, communication and capacity for attending meetings. Mr Evans advised that further appointments were being made and it was

R Evans

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4.2.3

4.2.4

likely that they would be in a position to commence from 7 January 2013. Performance Mr Evans reported that there were a number of areas which had improved across the Cluster including immunisations and screening. He noted that the winter challenges had started particularly around A&E although there appeared to be a reduction in the level of emergency admissions. He was not aware of the reasons for this reduction and confirmed that he would check the performance in each of the acute areas. Mr Cairns urged caution against attributing this reduction to the developments in integrated care as he suggested that it was too early for them to have made such an impact at this stage. Enhanced services In response to Dr Sharman’s query as to what were the transition plans for enhanced services across the Cluster, Mr Evans advised that a large piece of work was ongoing to look at the finances. He advised that the CCG financial leads and public health leads were working together to ensure that they had a complete list of enhanced services where claims for expenditure were forthcoming. It was anticipated that feedback from this work would come to the Cluster the following week and he undertook to share that information with the LLMC office. Mr Evans noted that some enhanced services already rested with public health and he advised that the Cluster was trying to clarify those budgets also.

R Evans

4.2 NCL Cluster Primary Care Strategy Mr Cairns asked for confirmation that the money identified for the primary care strategy still existed in full and how long it would last. Mr Hepworth responded to advise that the primary care strategy was a three year project and was an initiative to pump prime the development of change in primary care. He noted that it was in the very early stages of development as the CCGs had not had time to develop services locally. He reminded the group that there were nine domains for investment and that it was proceeding reasonably well. Mr Cairns noted that it appeared that the funding had not yet been identified for this year or the next two years and Mr Hepworth responded that NCB had indicated that it would support the strategy. Mr Cairns reminded the group that the NCL primary care strategy had been predicated on an assumption that £47m would be made available over the next three years and asked whether this amount of funding actually existed. Mr Hepworth confirmed that £12m had been allocated this year but that NCL was awaiting a guarantee that it would receive the funding next year although it was anticipated that this would happen. Mr Evans advised that all the indicators were that everything would continue as anticipated but this could not be guaranteed until information was received about the allocations. Dr Grewal considered that this was unsatisfactory given the assurances that were made that £47m would be available for use over the next 3

19

years and expressed regret that certainty about this was moving away. He asked how much of what had been spent to date on the strategy had actually sat in primary care. He noted that clinical leads and other managerial appointments had been made and asked how many had been appointed and what were their salaries. Mr Hepworth noted that a £7.5m spend was forecast for year-end but the position was improving day by day. He advised that the Cluster was looking for the CCGs to come up with initiatives to support primary care development in the next year. He advised that to date the Cluster had received 47 business cases. Dr Lennox advised that meetings took place every two weeks which were attended by a manager from each PCT and some of the key people from across NCL to share learning and to ensure that the main outcomes would improve primary care. She noted that each PCT/CCG had its own priorities and the Cluster was supporting them. Dr Grewal repeated his concern that to date no money had reached practices to support them in their face to face dealings with patients and asked whether the LMCs could submit business cases if they had any ideas. Mr Hepworth advised that this would be possible but any business cases would need to go through the relevant borough structures for the CCG to consider whether they aligned with their priorities for primary care development. He noted that business cases were locally owned and indicated that the Cluster would like to see more transformational things being done on the ground. Dr Grewal noted that in order to ensure that integrated care teams worked properly there would need to be enough district nurses and suggested that there was no reason why a network should not work together to employ nurses. Mr Hepworth advised that a nurse lead was in the process of discussing the issue of district nursing with the boroughs. Dr Lennox noted that the strategy was still in the early stages of development in that GPs were only beginning to come together across localities and involvement with practice managers and practice nurses was only beginning to happen. Dr Sharman repeated her views that the simplest way to get money out to GPs at the coalface would be by way of LESs. Mr Hepworth noted that business cases for LESs were beginning to come through and Dr Bunt noted that it seemed that many LESs in Islington had been discussed but they seemed to take a long time to get off the ground. Mr Hepworth advised that he was not aware that the Cluster group was slowing business cases up and was expecting the next tranche of LESs to be considered in January 2013. Mr Evans advised that the Primary Care Strategy Board had agreed a process of considering LESs two weeks previously whereby management and clinical leads of each CCG would consider and approve them. Dr Grewal advised that this was the first the LMC Chairs had heard of this process and reminded Mr Evans that the people who should be consulted on LESs were LMCs and was disappointed that

20

another process had been set up. Dr Bunt regretted that Mrs Taylor was not present at the meeting. He reminded the group of the previous commitment of the Cluster when reviewing the LESs that five new LESs would be rolled out on a cluster basis but this had not taken place and he asked what had happened to all the work which had been done in this area. Mr Evans advised that the nursing and residential home LES had been considered at the FRQ meeting in October 2012 and it had been agreed subject to a couple of caveats. Dr Grewal queried whether this LES had come to the LMC office for consultation as required. Mr Evans undertook to clarify what the position was with regard to the development of this LES. Dr Bunt noted that in Islington the LMC was working hard with the CCG to develop LESs but the problem seemed to be that having done the local negotiations they then reached a stumbling block. In addition he understood that Camden CCG seemed to be of the view that they could not commission enhanced services due to them having to follow the AQP process because of possible conflicts of interest. Mr Evans undertook to clarify what the challenges were in Camden particularly as the development of enhanced services was proceeding well in other areas Dr Lennox explained that every single project which had been approved had been published on the intranet and Mr Hepworth undertook to forward a copy of that to the LMC office

R Evans

R Evans

M Hepworth

5.0 Operational issues:

5.1 Primary Care QIPP: PMS Reviews

5.2

5.2.1

IM&T update Mr Thomas reported the following: Emis web 70 practice had gone live with Emis web with a further 50 to go live in the next four months. Mr Thomas was aware of the shortcomings in the quality and completeness of the training by EMIS and he confirmed that he had raised this with them. As a result he was looking to see if practices which had received the training and were now using the software could support practices transferring across and advised that they would be funded. Dr Bunt considered that this was a serious issue that needed to be addressed as soon as possible and that there was a need for practices to have a clear implementation plan in order that any unnecessary stress could be avoided. He had concerns about Emis’ capacity as an organisation and noted from his own experience that trainers had arrived up to an hour late and that different trainers had turned up at times so there had been no continuity in the training. In addition to have just one

21

5.2.2

5.2.3

5.2.3

trainer for a practice of his size had been insufficient. Mr Thomas acknowledged that there should be at least 2 dedicated trainers available and noted that some practices had not experienced any problems but this may have been due to the amount of time they had spent planning the migration. Dr Grewal asked that if there continued to be difficulties with training that the contract and or agreement with EMIS web be shared with the LLMC office. Dr Grewal advised that LMC members had pointed out that when they migrated to EMIS web any further maintenance needing to be done would have to be done during working hours due to security of working out of hours. He advised that a practice could not close down for half a day for IT purposes and asked Mr Thomas to take this back. He also asked what the response times were when contacting the help desk. Docman Dr Grewal further noted that many acute trusts were now handling communications by email only which was not satisfactory for a number of reasons but he asked whether EMIS web would be as good as Docman for extracting a report sent by email and putting it straight into the patient’s records. Mr Thomas advised that there was a shortfall in EMIS web in relation to electronic messaging but advised that capital money had been identified in NCL to enable the IT support to procure Docman for those practices which did not have it. Dr Grewal asked whether those practices which already had Docman would receive maintenance support as it appeared that the funding for this in Haringey might be inequitable. Mr Thomas undertook to clarify this. Dr Bunt noted that UCLH was funding Docman in Islington practices and that practices had received a letter confirming UCL funding and a licence agreement for two years but it was not clear what agreement practices were entering into and what would happen should practices wish to extract from the contract should a better system be introduced in the future. Mr Thomas confirmed that the duration of the contract with Docman would last for the duration of the funding. He advised that if there was no suitable funding to enable it to continue there would be no impact on practices should they wish to pull out. He apologised if this had not been made clear in the letter which had been sent to Islington practices and undertook to take this back to the CCG to ensure that a clear and consistent message was sent out. Capital funding for PCs and printers Mr Thomas advised that capital funding would also be available to fund any PC or printer which was to be out of warranty in the next 6 to 12 months. Although the money was available this year it was not known if it would be available for the following year. IT services for CSU Dr Bunt noted that Islington CCG was looking to procure IT services from

D Thomas

D Thomas

D Thomas

22

the CSU but noted that the LMC had not seen a copy of the draft contract which would set out conditions which would be relevant for practices and as such he considered it vital that the LMCs be kept in the loop. Mr Thomas noted that the CSU had prepared a prospectus of IT services which had been sent to North Central and North East CCG and LMC Chairs in September 2012. Discussions between the CSU and CCGs had taken place and expressions of interest had been received from CCGs. A draft contract/SLA based on the GPC Systems of Choice operating model had been drawn up and he confirmed that he would be email this to the LLMCs office. He advised that all 5 NCL CCGs had indicated that they would sign up to this and they had been asked to sign a Memorandum of Understanding by the previous Friday although he had not received any. He noted that he would need to talk to the CCGs as their commitment was needed in order to invoke the transition arrangements. In response to a query from Mr Cairns as to whether some of the borough based IT services would be lost with the move to a centralised service Mr Thomas advised that this would not happen. He advised that for core services the same borough people would continue at the CSU in response to the clear message from GPs that they wanted continuity. It was agreed that ideally the money for IT should be ring fenced but it was not clear whether this would be the case when the allocations were announced.

D Thomas

5.3 Premises issues: Dr Grewal expressed disappointment that Mr Hill had not engaged with these meetings to provide an update and discuss the concerns about various premises issues. Mr Evans undertook to feed that back to Mr Hill.

R Evans

5.3.1 Improvement grants Mr Evans reported that in the first wave of improvement grants of which £560k was available 67 practices had their bids approved. He advised that if possible all work must be completed by the end of February 2013 with invoices to be submitted by 14 March 2013 at the latest. He appreciated that this was a short turnaround time. Dr Grewal asked what would happen should a builder let a practice down and the work was not completed on time. He did not consider that practices should be put at risk in this way. Mrs Betts advised that she had attended the panel as the LMC representative and understood from Mr Tony Hoolaghan who had also been on the panel that if work was underway practices would not be disadvantaged and she considered that it would be helpful to have something to this effect in writing. Mr Evans undertook to take this back and clarify it to make sure that this was communicated to practices. He reported that four out of the five boroughs were underspent on this budget and Islington had overspent. In the circumstances the Cluster was considering whether practices should be able to apply for one of things such as a couch to ensure that there were no underspends. Dr

23

Grewal advised that care would need to be taken that some things which were put forward could be deemed to be essential so there would be a need to be clear that any payment made could not later be claimed as the practice having made claims for double payments. Mr Evans advised that there would be a second wave of improvement grants but it was not yet known how much money would be available. He confirmed, however, that the process would be started as early as possible to ensure there was an appropriate timescale for the bids to be submitted. Dr Grewal asked that the LLMCs office be given advance notice so that it could issue advice in the LMC newsletters to ensure that practices were aware of this. Mr Evans confirmed that he would do this.

R Evans

5.3.2 Premises survey Dr Grewal advised that he had not seen the standards or criteria being used by Oakleaf when conducting the premises surveys and asked that they be emailed to him as soon as possible which Mr Evans undertook to do. Dr Grewal expressed concern that at least two practices had quotes attached to their report in relation to areas identified as needing improvement which he considered to be totally inappropriate. Mr Evans assured Dr Grewal that he would make sure that Mr Martyn Hill was aware of this situation would have a conversation with the Chief Executive. He undertook to advise Dr Grewal of the outcome of those conversations.

R Evans

R Evams

5.3.3 PCT owned premises A letter which had been sent on 7 December 2012 to practices in Islington which operated from PCT owned premises was tabled. Dr Bunt advised that a letter was initially sent to the LLMCs office in June with a proposal that the Cluster clawback service charges from April 2010 and although the LLMCs office sent comments back nothing further was heard until the tabled letter was sent. Dr Bunt considered it unfortunate that the letter contained no information about how much money was owed and what would happen to the estate under the new arrangements. He asked for clarity around what was the NCL’s policy regarding leases and service charges for practices working in PCT owned premises. He further noted that the letter gave the Islington CCG Chief Officer and Primary Care Lead as the points of contact so it was not clear whether the borough or the Cluster was leading on this. Mrs Betts advised that she had met with Mr Martyn Hill who had agreed verbally that no local agreement or actions would be taking in relation to service charges while discussions were taking place about this issue at a higher level. Mrs Betts noted that initially discussions took place at a London level between LLMCs and NHS London but these were subsequently replaced by discussions taking place at a national level. Dr Grewal advised that the national discussions had since stalled and Mr David Sturgeon who had been the premises lead for London had recently given an indication that the negotiations would not revert back to pan

24

London ones but would have to be done at a sector level which Dr Grewal considered disappointing. Dr Grewal noted that the LLMCs would be advising practices not to sign anything in the meantime pending further discussions. Mr Evans confirmed that the discussions would take place at an NCL level although this would not preclude practices discussing the issue with the CCG contacts. He undertook to clarify the NCL policy about this. Dr Bunt also requested that the Cluster take into account the implications of Registry fees and stamp duty.

R Evans

6.0 Future meetings It was agreed that the date of the next meeting should be kept in the diary and Mr Evans undertook to see if Mr Roberts would be able to attend.

R Evans

7.0 Date of next meeting 26 February 2013

8.0 Any other business:

8.1 Management of Practitioner performance Dr Lennox advised that she had been alarmed to note that the GMC had send a communication directly to a CCG governance lead asking for information about the performance of a practitioner and detailing concerns. Dr Lennox noted that fortunately she had been able to intercept this and had advised the GMC that this was inappropriate. This had been caused as a result of the confusion at all levels regarding the transition but she was delighted to report that Dr Henrietta Hughes had been appointed as Medical Director for the NCNE LAT and was confident that the team was clear about where responsibility for practitioner performance should lay.

8.2 Barnet, Enfield and Haringey out of hours procurement Mrs Betts advised that she was the LMC representative on this procurement panel and noted that the process had been halted for a time to undertake some legal checks but noted that the process had resumed.

25

1

MEETING: Standing Joint Liaison Committee

DATE: 27 February 2013

TITLE: Improved Access Business case and specification

LEAD CCG BOARD MEMBER:

Dr Katie Coleman and Dr Jo Sauvage

LEAD DIRECTOR: Paul Sinden

AUTHOR: Samantha Milford, Primary Care Manager

CONTACT DETAILS:

Samantha.milford@nclondon.nhs.uk

SUMMARY:

The Business case attached proposes that there should be investment into improving patient access to GP surgeries, in line with key outcomes we are looking to achieve under Islington CCG’s primary care and urgent care strategies. The drive for doing so stems from patient feedback through the national GP patient Survey, local feedback through patient groups etc, and unsustainable increases in A&E attendance rates, which can be linked with poor primary care access.

The Business case proposes that there be an Improved Access Local Enhanced Service (LES) for GPs, containing 2 components. Practices may choose to deliver either Component 1 (Dr First programme) or Component 2 (review facilitated by Primary Care Foundation).

Initially it was suggested that there also be a Component 3 element based upon outcomes (e.g. improved patient satisfaction, reduction in certain in-hours Urgent Care Attendances), however this has been removed with a view to assessing the impact of the process in Year 1, before setting outcome-based payments in future years of an Improved Access LES.

It proposes that the LES pays for a full year’s delivery, in order that changes to practice systems can be implemented, embedded, and given enough time to operate so that outcomes can be achieved and measured, and success understood.

Component 1 of the LES asks practices to implement the ‘Doctor First’ approach within their practices for a full year, which means that all patients wishing to have a face to face appointment must be assessed via telephone by a GP, thereby directly dealing with the issue and averting the need for a face to face appointment, or booking an appropriate face to face appointment for a suitable time and length.

Component 2 asks practices to undertake a systematic data collection and review of their current systems, supported by provider Primary Care Foundation. PCF will process this data and assist practices to achieve transformational change, by giving practical suggestions and assisting practices to implement those changes. Re-collection of data will assist measurement of outcomes at the end of the project.

The Business case includes proposed costing based on full delivery of the LES by all 37 practices, plus associated costs for the support given by Primary Care Foundation(this associated cost is to be funded from Pathfinder money).

Benefits are expected to be improved in-house practice systems via transformational change resulting in long term change, overall reduction of pressure on GP practice appointment

26

2

systems and staff, increased patient satisfaction, increased staff satisfaction, improved quality of patient care, reduction of in-hours A&E attendances (specifically reduction of 3 less serious categories of in-hours 2 Urgent Care Centre attendances). In addition to this, robust data reporting by practices and robust evaluation of the project will support ‘Offer 4’ within the new guidance received from NHS Commissioning Board entitled ‘CCG Outcomes Indicator Set 2013/14’ which emphasises collecting better data and using it as a key tool for informed commissioning.

The paper has been discussed at the borough Primary Care Development Group, executive team, Service improvement Group, and Primary Care Programme Board meeting with extensive clinical and public health input.

SUPPORTING PAPERS:

Improved Access LES Pilot specification

RECOMMENDED ACTION:

The Standing Joint Liaison Committee is asked to:

• Discuss and approve the final specification, in preparation for launch on 1 April 2013.

Objective(s) / Plans supported by this paper:

Improving primary care access – in this case to GP practices – is a key outcome of both the primary care and urgent care strategies, and an ongoing issue for Islington, and more widely, a national priority across the UK. The improvement in access will also reduce some pressure on practices which will then enable them to engage in other upcoming local strategies, such as taking on clinical commissioning generally, engaging in increased identification of people with long term conditions, and subsequent improved management of LTC patients through a year of care approach and improvement of care planning. Anticipated reduction on demand on Urgent Care Centres will also free up capacity for those patients who really need to be seen in such a setting.

Audit Trail:

• Options paper went to Primary Care Development Group (ICCG),8 November 2012

• Business case and specification went to Primary Care Development Group (ICCG), 6 December 2012

• Business case and specification v2 went to Executive Management Meeting (ICCG), 19 December 2012

• Business case and specification v2 went to Service Improvement Group (ICCG), 20 December 2012

o Since Service Improvement Group, the following changes have been made:

� Refinement of indicators for evaluation in line with suggestions made by public health and CCG information team (table included in business case)

� Refinement of indicators which will be used for Component 3 outcome payments (NB: thresholds still to be finalised)

27

3

� Inclusion of staff survey to measure impact on staff over time of project

� Amendment to Appendix 2 & 3 (data submissions for Component 1 practices) to ensure robust data collected for subsequent evaluation

� Refinement of Dr First pathway including consideration of walk in patients, Dr booking the face to face appointment directly, and exclusion criteria

� Conclusion of only senior doctors being able to be triaging clinician for Dr First (no PNs)

� Refinement of start date and milestone dates

� Addition of note asking practices to consider Dr First in light of practice-specific population of non-English speaking patients at Specification Section 4.1.3

• Business case and specification v2 went to Primary Care Programme Board (NCL), 10 January 2013

• Business case and specification v2 went to Finance Recovery and QIPP (NCL), Jan

• Business case and specification went to Primary Care Development Group, 17 Jan 2013

• Business case and specification went to Primary Care Development Group, 14 Feb 2013

Patient & Public Involvement (PPI): None, though the impetus for this work stems from patient feedback collated through various means including MORI GP Patient Survey, Patient Group meetings, Islington LINk reports, general patient feedback to practices etc. Note that the LES will also require collection and analysis of patient feedback as part of the work to be delivered and outcome to be achieved.

Equality Impact Assessment: None

Risks:

Risk Mitigation Likelihood Impact Total

That only a small number of practices take up the local enhanced service, therefore reducing possibility of improving overall GP access across the borough

Good marketing of the enhanced service

Strong support from primary care commissioning team where necessary to assist, including contact by primary integrated care officers for each locality.

2 3 6

That practices who do sign up do not follow process e.g. strict daily data recording

Importance of process to be highlighted to practices, including support and clarification to practices where needed, on regular basis

Failure to complete process properly may result in deduction of payment

1 3 3

That practices do not make full effort to engage in the process

Importance of process to be highlighted to practices – requirement for regular reporting

1 3 3

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4

once signed up helps to ensure practices are completing daily process for Doctor First.

Primary Care Foundation will be following up practices closely and supportively to achieve the aims in Component 2

That the scheme is not able to be analysed effectively

Strong process for data collection by practices is in place, supported by payment mechanism upon completion of process

MORI GP patient survey results and SUS data is in place to measure specific measureable outcomes

Baseline and repeat data has been specified

1 4 4

That the scheme does not reduce A&E attendances / Urgent Care Category 1 & 2 attendances

Ensure that practices promote the changes to their systems as well as possible, to increase likelihood that patients will ring their practice before attending A&E.

2 3 6

That the scheme does not show any other benefits

This is unlikely, but extent of outcomes is to be determined. The money will be coming from Primary Care Investment money, which is a one-off pot and must be spent. Scope for extension of the LES will be determined upon strict analysis of outcomes

1 3 3

Resource Implications: One-off 50% investment from Primary Care Investment Money will be required, with the remainder to be funded by ICCG Operating Plan funds for 2013-14. The estimated spend in 2012/13 with half the practices doing option 1 and other half doing option 2 the amount of funding requested from Primary care strategy funds equates to approximately £400k to be spend by 31st March 2012.

Funds to pay Primary Care Foundation will be made from Pathfinder money.

The LES will be implemented, monitored and analysed by the primary care commissioning team at the CCG, with some initial extra resource within the team required for launching and supporting practices at the beginning of the service.

Next Steps: Upon finalisation, this will be sent to formal SJLC with a view to sending this out to practices as soon as possible in order to achieve sign up.

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5

1. Executive Summary

Primary Care access is a constant issue for GP practices. Not only does it affect patient experience of GP services, it also impacts upon GP practice staff satisfaction (due to high pressure on staff who have to deal with difficult daily systems and unhappy patients), and acute activity (specifically A&E attendances, when people who feel they need urgent help go to hospital when they cannot access their GP).

Additionally, the issues that affect one practice may not affect the next – access is such a broad area, and can be impacted by a wealth of different processes and systems that a GP practice has.

There are also many factors which continually increase the pressure on GP practices – as patient demand rises, so does the need to find ways to improve access to meet that demand.

This paper puts forward a case for supporting Islington general practices via a proposed Local Enhanced Service, and this paper should be read in line with the accompanying proposed LES specification.

Considering access problems are multidimensional and vary across practices within the CCG, the LES allows practices to choose from 2 different components which are aimed at improving same day / urgent access to GP practices, depending on what they feel will be best suited to them:

Component 1: Implement Doctor First strategy within the practice; OR

Component 2: Participate in a programme run by external providers Primary Care Foundation, which works with practices over a period of time to:

a. provide a framework for collecting specific measurable access data

b. produce a data report which highlights problems, provides benchmarking against other practices, and suggests actions which might result in improvement

c. support the practice to implement agreed actions

d. support the practice to measure the resulting outcomes.

It is felt that the work undertaken by practices as part of this enhanced service will, most importantly, offer the opportunity for long term change within Islington primary care to be able to provide good access to their services.

Published evaluations and studies demonstrate a number of benefits to the two approaches set out in the LES. The studies have been carried out in a variety of different populations with differing baseline levels of access to primary and secondary care services.

• A reduction in A&E attendances (Component 1, Component 2)

• A reduction in emergency admissions (Component 2)

• Increased capacity within primary care, including improved ability to provide same day access, advanced booking and to see preferred clinician (Component 1), matching capacity more closely to urgent and booked appointments (Component 2).

• Increased patient safety due to increased ability to provide urgent care within primary care (Component 1 & 2)

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6

Other anticipated benefits include:

• Increased patient satisfaction with GP practices, and fewer complaints.

• In-house benefits to GP practices which include new ways of working resulting in saving hours of GP and practice staff time, more efficient and cost effective systems which release money to be re-invested into the practice, reduced pressure on GP practices, more efficient systems, higher staff satisfaction.

• Reduced A&E attendance rates (specifically Category 1&2 urgent care attendances) as a result of easier GP access – which in turn frees up capacity within urgent care centres to deal with those who need to be seen in such a setting.

The evaluation of the LES will use both existing routinely available data sources (e.g. SUS, MORI patient survey) and datasets recorded by practices as part of the LES to assess the benefits and value of the pilot.

The specification takes into account the fact that all practices have unique problems, unique patients and unique systems already in place, and gives them a chance to either properly test the Doctor First approach for 12 months, or undergo a supported programme which helps the practice properly understand their problems and implement transformational change within their practice.

2. Introduction

Primary Care is under continual pressure to improve and maintain good access to their services, particularly within general practice. Significant challenges present themselves: growing patient expectations, an ageing population, local strategic work on reducing the gap between expected and recorded prevalence, better management of more long term conditions requiring greater initial investment of time, practitioners who are busier as clinical leaders in commissioning.

The responsiveness of local services is crucial for meeting the primary health needs of patients and also for avoiding a greater effect on the rest of the healthcare system, especially A&E and urgent care departments, when patients who are unable to access their GP surgeries look towards hospital to provide that care instead1. Improving access is both a national and local priority, forming key enablers for Islington Clinical Commissioning Group’s (ICCG’s) primary care and urgent care strategies.

Islington General Practices have been incentivised through various means in the past to look at their access, but the means of doing so have not proven effective or supportive enough to instigate real change and monitor outcomes. This paper proposes that funds be invested in supporting primary care to implement systems which may improve access (and therefore reap benefits as noted below in Section 3.2).

It is suggested that investment in primary care to either

• Incentivise a trial of the ‘Doctor First’ approach to appointments, or

• Incentivise participation in a supported programme which will support practices to understand their range of urgent care access issues and implement their own bespoke solutions leading to transformational change

1 Sean Boyle, John Appleby, Anthony Harrison, ‘A rapid view of access to care’, Kings Fund

(2010)

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will lead to improved primary care delivery across the borough, with practices who are more satisfied and able to deal with access problems in the future, happier patients, and reduced activity in A&E / Urgent care centres (cost benefit).

It is important to stress that the options within this LES are seen as a real opportunity for driving long-term, transformational change within practice, and that these benefits can be embedded and then self-sustainable.

3. Case for Change

3.1 Why do we need this?

Various pieces of information support the case for implementing a programme to improve access in primary care.

3.1.1 MORI patient survey

The national GP patient survey has been running for seven years, commissioned by the Department of Health and delivered by Ipsos MORI. The survey is sent to approximately 5% of randomly chosen registered patients from each GP practice, who answer questions about patient access and experience. There is approximately a 30% return rate on the surveys sent out.

Results collated over 2006-07 to 2009-10 show that results on access markers are generally declining across most questions, both locally, London-wide, and nationally. This is demonstrated in the table below which shows the change over a 4 year period for 5 key markers.

MORI GP patient survey results between 2006-07 and 2009-10

Satisfied with phone access (%)

Able to get an appt within 48 hours (%)

Able to book 2+ days ahead (%)

Able to book appt with specific GP (%)

Satisfied with opening hours (%)

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

England average

86 86 75 88 84 82 82 79 88 76 71 77 76 69 87 83 80 87 70 65

London Average

83 81 74 84 80 78 78 76 88 71 66 76 71 68 83 79 76 84 67 62

Islington average

86 78 75 85 81 77 77 75 84 70 65 73 75 67 80 78 74 85 67 63

As demonstrated above, Islington generally performs lower than the England average, and performs interchangeably against the London average (slightly above and below across questions). This is true across the full range of questions asked, not just in those shown above.

Unfortunately changes to questionnaire design and survey frequency in 2011-12 mean that results from 2011-12 and onwards cannot be compared with previous years, even where questions remain the same. However a full set of the most recent results for Islington for the period Jan 2012 – Sep 2012 is available in Appendix 9 of the LES specification.

Results do show that access, or at least patient perception of access, is worsening and requires attention.

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3.1.2 Other patient feedback

In addition to the survey which is now run twice yearly, patient feedback is received via many channels, such as through Islington’s PALS and Complaints department, patient participation groups, direct feedback to practices, NHS Choices, and reports created by Islington LINk. Feedback from all areas continually raises GP access as an issue.

3.1.3 A&E Attendances

In addition to patient feedback, emergency admissions and A&E attendances in Islington continue to rise unsustainably, driven by self-referrals to A&E. It follows that a lack of capacity within primary care is a contributing factor, with patients attending hospital when their GP practice is not available as the first option. A general unsustainable rise in acute activity drives our aim to deliver more services at cheaper cost in the community, which then means that even greater pressure will be placed on our primary care providers to meet growing demand. See Appendix 8 for data on 2011/12 and 2012/13 in-hours A&E/UCC attendances for Islington practices around 3 specific categories of patients.

3.1.4 Demand is increasing

Providing good access becomes harder as time passes. Islington GPs are challenged by the following:

• Population is ageing

• Local strategies require better management of patients with long term conditions which put a strain on the normal 10 minute appointment system

• Increase in case finding locally, especially through the new proposed Closing the Prevalence Gap LES will identify more new patients with conditions which need management

As demand increases, getting on top of managing it becomes more and more important to ensure practices can cope, and still provide responsive, high quality patient care. It must however be noted that there are other initiatives afoot which, in time, aim to reduce the demand on practices, such as empowering patients to self-manage where possible (and therefore requiring health professionals less).

3.2 Previous initiatives for improving access

It is important to note that there has been past work which has touched upon access, such as the recent ‘Improved Access (Dr First) Local Enhanced Service’ and some ‘demand management workshops’ which explored the impact of structural and behavioural sciences on managing demand within general practice, however these initiatives were not provided in a very robust way. The following proposal builds on previous work in a more structured way and for a longer period of time in order to allow processes to bed down and produce real, positive outcomes.

Note also that a number of practices are signed up to the Extended Hours DES, which pays practices for providing extended opening, above and beyond their contracted hours of 8.00am – 6.30pm, Mon-Fri. It is difficult to judge the impact of this on primary care and also on A&E attendance due to the multifarious factors which impact upon both, however it is clear that patients appreciate extended opening hours, especially for those who work during the day.

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Proposed changes to the GMS contract for 2013/14 suggest a new DES for improving online patient access (to appointments, test results, and repeat prescriptions) – therefore this proposal does not include anything which replicates Extended Hours or the proposed online patient access DES requirements.

4 Proposal for LES

4.1 Key areas in the LES:

• Component 1 – Implementing Doctor First approach

Practices are required to implement the Doctor First approach within their practice, which means that all patients who wish to make a face to face appointment must be spoken to on the telephone first by a doctor / nurse who assesses the issue and the actual need for a face to face appointment, prior to any face to face appointment being made.

It is suggested that the implementation of such an approach may result in up to 50% of patients being dealt with directly and averting the need for booking a face to face appointment. This system must be in place for the period between 1 April 2013 and 31 March 2014, and it is assumed that if this results in positive outcomes for the practice that the practice will continue to deliver their system in this way.

• Component 2 – Undertaking structured access review with support from Primary Care Foundation

Primary Care Foundation will support practices to review their access in a structured way. This programme of support is assisted by the use of a simple data reporting webtool, and a report summarising their data, showing benchmarking information and providing suggestions for change. Practices will then be provided with bespoke individual support to implement these solutions within their practice, in order to achieve transformational change. Primary Care Foundation will also measure the outcomes at the end of the process via a repeat data collection and report.

It is suggested that this will benefit practices who have ‘tried everything’ and need some targeted support to understand the issues and guide them through making significant changes to their systems. Please see Appendix 1 of this business case for the full proposal from Primary Care Foundation. For each practice the support provided by Primary Care Foundation equates to approximately £4000 per practice.

5 Outcomes and benefits

5.1 Evidenced outcomes and benefits of approaches within LES

Published evaluations and studies demonstrate a number of benefits to the two approaches set out in the LES. The studies have been carried out in a variety of different populations with differing baseline levels of access to primary and secondary care services. Therefore, it is important to establish how the initiatives will impact in Islington.

5.1.1 Doctor First approach

This approach has been used across the country, including in Milton Keynes which has reported various benefits.

Productive Primary Care, which came up with the Doctor First approach has reported such benefits as:

• A reduction in A&E attendances

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• Increased capacity within primary care, including improved ability to provide same day access, advanced booking and ability to see preferred clinician, more control of daily workload

• Reduction in patient complaints

• Reduction in DNAs

• Over a period of 6 months, a practice triaged 13,100 patients, saving over 5400 face to face consultations, and saving £18k in locum costs compared to the same period in the previous year.

• Savings of 5 hours of GP time per week, due to more efficient way of assessing need for face to face appointments, and the fact that a large number of issues can be dealt with more quickly by a doctor over the phone, therefore averting the need for a proportion of face to face appointments.

o On average every GP has 1,800 patients, and on average every patient needs to be seen 5 times per year = 9,000 appointments. Over 50 weeks = 9,000/50 = 180 per week

o There are 10 sessions in a week, therefore 18 patients per 3 hour session (10 min appointments).

o Each initial call with Doctor First has been averaged by those who have participated in the programme (as reported by Productive Primary Care2) to last approximately 2-3 minutes, say 3 calls in 10 minutes – i.e. 60 minutes to speak to 18 people.

o If even 50% of these people still need to attend the surgery for a face to face, this means 9 patients x 10 mins = 90 minutes

o Total time saved = 180 (total time) – 60 (calls made) – 90 (face to face appts needed) = 30 minutes saved per session

o This equates to 5 hours per week of freed up time for each GP.

5.1.2 Primary Care Foundation

Primary Care Foundation has carried out work in various parts of the United Kingdom with over 700 GP practices. Its support programme is based upon the principles and recommendations contained in the report by Primary Care Foundation entitled ‘Urgent Care – A practical Guide to Transforming Same-Day Care in General Practice’3. This report is supported by the Department of Health, Royal College of General Practitioners, British Medical Association, and General Practitioners Committee.

Primary Care Foundation has already shown that there are potentially significant gains if practices in each area manage urgent care effectively – outcomes include:

• Reductions in A&E attendances

• Reductions in emergency admissions, in some cases estimated to be between 20-40% as a result of good management of urgent care in general practice.

• 20% reduction in use of urgent care centre after working with a group of local practices.

2 http://www.productiveprimarycare.co.uk/.aspx

3

http://www.primarycarefoundation.co.uk/images/PrimaryCareFoundation/Downloading_Reports/Reports_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf

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• Improvement in capability of practices to undertake regular and ongoing capacity planning to ensure their response to urgent care is as effective as possible.

5.2 Other anticipated benefits

The work to be undertaken in the LES is mostly interested in driving a long term change in primary care, creating a GP practice cohort which uses its capacity in a different way which makes systems more efficient, user friendly, safe, and accessible. It is suggested that such transformational change takes a great deal of time to make and then embed as part of normal working, and so it is suggested that for the most part, the first year benefits will be seen more within patient satisfaction, staff satisfaction, and better use of GP / staff time. It is anticipated that more long term benefits, such as those to urgent care attendances will be more visible in years 2 and 3 after the change, but it is hoped that these benefits in acute will start to be seen towards the end of the first year.

In addition to the published benefits outlined above under Section 3.3, other anticipated benefits include:

• Increased patient safety through better identification and response to urgent cases

• Increased patient satisfaction with GP practices.

• Saving of overall administrative staff time due to better ways of working.

• Increased staff satisfaction due to:

• Opportunity for all practice staff to have their say, take part, and feel supported

• Reduction of pressure on staff time by implementation of smarter and more efficient processes

• Happier patients who are therefore less confrontational with front-of-house staff

• Reduced use of in hours A&E/Urgent Care Centre attendances specifically for the categories below, i.e. those patients who can reasonably be dealt with in primary care. This in turn frees up capacity within urgent care centres to deal with those who need to be seen in such a setting.

o HRG6 – Cat 1 investigation/ cat 3-4 treatment o HRG9 – Cat 1 Investigation/cat 1-2 treatment o HRG11 – No investigation/no significant treatment

• Opportunities for practices to work in new ways

• Increased confidence and competence of GPs, nurses, practice managers and support staff to deal with the challenges of access in the future, including collection of access data, reviewing, implementation and monitoring of system changes (more so for Component 2 practices which have gone through full review of their system).

• More people self-managing where appropriate rather than being seen face to face at the practice (due to Dr First initial consultation directing the patient appropriately)

• More people attending pharmacy where appropriate rather than being seen face to face at the practice (due to Dr First initial consultation directing the patient appropriately)

• Supports delivery of the Islington primary care strategy and Islington urgent care strategy.

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• Robust data collection by practices supports the delivery of the new CCG Outcomes Indicator Set 2013/14 released by NHS Commissioning Board around CCGs collecting better data and using it to conduct informed commissioning.

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6 Evaluation of the outcomes and value of the LES

The evaluation will use datasets recorded as part of the LES, together with routinely available datasets to assess the benefits and value of the pilot. Primary measures will be those that are directly amenable to actions under the LES (e.g. in-hours urgent care attendances for less severe categories which could reasonably be dealt with in primary care). It is however useful to set these within a wider context (e.g. overall trends in A&E attendance). The evaluation will therefore draw on the following data sources: EVALUATION OF OUTCOMES AND VALUE OF LES

Data sources

Related Component

Type of data Questions within / detail Relates to benefits What is the anticipated change?

Data recorded for the LES

1 and 2 Patient survey (Baseline vs repeat at month 9)

In Appendix 4 of specification

Increased patient satisfaction Anticipate improvement across some/all questions. Practices are paid for improvement on Question 6: ‘Regardless of the appointment you wanted and received, were you satisfied with the outcome?’

1 and 2 Staff survey (Baseline vs repeat at month 10)

In Appendix 7 of specification

Increased staff satisfaction Anticipate improvement across some/all questions

1 Data submission (Baseline vs repeat at month 10)

In Appendices 2 & 3 Increased ability to meet demand for appointments, qualitative feedback on how Dr First approach went

Anticipate reduction of difference between requested vs successfully- given appointments. Positive feedback given on practice’s assessment of benefits

1 Monthly data submission

In Appendix 5 of specification

Increased ability to meet demand for appointments, Tool with which to monitor monthly trends

Anticipate increasing numbers of people dealt with immediately on phone, and reducing numbers of people needing to be seen face to face

2 Action plan In Appendix 6 of specification

Does not specifically map to a benefit but is a tool for agreeing actions and the method by which to measure delivery of actions – the information does not specifically map to benefits

N/A: This records actions to be completed, but this does not measure change over time We do not expect to see change but we do expect actions to be implemented.

SUS data 1 and 2 Category 1 & 2 *HRG6 (Cat 1 investigation Reduced A&E / Urgent care Anticipate reduction in activity and therefore

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urgent care attendances (in hours)

/ Cat 3-4 treatment) *HRG9 (Cat 1 Investigation / Cat 1-2 treatment) *HRG11 (No investigation / no significant treatment)

attendances, and secondary care cost benefits associated with this

cost of each of these areas against previous year. Anticipate improvement against other benchmarks such as long term trends, similar areas, population subgroup analysis

1 and 2 Emergency Admissions

Overall unscheduled admissions

Reduced emergency admissions, and secondary care cost benefits associated with this

Anticipate reduction in activity and therefore cost of each of these areas against previous year. Anticipate improvement against other benchmarks such as long term trends, similar areas, population subgroup analysis

Other national data

1 and 2 MORI patient survey (Baseline up to March 2013 vs Surveys up to Sep 2013 and up to Mar 2014)

There are many indicators within this but most directly affected indicators are: *Accessing Your GP Services (Q3, Q8, Q9) and *Making An appointment (Qs12-17). *The global outcomes are under Overall Experience (Q28, Q29).

Increased patient satisfaction Anticipate improvement across some/all areas.

Other locally collected data

2 Data collection assisted by Primary Care Foundation (Baseline and repeat at 10 months)

The data collection covers a range of areas including matching capacity to demand via PDSA (Plan, Do, Study, Act) work.

Increased patient satisfaction Anticipate improvement across some/all areas.

1 and 2 Surveys of other related services, e.g. local pharmacies, neighbouring practices

To be determined

Satisfaction of other services Want to ensure that there is no adverse impact on other services as a result of primary care changes to access

1 and 2 Info from further Islington LINk reports

To be determined

Increased patient satisfaction Anticipate more positive comments and less negative comments from patients at those practices who carried out work under this LES

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*Note that all measures will be analysed in view of individual practices, localities, across all of Islington, and also by cross-analysis of those who do not participate at all vs those who sign up to Component 1 vs those who sign up to Component 2. **Outcomes will also, where possible, be benchmarked against national data, or data from similar areas. ***It may be possible to identify whether there are links between the changes in the above indicators through regression analysis – for example, will local analysis show that there has been a link between changes in measures of access or patient satisfaction with changes in A&E/UCC attendances or emergency admissions? This analysis may indicate areas for particular attention for future development. MODELLING OF LOCAL ENHANCED SERVICE COSTS The pilot project offers practices the same payment despite their choice of either Component 1 or 2. Where practices choose Component 2, there will be an extra cost to the CCG, with regards to paying Primary Care Foundation for facilitation of the work.

Costing based on Component 1 or 2 (same payment)

GP Practice List Size

1 Nov 2012

Total payment available per practice

(£3.40 per patient)

St. Johns Way Medical Centre 12313 £41,864

The Amwell Group Practice 7674 £26,092

Clerkenwell Medical Practice 9142 £31,083

Barnsbury Medical Practice 2632 £8,949

The Family Practice 3955 £13,447

Stroud Green Medical Clinic 5266 £17,904

City Road Medical Centre 6696 £22,766

The Medical Centre 4270 £14,518

Elizabeth Ave Group Practice 7122 £24,215

Bingfield Street Practice 2276 £7,738

Ritchie Street Group Practice 12678 £43,105

Goodinge Group Practice 11359 £38,621

Sobell Medical Centre 3320 £11,288

The Beaumont Practice 2524 £8,582

Dartmouth Park Practice 2511 £8,537

Wedmore Gardens Surgery 934 £3,176

The Tufnell Surgery 3187 £10,836

Dr Ko & Partner 4033 £13,712

Archway Medical Centre 5479 £18,629

Islington Central Medical Centre 14861 £50,527

The Village Practice 6437 £21,886

Hanley Primary Care Centre 5777 £19,642

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Mildmay Medical Practice 6375 £21,675

Mitchison Road Surgery 5622 £19,115

The Northern Medical Centre 7672 £26,085

River Place Group Practice 9421 £32,031

Partnership Primary Care Centre 3106 £10,560

Rise Group Practice 5575 £18,955

Pine Street Medical Practice 2524 £8,582

Killick Street Health Centre 9564 £32,518

Roman Way Medical Centre 4600 £15,640

New North Health Centre 1776 £6,038

St.Peter's Street Practice 9858 £33,517

The Miller Practice 9885 £33,609

Highbury Grange Health Centre 8747 £29,740

Andover Medical Centre 5047 £17,160

Holloway Medical Centre 2317 £7,878

Total £770,219

*Note that this estimate is based upon 1 Nov 2013 list size.

COSTS OF ENGAGING PRIMARY CARE FOUNDATION TO SUPPORT PRACTICES**

ACTIVITY DESCRIPTION COST

Activity 1 Receiving data and preparing reports for 37 practices £11,000

Activity 2 Initial workshop and visiting practices to discuss reports £14,000

Activity 3 Additional support if needed to implement change (£900 per day, suggest approx. 3 days support per practice)

£99,000

Activity 4 Repeat of analysis and generation of repeat reports £9,000

TOTAL £133,900

VAT (20%) £26,780

FINAL TOTAL FOR PRIMARY CARE FOUNDATION £160,680

**Note that costs for Primary Care Foundation will be reduced depending on the number of practices that choose Component 2. Costs of Primary Care Foundation facilitation will be paid separately from Pathfinder money.

5.0 Cost Benefits Associated cost benefits which may be realised will be those resulting from reduced acute activity because of a greater ability to access primary care in urgent circumstances (for less severe problems). The reasoning is that the project will result in reduced secondary Urgent Care attendances (in secondary care) in the following categories:

• HRG6 – Cat 1 investigation / Cat 3-4 treatment (£103 per attendance, incl MFF)

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• HRG9 – Cat 1 Investigation / Cat 1-2 treatment (£103 per attendance, incl MFF)

• HRG11 – No investigation/no significant treatment (£66 per attendance, incl MFF) The above categories of patients are those who could reasonably be expected to be dealt with in primary care and therefore those that improved primary care access would have a direct impact upon. We do not expect or wish to see a reduction in appropriate use of Urgent Care / A&E at the hospital (i.e. the more serious categories). Note however that the one year pilot of the enhanced service is primarily aimed at changing the way that GP practices operate, and investing in educating practices about how to assess their systems and tackle access issues in the future. It is envisaged that year one is mainly based on support to practices, with the smaller element of outcomes attached, in order to support the bedding down of new systems. It is hoped that cost benefits (i.e. reductions in acute) would start to be seen towards the end of the pilot year. Robust evaluation of the first year at approximately Month 9 and ongoing to year end will enable re-evaluation of the specification and consideration of how best to invest in a programme for year 2, based upon outcomes achieved (such as reduced acute activity) as a result of these processes, rather than investing in embedding the process itself. It is therefore suggested that, due to a shift in focus of the pilot at year 2, from bedding down process to achieving outcomes, that any discontinuation of the LES should not hugely affect practices and practices should be awarded for achieving high standards with the reduction in A&E attendances and UCC especially during GP opening hours

6.0 Risks

These are the project level risks.

Risk Mitigation

That only a small number of practices take up the local enhanced service, therefore reducing possibility of improving overall GP access across the borough

Good marketing of the enhanced service

Strong support from primary care commissioning team where necessary to assist, including contact by primary integrated care officers for each locality.

That practices who do sign up do not follow process e.g. strict daily data recording

Importance of process to be highlighted to practices, including support and clarification to practices where needed.

Failure to complete process properly may result in deduction of payment

That practices do not make full effort to engage in the process once signed up

Importance of process to be highlighted to practices – requirement for regular reporting helps to ensure practices are completing daily process for Doctor First.

Primary Care Foundation will be following up practices closely and supportively to achieve the aims in Component 2

That the scheme is not able to be analysed effectively

Strong process for data collection by practices is in place, supported by payment mechanism upon completion of process

MORI GP patient survey results and SUS data is in place to

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measure specific measureable outcomes

Baseline and repeat data has been specified

That the scheme does not reduce A&E attendances

Ensure that practices promote the changes to their systems and increased capacity as robustly as possible, to increase likelihood that patients will ring their practice before attending A&E.

That the scheme does not show any other benefits

This is unlikely, but extent of outcomes is to be determined. The money will be coming from Primary Care Investment money, which is a one-off pot and must be spent. Scope for extension of the LES will be determined upon strict analysis of outcomes

A register of problems raised (along with discussion and outcome) will be kept and this will feed into an end of service review, which may include planning for extension of the LES, or adjustment for further delivery.

7.0 Reporting and Governance

This proposal was developed by the Primary Care Commissioning team, in light of many different programmes being undertaken across England to improve primary care access. An options appraisal for improving access was presented to the ICCG Primary Care Development Group in November 2012, and the group provided feedback in order to develop this business case and the associated LES specification.

The primary care commissioning team will be continually monitoring the project as it proceeds, and undertake a full review at the end of the project, assessing problems, outcomes, whether the LES realised any of the identified benefits. It will be reported to the Primary Care Development Group at the end of the project’s term, taking into account time it takes for data collection and analysis (including delay of SUS data and MORI poll results).

The project will be reported using the key performance indicators outlined in the specification.

• Patients/carers views A patient / lay member now sits on the Primary Care Development Group, and there are lay members who sit on the Board which will have final approval of the Local Enhanced Service. Additionally, note that the GP patient survey forms a key indicator in Component 3 (outcomes assessment) and that this information on each practice is a direct result of patient feedback on access and patient experience of GP services. It is anticipated that through the changes directed by the work under this LES , there will be an improvement in patient experience of GP services.

Key Performance Indicators (KPIs) for GP practices:

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The Performance Measure Method i.e. Monitor, Audit or Portfolio

Frequency Responsibility of

Component 1 practices:

Recorded number of patients dealt with directly over the phone, i.e. averted from face to face appointment which takes approximately 3x longer

Audit Monthly Component 1 Practices

Component 2 practices:

Improved scores in data collection for Component 2 practices

Repeat data collection

Initial vs repeat data collection

Data collection by Component 2 practices, analysis / report by Primary Care Foundation

All practices:

Improved patient experience as measured by local patient survey

Audit

Baseline (Mar 2013) vs repeat survey (Jan 2013)

All practices

Improved scores in MORI patient survey around

• wanted vs received same day appointment

• people who instead ‘went to A&E / walk in centre’

• overall experience in GP surgery

Monitor MORI scores

At start (Dec 2012) and end of service (Jul 2013)

ICCG

Reduced ratio of in-hours attendances vs practice list size per year / specific categories of Urgent care attendances

Monitor SUS data

Average of Oct 2011 to Sep 2012 vs

Average of Apr 2013–end Mar 2014

ICCG

Reduced monthly average of overall A&E attendances

Monitor SUS data

Average of Oct 2011 to Sep 2012 vs

Average of Apr 2013–end Mar 2014

ICCG

Reduced rate of onward referral from A&E to day cases / zero length of stay cases

Monitor SUS data

Average of Oct 2011 to Sep 2012 vs

Average of Apr 2013–end Mar 2014

ICCG

Reduced rate of admissions from A&E

Monitor SUS data

Average of Oct 2011 to Sep 2012 vs

Average of Apr 2013–end Mar 2014

ICCG

Reduced rate of onward referral from A&E to outpatients

Monitor SUS data

Average of Oct 2011 to Sep 2012 vs

Average of Apr 2013–

ICCG

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end Mar 2014

• Communications:

Information about the LES will be sent out to all GP practices via email and the weekly GP bulletin, as soon as possible after approval.

8.0 Next Steps

• Equality Impact Assessment

• Business case and specification approval as per ICCG governance procedures • Audit and action plan templates to be finalised

• Communication to practices / launch

9.0 Delivery of the Project

Date Event / milestone for

Doctor First practices

Event / milestone for

Primary Care Foundation practices

28 Feb 2013 Final date for sign up to LES Final date for sign up to LES

2nd

– 3rd

wk Mar 2013

Send out baseline patient survey Send out baseline patient survey

31 Mar 2013 Due date for initial data submission

31 Mar 2013 50% upfront payment for Component 1 50% upfront payment for Component 2

1 Apr 2013 Enhanced service launched Enhanced service launched

1st / 2

nd week

Apr Initial workshop with Primary Care

Foundation

3rd

/ 4th / 5

th

week Apr Practice completes one week of data

collection

Practice schedules follow up meeting with PCF in May 2013

10 May 2013 Apr monthly data due Practices receive report from Primary Care Foundation based on data submitted

10 May – end May 2013

Follow up meeting with each practice to discuss report

31 May 2013 Action plan due

10 Jun 2013 May monthly data due

1 Jun – end Jun 2013

All practices to have implemented agreed changes by end June and continue to work in new way. Implementation supported by PCF

10 Jul 2013 Jun monthly data due

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10 Aug 2013 Jul monthly data due

10 Sep 2013 Aug monthly data due

10 Oct 2013 Sep monthly data due

10 Nov 2013 Oct monthly data due

Dec 2013 ICCG to collect MORI data (to Mar 2014)

ICCG to collect in-hours SUS data (Urgent Care HRGs 6, 9, and 11) and emergency admissions for Apr 2013 – Mar 2014

ICCG to collect MORI data (to Mar 2014)

ICCG to collect in-hours SUS data (Urgent Care HRGs 6, 9, and 11) and emergency admissions for Apr 2013 – Mar 2014

Dec 2013 ICCG review of all data to date in light of continuation or discontinuation of LES

ICCG review of all data to date in light of continuation or discontinuation of LES

10 Dec 2013 Nov monthly data due

Jan 2014 Practice to conduct repeat patient survey

Practice to conduct repeat patient survey

10 Jan 2014 Dec monthly data due

Feb 2014 Repeat staff survey due Repeat staff survey due

Feb 2014 Repeat data submission due

10 Feb 2014 Jan monthly data due

10 Mar 2014 Feb monthly data due

2nd

-3rd

week Mar 2014

Practices to complete one week of repeat data collection

31 Mar 2014 End of LES (practices to ensure successful systems of working are continued)

End of LES (practices to ensure successful systems of working are continued)

10 Apr 2014 Mar monthly data due

Jun-Jul 2014 Final collection of outcome achievements upon receipt of SUS data, and final payment to practices

Final collection of outcome achievements upon receipt of SUS data, and final payment to practices

Supporting links and documents

• ‘Improving Urgent Care: The beast of many heads’, Health Services Journal, 24th November 2011

• ‘Urgent care – a practical guide for transforming same day care in general practice’, Primary Care Foundation, 2009: http://www.primarycarefoundation.co.uk/images/PrimaryCareFoundation/Downloading_Reports/Reports_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf

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Appendix 1

Primary Care Foundation – Initial Proposal for

Islington CCG

managing access and urgent care in general practice

The proposal is in three parts:

1. The first part of this proposal outlines our approach, describing the web based tool in a bit more detail, the data we collect, how we report, the work involved for practices, potential benefits and what results show so far.

2. The second describes in practical terms the support we might offer.

3. Finally, the Appendix provides more information about the Primary Care Foundation and who we are.

1. Our approach

A. Developing the tool and what it does

We have been working with increasing numbers of sites and more than 600 practices across England to develop and refine a web based tool that can analyse practice data, compare key indicators, offer practical suggestions for improving care in the practice and a learning tool for reception teams. We have now reached the point where the tool is developed. A practice enters data covering a week in the practice and a largely automated report is produced. As more practices take part, practices will also be able to benchmark their own system and process against other local practices as well as those from further afield. The process is improved by a follow up session in the practice and the opportunity to access on-going advice and support. The eventual aim is to automate reporting to the point where it is simple for the practice manager to submit date for regular reporting to monitor progress in improving access and care.

B. What information do we collect?

There are basically three different types of information collected through the survey.

1. How you work in your practice. The first section of the survey has 14 multiple choice questions providing an important description of the practice that, combined with other data, helps us suggest areas that the practice may be able to address to improve the way they manage access and urgent care. They explore both how you manage your practice and your philosophy of care.

2. Data for a sample week. The second part covers ‘Opening Hours’, ‘Telephony’, ‘Walk In Appointments’, ‘Consultations’ and ‘Additional Information’. These each require the practice to enter data about one week that they select as a reasonably normal week for the practice.

3. The Reception Quiz. This third part designed as a support tool for everyone who carries out reception duties in the practice, either taking calls or speaking to patients who walk in to the surgery. It looks at levels of confidence to manage urgent cases before asking how they would deal with 13 different scenarios of patients presenting with potentially urgent problems. This is not a clinical quiz but it does check on whether there is a consistent response. The quiz is intended to be the basis for a follow up session in the practice for reception staff, preferably with the practice manager and a GP.

We also import the most recent results from the General Practice Patient Survey so that we can include the patient perception of the practice and triangulate this against the other information we collect.

C. How do we report results and make suggestions for improvement?

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The tool allows us to prepare a report for practices analysing practice performance on a number of key factors for managing access and urgent care, including ease of access by phone, consultation rate, patient experience, balance of same day and book ahead appointments, use of telephone consultations, home visits, workload by staff group, and variation in response by reception team. Practices will also be able to compare themselves with others that are similar to them in terms of a number of possible explanatory factors both locally and nationally. Finally, we offer suggestions for how the practice might look to make improvements.

D. How much work is involved for the practice?

We have made the whole process of collecting data much simpler through designing an easy to use web based system. Most of the general information can be provided by the practice manager or one of their team. The data collected during the week you select requires the reception team to record all calls, or people walking in, requesting appointments, by hour, for Monday to Friday of the week. You also need to record all consultations but this can be done retrospectively by looking at the appointments system on the computer. The reception team also need to complete an on line quiz, that takes about 10 minutes per person. Finally, we need a quick audit of how long calls take, so we can have a figure for average call length in the practice.

Overall, this is likely to be perhaps 4 hours for the practice manager plus some extra work, mainly for the reception team, during the week that you are collecting data. We send through simple instruction that make all of this clear, including examples of how you might want to collect data, although most people find that the website explains everything you need to know.

E. The benefits for General Practice

• Patient safety. There are obvious safety benefits if patients can get through to the practice by phone quickly, if receptionists are alert and trained to spot the signs of urgency and if the practice is able to respond quickly as necessary.

• Opportunities to work in new ways. We described in the 2009 report on urgent care in general practice a number of examples including one where small and single-handed practices had jointly commissioned a home-visiting service that ensured that patients could be seen promptly when previously too many of these cases would have resulted in an emergency response.

• Working smarter not harder. We have found that many practices struggling to keep up are offering a higher than expected level of consultations – the solution is often to find ways of treating patients first time rather than offering repeat consultations.

• Same number of appointments, scheduled in a better way. Other practices are faced with increasing numbers of ‘extras’ at the end of the day. By rescheduling capacity and using it in different ways, patients can be seen when they want in a way that is planned and makes life easier for doctors, nurses and the reception team.

F. What do results show so far?

Results so far suggest that practices are far more likely to change if reports are based on their own data with practical suggestions for how to make improvements. There are potentially significant gains if practices in each area manage urgent care effectively as we have seen reductions in acute admissions in some cases that are estimated as between 20 and 40% as a result of good management of urgent care in general practice. Although this benefit will not be achievable in every case the aim of the work is to fill the gap in capability of practices to undertake regular and ongoing capacity planning to ensure their response to urgent care is as effective as possible. More recently, we have seen a 20% reduction in use of an Urgent Care Centre after working with a group of local practices.

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There is also other recent research supporting our approach. A recent review by the Kings Fund (December 2010) identified continuity of care in general practice as a significant factor in reducing emergency admissions. A study published in June 2011 found a link between continuity of care with a particular GP and lower emergency admission rates, while a related study found that lower satisfaction with practice telephone access is associated with higher emergency department attendance rates. For more information on this please go to our website at http://www.primarycarefoundation.co.uk/evidence-making-a-differeence.html

Finally, a recent independent review of our work appeared in the Health Service Journal on 24th November 2011, again it can be downloaded at http://www.primarycarefoundation.co.uk/downloads.html

2. How we could work with you

We are happy to adapt this proposal to reflect your local needs, but as a starting point, we propose eight stages in working with your practices:

1. CCG to recruit practices from each locality across Islington – we have assumed two possible scenarios in which all practices participate or where 60% take part.

2. Initial workshop aimed primarily at practice managers (other staff in the practice are also welcome) to discuss all aspects of access and the management of same day urgent care. We also explain exactly what information we need and how to enter data onto the website. If there are practices that want to hear more about the process before taking part this is a good opportunity for them to understand more.

3. Practices prepare information and submits data on to the web based tool. We normally expect practices to choose a suitable week from a three or four week period.

4. Data is analysed and a report is prepared based on information about the practices processes and hard data, all collected via the web site as well as recent results from the GP Patient Survey. The primary focus in on the practice itself, whether there are sufficient telephone line and appointments to meet demand and suggestions for making improvements. There will also be comparisons with other practices across the cluster and with practices from other sites across the Country.

5. Individual review meetings with practices to discuss the report and what this means for the practice and explore any potential changes. We would encourage your ‘network champions’ to join us for as many as possible of the review meetings with practices in their localities.

6. Follow up workshop with the practices to review overall results, share learning and tackle problems that are common across a number of practices.

7. A review with the senior team across Islington CCG to look at the overall findings across the practices, how they compare with others across the country and to agree where additional support will be valuable to the practices. .

8. Implement further support as required - we have provided some estimate of possible scenarios - be believe that the attraction of this approach is that the CCG can decide how to get 'the best bang for the buck'

Timescales

Indicatively, based on starting in January as was initially mentioned, we could:

• CCG to recruit practices during early January

• Schedule the initial 2-hour introductory workshops for practices across the four localities in mid January.

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• Practices encouraged to collect data for a suitable week, with normal levels of staffing, by mid-February.

• Practices receive back a report based on the data they have submitted, including suggestions for improving the management of access and urgent care by end of February.

• Follow up meetings in all practices by end of March.

• Follow up workshop in early April

• Review meeting with senior team also in early April

• Follow-up work with practices as required in May and June

• Repeat of data collection and new reports to be prepared - at a time that the practices choose from 6 to 9 months later - say to be completed by the end of the financial year 2013/2014.

Costs & other resource issues

We would need support from Islington CCG to brief and recruit practices, set up the workshop and venue and help organise any follow up events.

• The cost for preparing reports for the 37 practices would be £11,000 (or £6600 for 22 practices).

• The cost for the introductory workshop and to meet with 37 practices to discuss reports and look at potential improvements, and a follow up workshop would be a further £14,000 (based on 3-4 visits a day). For 22 practices it would be £9000.

• In addition, if you then would be looking for any further support it would be available at a reduced day rate of £900 a day. Assuming that we were providing support to approximately half of the practices and visiting each one two or three times for half a day it might be advisable to budget £20,000.

• Note that there are alternative approaches if practices are prepared to work in small groups and to be open about the issues that they face and willing to share data. This might allow two practices to 'buddy up' or for practices within a locality that needed support to meet jointly for working days during which they could learn from each other as well as work jointly in specific tasks.

• Finally we would be happy to repeat the analysis for practices six to nine months later for the sum of £9000 (or £6000 if the smaller number)

We would be happy to discuss which aspects of the above menu are of most interest and to work with you to agree how we can deliver cost-effective support to your practices. This might include working with local practice support staff who can provide support with the agreed changes.

For a project of this length we would be looking for 35% of the cost at the beginning of the project, with the rest (including expenses) billed monthly in line with the work done.

Activity 37 practices 22 practices

Preparing reports for the practices £11,000 6,600

Initial workshop and visiting practices to discuss reports £14,000 £9,000

Additional support if needed (£900 a day) Say£20,000 Say £12,400-

Repeat of analysis and generation of reports £9,000 £6,000

Total (excluding expenses capped at 15% of the total and VAT)

£54,000 £ 34,000

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We are conscious of the needs to control costs throughout the NHS and look forward to discuss how we can adapt this proposal to best meet your needs and then provide a fixed cost for the plan of work that we agree.

I look forward to hearing from you

Best wishes

Henry Clay

Director, Primary Care Foundation

07775 696360

Appendix 1a - the Primary Care Foundation

The Primary Care Foundation was set up with the explicit aim of ‘developing and spreading best practice in unscheduled, emergency and primary care in the UK’. We do this by:

• Using information to create understanding that drives improvements in care

• Seeking to reduce unnecessary variation, both across organisations and between individual clinicians

• Developing practical tools that can be widely applied across the urgent care system

• Applying our understanding of national policy in urgent care to support local changes

We are interested in all aspects of urgent and primary care, from general practice through to A&E and hospital care. This includes working with all partners of the urgent healthcare system, either separately or together, to make improvements in patient care. We specialise in carrying out reviews, based on analysing a range of data sources and examining local practice, that make local and national recommendations. We also look for opportunities to share learning, building resources that can solve problems more widely across the NHS. This includes benchmarking performance across urgent care as a key tool for driving service improvement. We are also interested in exploring and understanding international comparisons in urgent care.

Most of our work is carried out by the three directors about whom further detail is included below, but we do bring in associates with specific skills and experience when required.

Dr David Carson

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David was a GP for 10 years before spending 6 years in an inner London Health Authority leading primary care policy and performance. Whilst there he led a service and strategy review of primary and acute services resulting in the delivery of £13M of savings, much of it through de-commissioning services and commissioning a rather different range of services. He also developed and implemented performance management systems for general practice in East London and led an educational project within which joint training and development structures for doctors and nurses were developed compliant with multi-professional regulatory frameworks.

David spent 4 years developing GP Out of Hours services and emergency care policy and performance for the Department of Health. During this time he published – 'Raising Standards for Patients: New Partnerships in Out-of-Hours Care' (known as the ‘Carson Report). David was also the primary care lead on the development of ‘Reforming Emergency Care’.

The ‘Carson Report’, for which David is probably best known, defined the way ahead and set the standard - embodying integrated services and co-operative staff working as core principles as well as introducing new thinking and new approaches to unscheduled care into the Healthcare community. He was also part of a performance team from the Department that looked at well over 50 NHS Trusts looking at how they operated within their local health economies.

More recently David has also acted as an adviser to the National Audit Office, the Healthcare Commission and the Care Quality Commission in a number of high profile reviews that these bodies have carried out. He has also looked at other health economies including those in Australia (primary care), Italy (accreditation) and Scandinavia and Holland (urgent primary care).

Rick Stern

Rick was the Chief Executive of Bexhill & Rother PCT until the end of July 2005 where he led a national pilot to develop out-of-hours services and was the lead Chief Executive for the South East within NatPaCT, the national PCT development programme. It was the only PCT in the South East to receive a 3-star award when the new ratings were introduced in 2003 and it consistently featured in the top 10 PCTs in the annual staff survey.

Rick is also the Chief Executive of the NHS Alliance and was up until April 2012 its urgent care lead. He currently serves as a member of the Department of Health’s governing board for urgent and emergency care.

Rick has worked across a range of sectors and in a variety of roles, including general management, internal consultancy, research and face-to-face with vulnerable clients. He led Access to Health, a Kings Fund initiative in the early 90’s to improve health care for homeless people, was responsible for developing quality standards in a mental health and community trust in Inner London and for developing commissioning within a regional health authority. He is also a practicing psychodynamic counsellor.

Henry Clay

After a background in manufacturing organisations including roles as operational manager, accountant and general manager, Henry has spent some 20 years as a consultant to organisations in both the private and public sector. Much of this work has involved the specification and commissioning of a range of public sector services from benefits, through support services including (for the NAO) a review of the way in which IT services were outsourced by the Inland Revenue to primary and secondary healthcare services.

Henry has advised the Care Quality Commission and the Healthcare Commission not

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just on their investigations into specific cases (such as the investigation into Take Care Now) but also in their wider evaluations of value for money (such as the report 'Not just a matter of time' into GP out of hours services). A particular interest is in making sure that the data collected through systems is useable and used to support improvement of the service.

Work within the acute healthcare sector has involved him in A&E, Urgent Care services of all types, Diagnostics and Pathology, IT systems , Imaging, Medical assessment as well as in Health Insurance. In Primary Care, Henry has worked with many Out of Hours providers, particularly in benchmarking their performance and looked at the operation of numerous general practices, Walk in Centres and Minor Injury Units. He has also worked with Practice Based Commissioning groups looking to specify services, groups of GPs forming provider service organisations and in looking at mutual and social enterprise models of provider.

Simon Lawrence

Simon has worked with primary care providers for the majority of his NHS career and was the Director of Primary Care at Bexhill and Rother PCT from 2003. He led many improvements and initiatives to support and strengthen service provision including performance management, service development, commissioning and contract management. He also worked with the Commission for Health Improvement (CHI) as part of a team that undertook clinical governance reviews of health providers including hospitals and primary care trusts.

Simon was appointed the Director of Business Development at South East Health Ltd in 2007 and contributed to their corporate governance arrangements for GP primary care out of hours services. He led a number of successful initiatives for new business including GP led health centres, pharmacies, urgent and GP out of hours care services. During 2009 he worked with the Primary Care Foundation to support their review of urgent care centres on behalf of the Department of Health.

Since July 2010, Simon has worked independently and has offered consultancy services to a number of organisations. These include the NHS Emergency Care Intensive Support Team, Brighton & Hove Integrated Care Service (leading urgent care improvements in general practice to help reduce non-elective admissions to hospital) and most recently working with NHS Brighton & Hove, where he undertook a whole system review and service re-design for urgent mental health care, working with the clinical commissioning group, mental health trust, acute hospital and ambulance service. He has worked closely with us on the development of the tool

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Local Enhanced Service Specification for Improved Access

Pilot project

1 April 2013 – 31 March 2014

Between Islington Clinical Commissioning Group (ICCG) and Islington GP practices

This is a 12 month pilot to support practices to improve access to primary care

Overview

This Improved Access Local Enhanced Service (LES) pilot project aims to improve access to GP practices by offering practices a choice between 2 options:

a) Option A: Implement a specific programme (Doctor First approach) within your practice, or

b) Option B: Receive dedicated support to undertake a structured review of your current systems and problems, and be supported to implement bespoke changes to your system.

Practices are asked for expressions of interest, and those who wish to participate will need choose one of the above options, after careful consideration of this specification, your own registered population and demographics, challenges facing the practice, and perceived needs.

The pilot is offered as a chance to measure the impact of structured programmes which have shown good outcomes from implementation in other locations, within our local population. It provides the opportunity for driving long-term, transformational change within primary care, and it is hoped that outcomes will benefit patients, practice staff, practice systems, and have a resulting impact on reducing acute activity.

Through evaluation and assessing the impact of this work upon various facets of the practice and wider system, the potential of a future local enhanced service for practices will be based upon achievement of outcomes rather than process. Evaluation and scoping of the future enhanced service will be carried out through close working with LMC.

1. Introduction and Background

1.1 Access and national priorities

Primary Care is under continual pressure to improve and maintain good access to their services, particularly within general practice. There are significant challenges: growing patient expectations of services, an ageing population, local strategic work around case finding long term conditions (LTCs), greater investment of clinical time in managing patients with long term conditions, and in clinical commissioning.

Improving access has long been a national priority, with the Department of Health previously implementing a range of methods to incentivise better access-related performance – such as Quality and Outcomes Framework (QOF) markers rewarding GP practices for offering routine appointments within 48 hours and ability to book further ahead (PE7 and PE8) (removed from QOF from 1 April 2011); Extended Hours Directed Enhanced Service (paying practices for opening at times other than core GMS hours), and the Patient Experience DES. The Department of Health has, for a number of years, also commissioned Ipsos MORI to run a national patient survey. This data has long been used to inform primary care contracting teams (as access has an effect on the provision of core services which are reasonably necessary for their patients), and is now being reviewed widely by CCGs, in an effort to inform benchmarking and what levels of support practices might need to improve.

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1.2 Local strategy and current access

Locally, improving access to primary care (including to GP practices) is a key outcome of Islington CCG’s primary care and urgent care strategies. Unfortunately, a number of things have been tried before, and there is evidence for some different programmes, implemented in other locations.

If this project were to be successful it would

• Improve access to primary care (Primary care and Urgent care strategy)

• Improve patient experience (Primary care strategy)

• Improve ability to access own GP practice urgently where necessary and appropriate

(Urgent care strategy)

The responsiveness of local services is crucial for meeting the primary health needs of patients and also for avoiding a greater effect on the rest of the healthcare system, especially urgent care / A&E departments, where patients who are unable to access their GP surgeries look towards hospital to provide that care instead1

.

Islington has its own specific challenges which place a greater demand on practices – we have a mobile population and a great deal of deprivation, unmet need, challenges presented by a wide variety of languages spoken and ethnicities. The case for change / drive to improve access can be gauged through a number of sources:

1.2.1 GP patient survey, run by Ipsos MORI

The national MORI patient survey has been running for seven years, and is sent to a number of randomly chosen registered patients from each GP practice, who answer questions about patient access and experience.

Results collated over 2006-07 to 2009-10 show that results on access markers were declining across most questions, locally, London-wide, and nationally. The table below demonstrates the general decline in scores over a 4 year period for 5 key markers, including getting an urgent appointment (within 48 hours).

MORI GP patient survey results between 2006-07 and 2009-10

Satisfied with phone access (%)

Able to get an appointment within 48

hours (%)

Able to book 2+ days ahead (%)

Able to book appointment with specific GP (%)

Satisfied with opening hours (%)

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

06

-07

20

07

-08

20

08

-09

20

09

-10

England

average 86 86 75 88 84 82 82 79 88 76 71 77 76 69 87 83 80 87 70 65

London Average

83 81 74 84 80 78 78 76 88 71 66 76 71 68 83 79 76 84 67 62

Islington average

86 78 75 85 81 77 77 75 84 70 65 73 75 67 80 78 74 85 67 63

Islington generally performs lower than the England average, and interchangeably against the London average (slightly above and below across questions). This is true across the full range of questions asked, not just in the sample above. Unfortunately changes to questionnaire design and survey frequency in 2011-12 mean that results from 2011-12 onwards cannot be compared with previous years, even where questions remain the same.

1 Sean Boyle, John Appleby, Anthony Harrison, ‘A rapid view of access to care’, Kings Fund (2010)

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However a full set of the most recent results for Islington for the period Jan 2012 – Sep 2012 is available at Appendix 9.

Results do show that access, or at least patient perception of access, is declining and requires attention.

1.2.2 Additional Patient feedback

Apart from the national survey run twice yearly, patient feedback is received via many other channels, such as through Islington’s PALS and Complaints department, patient participation groups, direct feedback to practices, NHS Choices, and reports from Islington LINk. The feedback we collate continually raises GP access as an issue. This is quite difficult to quantify and cannot be analysed further in terms of at practice or locality level.

1.2.3 A&E Attendances

In addition to patient feedback, it also transpires that emergency admissions and A&E attendances in Islington continue to rise unsustainably, driven by self-referrals to A&E. It follows that a lack of capacity within primary care is a contributing factor, with patients attending hospital when their GP practice is not available as the first option. A general unsustainable rise in acute activity drives our aim to deliver more services at cheaper cost in the community, which then means that even greater pressure will be placed on our primary care providers to meet growing demand.

1.2.4 Demand is increasing

Islington GPs are challenged by the following:

• The population is ageing

• Patients’ expectations of services are increasing

• An increase in case finding locally, especially through the new Closing the Prevalence Gap LES which will identify more new patients with conditions requiring management

• Local strategies require better management of patients with long term conditions which put a strain on the normal 10 minute appointment system

As demand increases, managing it well becomes more and more important so that practices can cope and still provide responsive, high quality patient care. It must however be noted that there are other initiatives afoot which, in time, aim to reduce the demand on practices, such as empowering patients to self-manage where possible (and therefore requiring health professionals less).

1.3 Summary of the Components

This project requires practices to choose one out of two components:

1. Implement Doctor First approach within the practice; OR

2. Participate in a programme run by external providers Primary Care Foundation, who work with the practice over a period of time to:

a. provide a framework for collecting specific measurable access data

b. produce a data report which highlights problems, provides benchmarking against other practices, and suggest actions which might result in improvement

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c. support the practice to implement agreed actions

d. support the practice to measure the resulting change

Any Islington GP practice may sign up to the LES. However note that all practices must choose to undertake either Component 1 (Doctor First programme) or Component 2 (Primary Care Foundation programme). Both components are primarily aimed at improving same day / urgent access, so practices must choose one option or the other.

This pilot will run for 1 year, i.e. between 1 April 2013 and 31 March 2014. Component 1 practices will be expected to deliver Doctor First for the full year of the LES. Component 2 practices will be expected to work with Primary Care Foundation to agree and implement actions, and deliver those changes until 31 March 2014.

Robust evaluation of both options will be undertaken towards the end of the project and this will inform further work in this area – whether that be wider roll out of these options across Islington, or undertaking of a different approach to improving access. Note that future years will be based more upon outcomes rather than process.

2. Aims

The overarching aim of this project is to improve urgent (same day) access to primary care (GP services) for patients, which should also improve overall patient experience of GP services.

Full set of aims / benefits expected from the LES are:

• Improved access to GP practice same-day appointments, freeing up space in the rest of the GP system

• Increased patient safety through better identification and response to urgent cases

• Opportunities for practices to work in new ways

• Reduction of certain in-hours Urgent Care attendances due to greater access to same-day GP appointments (see Appendix 8 for baseline information)

• Increased practice staff satisfaction through:

• Opportunity for all practice staff to have their say, take part, and feel supported

• Reduction of pressure on staff time by implementation of smarter and more efficient processes

• Happier patients who are less likely to be confrontational with front-of-house staff

• Reduced DNAs in general practice

• Reduced GP referrals to A&E / Urgent Care Centres

• Increased confidence and competence of GPs, nurses, practice managers and support staff to deal with the challenges of access in the future, including collection of access data, reviewing, implementation and monitoring of system changes.

• Supports delivery of the Islington primary care strategy and Islington urgent care strategy.

The success of the LES will be monitored via robust evaluation, details of which are in the table below.

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EVALUATION OF OUTCOMES AND VALUE OF LES Data sources

Related Component

Type of data Questions within / detail Relates to benefits What is the anticipated change?

Data recorded for the LES

1 and 2 Patient survey (Baseline vs repeat at month 9)

In Appendix 4 of specification

Increased patient satisfaction

Anticipate improvement across some/all questions. Practices are paid for improvement on Question 6: ‘Regardless of the appointment you wanted and received, were you satisfied with the outcome?’

1 and 2 Staff survey (Baseline vs repeat at month 10)

In Appendix 7 of specification Increased staff satisfaction

Anticipate improvement across some/all questions

1 Data submission (Baseline vs repeat at month 10)

In Appendices 2 & 3 Increased ability to meet demand for appointments, qualitative feedback on how Dr First approach went

Anticipate reduction of difference between requested vs successfully- given appointments. Positive feedback given on practice’s assessment of benefits

1 Monthly data submission

In Appendix 5 of specification Increased ability to meet demand for appointments, Tool with which to monitor monthly trends

Anticipate increasing numbers of people dealt with immediately on phone, and reducing numbers of people needing to be seen face to face

2 Action plan In Appendix 6 of specification Does not specifically map to a benefit but is a tool for agreeing actions and the method by which to measure delivery of actions – the information does not specifically map to benefits

N/A: This records actions to be completed, but this does not measure change over time We do not expect to see change but we do expect actions to be implemented.

SUS data 1 and 2 3 specific areas of in-hours Urgent Care Attendances

*HRG6 (Cat 1 investigation / Cat 3-4 treatment) *HRG9 (Cat 1 Investigation / Cat 1-2 treatment) *HRG11 (No investigation / no significant treatment)

Reduced A&E / Urgent care attendances, and secondary care cost benefits associated with this

Anticipate reduction in activity and therefore cost of each of these areas against previous year. Anticipate improvement against other benchmarks such as long term trends, similar areas, population

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(see Appendix 8 for baseline) subgroup analysis 1 and 2 Emergency

Admissions Overall unscheduled admissions

Reduced emergency admissions, and secondary care cost benefits associated with this

Anticipate reduction in activity and therefore cost of each of these areas against previous year. Anticipate improvement against other benchmarks such as long term trends, similar areas, population subgroup analysis

Other national data

1 and 2 MORI patient survey (Baseline up to March 2013 vs Surveys up to Sep 2013 and up to Mar 2014)

There are many indicators within this but most directly affected indicators are: *Accessing Your GP Services (Q3, Q8, Q9) and *Making An appointment (Qs12-17). *The global outcomes are under Overall Experience (Q28, Q29).

Increased patient satisfaction

Anticipate improvement across some/all areas.

Other locally collected data

2 Data collection assisted by Primary Care Foundation (Baseline and repeat at 10 mths)

The data collection covers a range of areas including matching capacity to demand via PDSA (Plan, Do, Study, Act) work.

Increased patient satisfaction

Anticipate improvement across some/all areas.

1 and 2 Surveys of other related services, e.g. local pharmacies, neighbouring practices

To be determined

Satisfaction of other services

Want to ensure that there is no adverse impact on other services as a result of primary care changes to access

1 and 2 Info from further Islington LINk reports

To be determined

Increased patient satisfaction

Anticipate more positive comments and less negative comments from patients at those practices who carried out work under this LES

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3. Eligibility and exclusions

All Islington GP practices are eligible to sign up to this project.

4. Service Specification

4.1 Component 1 – Doctor First Approach

4.1.1 Background

The ‘Dr First’ approach suggests that appointment systems and patients benefit from being able to speak to a Doctor prior to booking an appointment. This system of ensuring that every patient who wants a face to face appointment speaks to a ‘Doctor First’ allows the practice to:

a) Achieve a service which deals with the most ill people first;

b) Filter out patients who don’t actually need to be seen, as they can be reassured that they actually do not need to be seen, or can be dealt with there and then on the phone (thereby reducing the number of inappropriate appointments and freeing up space in the system for those who need it);

c) Where patients do need appointments, give them appointment lengths which more closely match their need

d) Provide early reassurance and improve patient experience.

e) Reduce stress on doctors, staff and appointment systems.

The premise of the programme is that the appointment system is freed up for patients who actually need to be seen, demand is reduced and overrunning clinics are less likely, and overall individual service for each patient is improved. This system ‘puts the two people who need to talk to one another together in the shortest possible time’.

4.1.2 Previous delivery

The ‘Doctor First’ LES was offered across all 5 boroughs in NHS North Central London in January 2012. The LES ‘pump primed’ practices by providing backfill to increase the number of extra appointments delivered in the practice, to a ratio determined by practice list size. Unfortunately, due to funding, the LES was only delivered for one month (March 2012) and the anticipated impact on A&E attendances was not evident from such a short period.

The loose guidelines of the one month pilot and rapid implementation allowed a shying away from the true spirit and specification of a doctor first strategy, backfilling extra capacity rather than changing the way that appointments were delivered. However the programme, when delivered in its true form, has proved beneficial in other parts of England such as Milton Keynes, showing that practices who conduct more initial telephone assessments can manage the same amount of demand for appointments in a shorter space of time, improving patient satisfaction levels and reducing patient demand for A&E services, where their presenting complaint could be safely and appropriately managed by their practice.

Islington CCG is keen to test this for a 1 year period in order to properly evaluate outcomes and any associated benefits from this way of working.

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4.1.3 Aim

To give practices the chance to pilot the implementation of the ‘Doctor First’ strategy within practice. However practices are asked to seriously consider their practice population, specifically with regards to proportions of non-English speaking patients, and whether this may create too much of a barrier for a large majority of your patients. If you have a large population of non-english speakers for whom initial phone triage will not be suitable, then the system will be undermined by these exceptions and benefit is less likely to be obtained. (This may not be the case if the clinician performing the Dr First assessment is multi-lingual).

4.1.4 Process

Practices are required to implement the Doctor First approach within their practice between 1 April 2013 and 31 March 2014:

a) Prior to implementing Doctor First for 1 year, the practice must complete an initial data submission (Appendix 2) which includes summary of data collected for 1 week in March 2013.

b) Prior to implementing Doctor First for 1 year, the practice must send out a baseline patient survey (see Appendix 4) in March 2013. Guidelines:

o Must be sent out to at least 5% of the practice population

o The target population must have been seen by the practice within the last 6 months

NB: The CCG estimates, based on MORI poll response rate, that approximately 30% of patients who receive the survey will respond.

The practice is to submit a summary of the survey results, as well as a copy of all surveys received (template to be provided).

c) Prior to implementing Doctor First for 1 year, the practice must have all staff within the practice complete a short staff survey (Appendix 7). The practice is to submit a summary of results (template to be provided).

d) Prior to implementing the programme, the practice should have an internal meeting to discuss the logistics of the programme, including any training for GPs / PNs on accessing the appointment system where appropriate, how staff should communicate the change to patients etc.

e) During the period of delivery, Flowchart 1 should be followed. This covers patients who walk in and patients who call. The main points to be noted are:

o Anyone requiring a face to face appointment must go through triage UNLESS they meet specific exclusion criteria determined by the practice. This includes those wanting same day or non-same day appointments.

o The exclusion criteria is to be determined by the practice, and further detail and examples are provided in Flowchart 1. Practices are required to specify these categories on the initial data submission form.

o The clinician will then either deal with the patient directly (i.e. patient does not require any further appointment), or else book an appropriate face to face appointment if required. The GP can determine what appointment is appropriate (i.e. when, for how long, with who).

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o Only senior doctors should be undertaking the initial doctor first triage – this excludes locum doctors.

o Practices should take account of busy times when patients tend to call for appointments, i.e. Mondays, mornings, and ensure that a greater number of GPs are on hand to conduct the triage

o Where possible, patient should be put straight through to the GP when they phone; where not possible, the doctor should endeavour to call the patient back as soon as possible (practice to determine their response time) – patients should never be asked to call back.

o Note that if a patient calls the practice requesting a phone appointment only (no face to face), then the administrator may book a phone consultation with a clinician as per normal process.

o Online bookings are excluded from Dr First Triage.

f) The practice must keep a daily record of appointment requests and outcomes via a monthly data submission form (Appendix 5), and submit after each month.

g) At the 9 month mark of delivery, the practice must send out a repeat patient survey, the same as which was sent out at baseline (see Appendix 4), minus Q8.

o Must be sent out to at least 5% of the practice population

o The target population must have been seen by the practice within the last 6 months

The practice is to submit a summary of the survey results (template to be provided).

h) At the 10 month mark of delivery, the practice must complete the Repeat Data Submission (See Appendix 3).

i) At the 10 month mark of delivery, the practice must ensure all staff complete a short repeat Staff survey (Appendix 7). The practice is to submit a summary of results (template to be provided).

Please see Flowchart 1 below for outline of process.

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EXCLUSION CRITERIA FROM TRIAGE *It is possible that the GP practice has pre-determined in-house rules about specific categories of patients to whom they will always give a face to face appointment, for example, all children under 1 year

of age, specific vulnerable patients, or specific patients with mental health problems. Where these specific categories exist, it is acceptable for these patients to be given a direct face-to-face appointment

by the administrator, without going through Doctor First triage (fall into exclusion criteria for triage). Some patients may have routine appointments (e.g. regular warfarin monitoring appointments) and

therefore might fall into this exclusion criteria too. The examples above are not exhaustive and it is for individual practices to determine.

SAME DAY VS NON-SAME DAY Note that the focus is mainly on same day urgent appointments, however the rationale for triaging non-urgent appointments is to support practices in planning and providing appropriate (with correct

person and for correct length of time) appointments for patients. E.g. a patient calling up for a non-urgent appointment might actually need to see the HCA first for some tests, and then a GP/PM for a

triple appointment a few weeks later (i.e. care planning process) and this can be understood, directed and correctly booked in by the triaging GP.

CALL BACK TO PATIENT FROM SENIOR GP

**Practice is to determine their own response time, keeping in mind that patients who are not assured of a fast response may attend other places such as A&E for their care.

Flowchart 1: Doctor First process – telephone calls and walk in patients

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4.1.4 Payment

Practices implementing Doctor First approach will be paid £3.40 per registered patient, according to the practice list size taken at 1 Nov 2012. The following is taken into consideration with regards to payment:

• Implementation of Dr First in other places has shown that approximately only half the number of patients requesting a face to face appointment actually need one, and that the other half are helped directly (at the doctor first contact by telephone)2. Therefore, if a number of face to face appointments are averted, successful implementation of this system will not require employment of any extra GPs, but rather capacity should be enhanced.

Payment is contingent upon practices following the process outlined above and submitting monthly data in order to help assess the effectiveness of the Doctor First programme, as well as any baseline and repeat data specified. Failure to submit full monthly data will result in deduction of 1/12th payment for each month that data is not completed. Practices are advised of the importance of data submission for proper evaluation of overall outcomes.

Payment includes all incidental costs of running the programme, including the coordination, administration and stationery costs for the local patient surveys.

4.2 Component 2 – Structured Access Review supported by Primary Care Foundation

4.2.1 Background

In 2009, Primary Care Foundation produced a report entitled ‘Urgent Care – a practical guide to transforming same-day care in general practice’3, which has since been endorsed by the Department of Health, Royal College of General Practitioners (RCGP), British Medical Association (BMA) and General Practitioners Committee (GPC) . This report suggests that poor urgent care delivery has a negative effect on:

• Patients who may become distressed at delayed attention;

• Practice, whose general workload can become unmanageable, and whose reputation can be damaged; and

• The rest of the system, which then receives extra pressure because of failure to deliver in primary care (e.g. A&E, admissions).

On this basis, Primary Care Foundation run a programme which has supported a number of PCTs / CCGs and over 600 practices across the country to review urgent care delivery within their practices, improvement of which can reduce pressure on both the GP system and also A&E departments. The Primary Care Foundation programme is structured and supportive, helping to create transformational change by:

2 http://www.productiveprimarycare.co.uk/.aspx

3 ‘Urgent care – a practical guide for transforming same day care in general practice’, Primary Care Foundation, 2009:

http://www.primarycarefoundation.co.uk/images/PrimaryCareFoundation/Downloading_Reports/Reports_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf

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• using a simple web tool to aid practices to collect and report data on an average week in their practice.

• producing a report based on this data combined with MORI GP patient survey results which indicates areas for improvement, benchmarking across practices, and suggestions of changes which could be made to improve access for each practice.

• providing hands-on support to help practices instigate these practical changes (which could range from 0 – 5 sessions of contact), and

• aiding the re-collection of data to measure the outcomes of the structured review at the end of the period (9-12 months).

4.2.2 Aim

To give practices the opportunity to review their ways of working (in particular with regard to urgent / same day access) in a structured and supported way, receive real suggestions for improvement, gain support to implement changes within their practice, and measure outcomes.

So far, other sites show that there are potentially significant gains if practices in each area manage urgent care effectively – there have been reductions of 20-40% in acute admissions in some cases. Whilst this will not be achievable in every case the aim of the work is to improve the capability of practices to undertake regular and on-going capacity planning to ensure their response to urgent care is as effective as possible. One site showed a 20% reduction in use of an Urgent Care Centre after working with a group of local practices.

4.2.3 Process

Practices will be required to complete the following:

a) Prior to undertaking the programme, the practice must send out a baseline patient survey (see Appendix 4). Guidelines:

o Must be sent out to at least 5% of the practice population

o The target population must have been seen by the practice within the last 6 months

NB: The CCG estimates, based on MORI poll response rate, that approximately 30% of patients who receive the survey will respond.

b) Prior to implementing Doctor First for 1 year, the practice must have all staff within the practice complete a short staff survey (Appendix 7). The practice is to submit a summary of results (template to be provided).

c) Attend an initial pan-borough workshop run by Primary Care Foundation (2 hours) aimed at practice managers and one GP (other practice staff also welcome to attend) which discusses all aspects of access and the management of same day urgent care, and explains information and the data collection webtool.

d) Collect data over a one week period and enter it on the easy-to-use webtool. This involves a survey with 3 parts:

i. How you work in your practice – soft intelligence from various practice members

ii. Data collected by the practice (generally by practice manager or administrator) for a standard sample week. Data includes:

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i. ‘Opening Hours’,

ii. ‘Telephony’,

iii. ‘Walk In Appointments’,

iv. ‘Consultations’ and

v. ‘Additional Information’

iii. Reception quiz – for all those who carry out reception duties in the practice (e.g. take calls, speak to patients walking into surgery) – which measures levels of confidence to manage urgent cases

e) Full practice meeting with Primary Care Foundation (2 hour meeting) to discuss the report provided by PCF, what this means for the practice, and explore potential changes which could be made.

f) Practices to complete and submit action plan (Appendix 6).

g) Practice to implement agreed changes within the practice, with hands on support from Primary Care Foundation available, if the practice requires it

h) At the 9 month mark of delivery, the practice must send out a repeat patient survey, the same as which was sent out at baseline (see Appendix 4), minus Q8.

o Must be sent out to at least 5% of the practice population

o The target population must have been seen by the practice within the last 6 months

i) At the 10 month mark of delivery, the practice must collect data over a 1 week period again, in order for Primary Care Foundation to evaluate change achieved.

j) At the 10 month mark of delivery, the practice must ensure all staff complete a short repeat Staff survey (Appendix 7). The practice is to submit a summary of results (template to be provided).

4.2.4 Payment

Practices working with Primary Care Foundation will be paid £3.40 per registered patient, according to the practice list size at 1 November 2012.

Payment is contingent upon practices following the process outlined above and submitting the requisite data in order to help assess the effectiveness of the programme, as well as any baseline and repeat data specified. The CCG stresses the importance of data submission for proper evaluation of overall outcomes.

Payment includes all incidental costs of running the programme, including the coordination, administration and stationery costs for the local patient surveys.

Note that for this component, the practice benefits from being supported by dedicated consultants who have worked with practices across England. The CCG will cover the costs of the programme provided by Primary Care Foundation. Also note that dedicated hands-on support to implement change is available to each practice upon their request (up to 3 days of support) and this is entirely up to the practice and what they feel their level of need for support is – the cost of this support by Primary Care Foundation is also covered by the CCG.

Payment includes all incidental costs of running the programme, including the coordination, administration and stationery costs for the local patient surveys.

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5. Payment Schedule

Payment for delivering Component 1 or 2, including all requirements

£3.40 per registered patient*

*based on patient list size as at 1 Nov 2012

The above payments are all-encompassing, and include any other associated expenses which might be borne by the practice, such as staffing costs, premises costs, stationery expenses.

Component 2 practices are to note that in addition to practice payment for engaging in the programme, the CCG is investing approximately £4,000 per practice in funding Primary Care Foundation to provide the facilitated support.

50% upfront payment of Component 1 / Component 2 will be made to practices. Any outstanding payment will be made upon receipt of all data enabling the assessment of outcomes.

6. LES milestones / timeline

Date Event / milestone for Doctor First practices

Event / milestone for Primary Care Foundation practices

28 Feb 2013 Final date for sign up to LES Final date for sign up to LES

2nd

– 3rd

wk Mar 2013 Send out baseline patient survey Send out baseline patient survey

31 Mar 2013 Due date for initial data submission

31 Mar 2013 50% upfront payment for Component 1 50% upfront payment for Component 2

1 Apr 2013 Enhanced service launched Enhanced service launched

1st / 2

nd week Apr Initial workshop with Primary Care

Foundation

3rd

/ 4th / 5

th week Apr Practice completes one week of data

collection Practice schedules follow up meeting with PCF in May 2013

10 May 2013 Apr monthly data due Practices receive report from Primary Care Foundation based on data submitted

10 May – end May 2013

Follow up meeting with each practice to discuss report

31 May 2013 Action plan due

10 Jun 2013 May monthly data due

1 Jun – end Jun 2013 All practices to have implemented agreed changes by end June and continue to work in new way. Implementation supported by PCF

10 Jul 2013 Jun monthly data due

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10 Aug 2013 Jul monthly data due

10 Sep 2013 Aug monthly data due

10 Oct 2013 Sep monthly data due

10 Nov 2013 Oct monthly data due

Dec 2013 ICCG to collect MORI data (to Mar 2014) ICCG to collect in-hours SUS data (Urgent Care HRGs 6, 9, and 11) and emergency admissions for Apr 2013 – Mar 2014

ICCG to collect MORI data (to Mar 2014) ICCG to collect in-hours SUS data (Urgent Care HRGs 6, 9, and 11) and emergency admissions for Apr 2013 – Mar 2014

Dec 2013 ICCG review of all data to date in light of continuation or discontinuation of LES

ICCG review of all data to date in light of continuation or discontinuation of LES

10 Dec 2013 Nov monthly data due

Jan 2014 Practice to conduct repeat patient survey Practice to conduct repeat patient survey

10 Jan 2014 Dec monthly data due

Feb 2014 Repeat staff survey due Repeat staff survey due

Feb 2014 Repeat data submission due

10 Feb 2014 Jan monthly data due

10 Mar 2014 Feb monthly data due

2nd

-3rd

week Mar 2014 Practices to complete one week of repeat data collection

31 Mar 2014 End of LES (practices to ensure successful systems of working are continued)

End of LES (practices to ensure successful systems of working are continued)

10 Apr 2014 Mar monthly data due

Jun-Jul 2014 Final collection of outcome achievements upon receipt of SUS data, and final payment to practices

Final collection of outcome achievements upon receipt of SUS data, and final payment to practices

7. Monitoring

Component Monitoring requirement Source of data

Component 1 Practice list size

Practice list size as at 1 Oct 2013

Initial Number of appointments, assessment of current systems

Practice data submission of Appendix 2 (baseline) and Appendix 3 (repeat)

Data capture of appointments per month

Practice monthly submission of Appendix 5

Staff survey Practice submission of Appendix 7 (baseline and repeat at month 10)

Component 2 Staff survey Practice submission of Appendix 7 (baseline and repeat at month 10)

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Attendance at introductory workshop

Sign in sheet

Data collection

Practice submission of 1 week of data via Primary Care Foundation webtool (baseline and at month 10)

Full practice meeting with Primary Care Foundation

Report from PCF

Actions agreed to by practice

Completed action plan from practice (Appendix 6)

Actions implemented

Report from PCF through follow up with practice

Component 3 Local patient survey results Practice completion of Appendix 4 Local patient survey (at baseline March 2013 and at month 9) and submission of summary of results

In hours A&E/UCC attendances

• HRG6 – Cat 1 investigation / Cat 3-4 treatment

• HRG9 – Cat 1 Investigation / Cat 1-2 treatment

• HRG11 – No investigation / no significant treatment

SUS data

7. Review of the Service

The Improved Access pilot LES will be managed and monitored by the ICCG Primary Care Commissioning Team and will be reported to the formal Primary Care Development Group. The outcome measures for analysis have been included within the business case.

The Improved Access pilot LES will be reviewed during and after completion to assess outcomes and possibility of extending the scope of the pilot LES in the future.

8. Variation/Termination of Agreement

Islington CCG will give a minimum of 14 days notice period to practices, but where possible this will be extended to a maximum of 3 months’ notice.

9. Protecting Patient Confidentiality

There is no reason for submission of patient level data in this LES. However if this were the case, all patient identifiable data would be required to be sent to pbc.secure@nhs.net as per Caldicott Guardian principles.

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Acceptance of Terms: Service Specification for Improved Access Pilot Local Enhanced Service (LES)

Practice Code

Name of Practice

I confirm that the practice wishes to sign up to the following components of the LES (please mark ‘x’ for either Component 1 or Component 2)

Component 1: Doctor First approach

Component 2: Primary Care Foundation

By signing this document the practice agrees to provide the LES according to the specification. This document will become part of the contract documentation between NHS Islington Clinical Commissioning Group (commissioner) and the practice to provide the Enhanced Service. The Enhanced Services the practice has contracted to provide will also be included in the relevant schedule of your contract.

I hereby confirm my acceptance of the terms of this service. Please sign and date below to confirm acceptance:

Signed on behalf of the practice by.………………………………………………………..

Print name…………………………………………………… Date: ………………………..

Practice Stamp:

I hereby confirm that the commissioner will pay the practice for delivery of the service as per the specification.

Signed on behalf of [Commissioner]………………………………………………

Print name………………………………………………… Date: ………………………..

Appendix 1

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Component 1 – Initial data submission

Name of Practice:

Please state the times that your telephone lines are open, and when doors open.

If either your phones or doors close down at lunch time, please make this clear

Telephone is opened and closed when?

Practice doors open and close when?

Mon e.g. 08.00 to 18:30 hours e.g. 08.00 to 18:30 hours

Tue

Wed

Thu

Fri

Sat

Sun

Please state how patients currently book an appointment with the practice. Please include reference to what kinds of appointments are available, what methods can be used to book, when patients can book certain appointments, any walk in clinics if applicable.

Please specify any issues that your practice has with language barriers: i.e. what main languages other than English do your patients speak, and what languages do your clinicians delivering Dr First speak? (Practices are to think about impact of Dr First on these non-english speaking patients, and how you will ensure that this does not pose a barrier to this cohort of patients)

Please list what you perceive are your practice’s difficulties with access: (think about what your MORI survey says, what your patients feed back to you, what you notice as problems)

Please give a brief outline of how you will implement the Doctor First appointment system in your practice. Please include the names of GPs who will be delivering the system, any in-house training you will carry out etc.

Appendix 2

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Please list any pre-determined categories of patients that your practice will exclude from the doctor first requirement, i.e. are there any types of patients whom you will always give a face to face appointment regardless of the concern, (e.g. all children under 1 year of age). NB: your practice may not have any exclusions.

Please explain how you will make patients aware of the changes to your appointment system.

Please state how many face to face and telephone appointments were carried out in January 2013 by GPs from the practice?

Telephone Appointments = __________

Face to Face Appointments = ________

During one full week in February 2013 please record the following information:

Same day appointments Other non-urgent appointments

Total Requested Total successfully given

Total requested Total successfully given

Monday

Tuesday

Wednesday

Thursday

Friday

I declare that all information stated is accurate to the best of my knowledge:

Name of person completing this form

Signature

Date

Due by 31st March 2013

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Component 1 – Repeat data submission

Name of Practice:

Please state the times that your telephone lines are open, and when doors open to your practice.

If either your phones or doors close down at lunch time, please make this clear by specifying times

Telephone is opened and closed when?

Practice doors open and close when?

Mon e.g. 08.00 to 18:30 hours e.g. 08.00 to 18:30 hours

Tue

Wed

Thu

Fri

Sat

Sun

Please state how patients currently book an appointment with the practice. Please include reference to what kinds of appointments are available, what methods can be used to book, when patients can book certain appointments, any walk in clinics if applicable.

Please give a brief outline of who has been implementing the Doctor First appointment system in your practice. Please include the names of GPs who have been delivering the system, any in-house training you carried out etc. Please advise if there were any changes to your initial submission during the course of delivering Dr First.

You stated pre-determined categories of patients that your practice would exclude from the doctor first requirement. Did this change at any point during your delivery of the Dr First approach?

Appendix 3

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Please clarify the communications made to patients about the changes to your appointment system.

Please state how many face to face and telephone appointments were carried out in January 2014 by GPs from the practice?

Telephone Appointments (including Dr First initial telephone assessments) = __________

Face to Face Appointments = ________

During one full week in February 2014 please record the following information:

Same day appointments Other non-urgent appointments

Total Requested

Total successfully given. Success

means:

-dealt with directly by initial Dr first phone call

-given an urgent face to face

-deemed non-urgent and patient happy with

non-urgent appt

Total requested Total successfully given. Success

means:

-dealt with directly by initial Dr first phone

call

-given an urgent face to face

-deemed non-urgent and patient happy

with non-urgent appt

Mon

Tue

Wed

Thu

Fri

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It is really useful to have the practice’s views about the the Dr First programme. Please therefore give as much detail as possible:

What positive changes did you notice within your practice as a whole? Please include changes to time and resources, efficiency, different ways of working, dynamics, overall feeling by staff and patients

What negative changes did you notice within your practice as a whole? Please include changes to time and resources, efficiency, different ways of working, dynamics, overall feeling by staff and patients

Will you continue with Dr First within your practice?

If not, what is your exit strategy (how will you change your working, and what will you change it to?)

I declare that all information stated is accurate to the best of my knowledge:

Name of person completing this form

Signature

Date

Due by 31st January 2014

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COMPONENT 1 & 2: PATIENT SURVEY

(Practices are to amend this to include practice letterhead)

(Please mark x in the box next to your answer for each question)

1) Last time you tried to contact the practice by phone, how many times did you have to ring before you got through?

a) Only once, I got through on first attempt

b) Twice, I got through on the second attempt

c) Three or four times

d) Five to ten times

e) I have never tried to ring the practice

f) 2nd / 3rd attempt

g) Booked face to face at reception

1) Once you got through, how long do you think you waited for the call to be answered / how long were you on hold for?

a) Less than 30 seconds

b) Between 30 secs and 1 minute

c) 1 to 2 minutes

d) 2.5 to 5 mins

e) 5 to 10 mins

f) Over 10 mins

2) Waiting time at the surgery:

a) Don’t normally have appointments at a particular time

b) Less than 5 minutes

c) 5-15 minutes

d) More than 15 mins

e) Can’t remember

3) Last time you wanted an appointment at the practice with either a GP or nurse, what type of appointment did you want?

a) Appointment to be seen at the surgery on the day

b) Appointment to be seen at the surgery within the week

c) A telephone consultation on the day

Appendix 4

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d) A telephone consultation within the week

e) Appointment for someone to visit at home on the day

f) Appointment for someone to visit at home within the week

g) Can’t remember

4) What type of appointment did you get? (if you received more than one, please tick all answers)

a) Appointment to be seen at the surgery on the day

b) Appointment to be seen at the surgery within the week

c) A telephone consultation on the day

d) A telephone consultation within the week

e) Appointment for someone to visit at home on the day

f) Appointment for someone to visit at home within the week

g) Can’t remember

5) Regardless of the appointment you wanted and received, were you satisfied with the outcome?

a) Yes

b) No

c) Not applicable as I received a face to face appointment

d) Other: Please give your comments here:

6) If you were not satisfied with the outcome, what did you do?

a) Accepted the appointment offered anyway

b) Went to A&E / a walk in centre

c) Saw a pharmacist

d) Decided to contact the surgery another time

e) Didn’t see or speak to any GP or nurse

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7) Overall, how would you describe your experience of making an appointment?

Very good

Good

Average

Poor

Very poor

This question is about telephone consultations:

8) If you called the practice to book a same day appointment, how would you feel if the GP answered the phone and dealt with your query there and then on the telephone (where appropriate)? Note that if you still needed it, the GP would book you in for a face to face appointment.

a) I would like this

b) I would not like this

Comments:

9) Please add any additional comments here:

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COMPONENT 1: MONTHLY DATA RECORDING FORM

(for triaging GP to complete)

Practice:

Month

DATE Total no. of people spoken

to by doctor first (i.e. total no. of people

wanting a face to face

appointment)

Total no. of people who bypassed Dr First system

due to ‘exceptional

category’

Total no. of people dealt with

directly (no further face to

face appointment needed)

Total no. of people still requiring same day

face to face appointment

Total number of

people given a non-urgent face to face appointment

(not same day)

Approximately how long did each initial Doctor First assessment

take?

(please estimate in

mins)

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

13th

14th

15th

16th

17th

18th

19th

20th

21st

22nd

23rd

Appendix 5

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27

24th

25th

26th

27th

28th

29th

30th

31st

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COMPONENT 2 – ACTION PLAN

PRACTICE NAME

DATE OF MEETING WITH PRIMARY CARE FOUNDATION TO DISCUSS REPORT

The areas which were identified as issues for our practice are:

Suggestions which were made by Primary Care Foundation were:

ACTION PLAN:

Problem identified

Agreed action / change to be implemented

Lead person To be implemented by (date)

1

2

3

4

Appendix 6

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5

Completed by (name)

Signed

Date

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COMPONENTS 1 & 2: STAFF SURVEY FOR GP PRACTICE STAFF

This survey is for all of your practice staff to complete. Questions centre mainly around appointment system and other working systems, and the impact of these upon your job.

Please tick the appropriate box for each question.

PRACTICE NAME

Q1: My role is:

GP PN

PM Front of house receptionist / admin with patient contact

Administrator with no patient contact

Q2: In your opinion, how do you think your current appointment system works?

I think it works well

It is average It does not work well

N/A (does not impact upon me)

1 2 3 4 5 6

Any further comments:

Q2: Impact upon you from patients about appointment system

I receive a lot of aggravation from patients about the appointment system

I receive an average amount of aggravation from patients about appointment system

I do not receive any aggravation from patients about the appointment system

N/A (I am not in a role which receives any direct feedback from patients)

1 2 3 4 5 6

Any further comments:

Q3: In your opinion, how do you think other administrative processes work?

All processes are efficient as they can be

Some processes are efficient, some need changing.

Most processes are inefficient

1 2 3 4 5

Any further comments:

Q4: Amount of work you have to do every day

Appendix 7

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Good amount, I can always deal with workload

Workload is varied – some days are fine, some days are not

I always find the workload too much

1 2 3 4 5

Any further comments:

Q5: Impact upon you from patients about general systems (not just appointment system)

I feel very pressured by patients as a result of our systems

I feel moderate pressure from patients as a result of our systems

I do not feel at all pressured by patients as a result of our systems

1 2 3 4 5

Any further comments:

Q6: Job satisfaction

Very satisfied with my job

Average satisfaction Unsatisfied with my job

1 2 3 4 5

Any further comments:

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IN HOURS URGENT CARE ATTENDANCES, PER PRACTICE, BETWEEN OCT 2011 - SEP 2012 – BASELINE DATA

Practice

list size

(Oct 2012)

Category 1 investigation

with category 1-2

treatment

(£103 incl MFF)

Category 1 investigation

with category 3-4 treatment

(£103 incl MFF)

No investigation with no

significant treatment

(£66 incl MFF)

Total

Activity Total Costs

Baseline ratio

of all UCC

attendances

against

practice list

ACTIVITY COST ACTIVITY COST ACTIVITY COST

AMWELL GROUP 7674 408 £42,148.20 28 £2,885.47 100 £6,649.73 536 £51,683.40 6.98%

ANDOVER 5047 193 £19,367.62 18 £1,776.70 237 £15,715.45 448 £36,859.77 8.88%

ARCHWAY 5479 271 £27,372.58 37 £3,694.17 318 £21,053.89 626 £52,120.64 11.43%

CITY ROAD 6696 517 £53,035.53 34 £3,487.58 119 £7,768.20 670 £64,291.31 10.01%

CLERKENWELL 9142 389 £39,758.93 24 £2,433.60 115 £7,499.99 528 £49,692.52 5.78%

DARTMOUTH PARK 2511 105 £10,554.31 15 £1,489.90 119 £7,897.94 239 £19,942.15 9.52%

BINGFIELD STREET 2276 161 £16,636.77 14 £1,432.55 74 £4,959.76 249 £23,029.08 10.94%

BARNSBURY MP 2632 170 £17,620.31 13 £1,343.55 62 £4,156.45 245 £23,120.31 9.31%

DR KO 4033 220 £22,300.25 31 £3,080.49 193 £12,817.30 444 £38,198.04 11.01%

ELIZABETH AVE 7122 364 £37,080.59 45 £4,524.05 133 £8,693.49 542 £50,298.13 7.61%

HANLEY PCC 5777 278 £28,067.00 50 £4,984.00 366 £24,206.00 694 £57,258.00 12.01%

HIGHBURY GRANGE 8747 321 £46,872.11 41 £4,113.00 245 £16,245.00 607 £52,795.00 6.94%

HOLLOWAY MEDICAL

CLINIC 2317 87 £8,800.00 11 £1,106.00 117 £7,735.00 215 £17,641.00 9.28%

ISLINGTON CENTRAL 14861 671 £68,449.00 60 £6,068.00 300 £19,798.00 1031 £94,315.00 6.94%

KILLICK STREET 9564 428 £44,255.00 36 £3,690.00 153 £10,387.00 617 £58,333.00 6.45%

MILDMAY MP 6375 356 £35,770.00 36 £3,541.00 119 £7,769.92 511 £47,080.35 8.02%

PARTNERSHIP PCC 3106 134 £13,569.80 15 £1,507.60 120 £7,987.47 269 £23,064.87 8.66%

PINE STREET 2524 191 £19,603.94 20 £2,027.92 73 £4,826.58 284 £26,458.44 11.25%

NEW NORTH HC 1776 102 £10,507.97 10 £1,031.81 24 £1,578.17 136 £13,117.95 7.66%

RITCHIE STREET 12678 642 £66,428.39 42 £4,356.39 175 £11,635.56 859 £82,420.34 6.78%

RIVER PLACE 9421 446 £45,573.27 43 £4,322.46 198 £13,206.28 687 £63,102.01 7.29%

ROMAN WAY MC 4600 184 £18,791.13 24 £2,395.05 162 £10,783.48 370 £31,969.66 8.04%

SOBELL MC 3320 108 £10,892.74 11 £1,091.31 128 £8,460.19 247 £20,444.24 7.44%

ST JOHNS WAY 12313 456 £45,989.55 88 £8,739.61 517 £34,187.93 1061 £88,917.09 8.62%

ST PETERS MP 9858 522 £53,495.21 41 £4,130.98 164 £10,819.89 727 £68,446.08 7.37%

STROUD GREEN 5266 153 £15,359.72 28 £2,785.42 228 £15,052.02 409 £33,197.16 7.77%

BEAUMONT PRACTICE 2524 124 £12,501.35 25 £2,480.25 163 £10,799.63 312 £25,781.23 12.36%

THE FAMILY PRACTICE 3955 174 £17,619.20 21 £2,063.31 146 £9,675.71 341 £29,358.22 8.62%

GOODINGE GROUP

PRACTICE 11359 470 £47,921.93 66 £6,622.15 317 £21,139.94 853 £75,684.02 7.51%

THE MEDICAL CENTRE 4270 205 £20,814.14 23 £2,263.27 188 £12,434.03 416 £35,511.44 9.74%

THE MILLER PRACTICE 9885 356 £36,231.80 30 £2,934.86 181 £11,927.57 567 £51,094.23 5.74%

MITCHISON ROAD 5622 275 £28,005.81 37 £3,704.68 135 £8,943.70 447 £40,654.19 7.95%

NORTHERN MEDICAL

CENTRE 7672 341 £34,326.63 48 £4,793.24 374 £24,773.03 763 £63,892.90 9.95%

RISE GROUP PRACTICE 5575 226 £22,772.76 48 £4,764.04 309 £20,399.72 583 £47,936.52 10.46%

TUFNELL SURGERY 3187 135 £13,713.45 12 £1,198.17 146 £9,696.04 293 £24,607.66 9.19%

VILLAGE PRACTICE 6437 301 £30,448.24 39 £3,899.25 341 £22,584.39 681 £56,931.88 10.58%

WEDMORE GARDENS 934 31 £3,132.24 10 £992.10 51 £3,391.95 92 £7,516.29 9.85%

TOTAL 226535 10515 £1,085,787.47 1174 £117,753.93 6910 £457,656.40 18599 £1,646,764.12

Appendix 8

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<date>

To all Islington GP Practices

Dear practices,

Re: ‘Improving access to primary care – 12 month pilot opportunity

As a key part of the Primary Care and Urgent Care strategies, the CCG has identified a need for

practices to be supported to improve access to their services. As we know, access is a continuing

pressure across England; in Islington we know it is an issue through a number of different sources of

feedback, such as the National MORI GP patient survey, Islington LINk reports, feedback at patient

participation groups etc. and from practices themselves, who report being stressed by huge

demand.

We especially recognise that the registered population is increasing and that greater demand is

being placed on practices, with an emphasis on managing more long term conditions in primary

care, and on leading and engaging with commissioning work.

Islington CCG has a 3 year primary care strategy. One of the goals within the strategy is to achieve

improved sustainable access to primary care. In Year 1, we want to offer practices the opportunity

to be part of this 12 month Local Enhanced Service pilot to improve access to same day care.

Through robust evaluation we will use outcomes to inform commissioning in years 2 and 3.

This pilot project involves a choice from two options:

1. To implement a specific initiative in their practice: Dr First, i.e. everyone who wishes to have

a face to face appointment is assessed / triaged by a Dr First over the phone;

2. To work with an external facilitator ‘Primary Care Foundation’ who will help you understand

your own practice’s issues, particularly around meeting the need for same day

appointments, make suggestions for change, and provide hands on support to help you

implement that change. This option is more bespoke around your specific practice’s issues

and needs.

Both options have been implemented in other parts of England and there is a range of outcomes

which have been identified, the details of which are in the attached specification. Some of these

outcomes include:

• Increased capacity within primary care, including improved ability to provide same day

access, advanced booking and ability to see preferred clinician, more control of daily

workload. Savings of 5 hours of GP time per week.

• Savings in locum costs

• A reduction in A&E attendances

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• A reduction in emergency admissions, in some case between 20-40%

• Reduction in patient complaints

• Reduction in DNAs

• Improvement in capability of practices to undertake regular and on-going capacity planning

to ensure their response to urgent care is as effective as possible.

However, we do know that Islington has a unique population, and we do acknowledge with the LMC

that we therefore need to pilot these options for 12 months to start off with, in order to allow

enough time to embed new systems and see the effects of such changes locally. Islington CCG is

committed to robust measurement and analysis of all impacts of this project upon patients, primary

care systems and staff, secondary care activity, and the general local NHS system. As stated, robust

evaluation will enable us to assess the local evidence for further work on improving access in

subsequent years.

It is acknowledged that there have been various interventions offered in the past which have not

proven beneficial. These include the 1 month NCL Dr First pilot, for which there were no outcomes /

benefits seen due to short timescale and fast implementation. However, evidence from other areas

shows that the system may have merit and this is why we are including it as an option to test for a

longer period of time with stricter data reporting and evaluation.

This specification has been developed with the input of the LMC, GPs, practice nurses, practice

managers, public health and our informatics team, through our working groups within the CCG. It

will also be monitored and evaluated robustly through these same routes, to inform what form any

future programme might be in 2014/15 (however it is likely that any future commissioned service

will be more wholly based on achievement of outcomes rather than payment for process).

We are hoping that this will provide practices with the opportunity for some real transformational

change within primary care, empowering practices to work in better ways, in order to increase

primary care’s ability to meet patient demand, and improve patient experience.

We encourage all practices to consider this pilot, and ask for your expressions of interest. Please

read the attached specification, and complete the form provided, returning it to

Samantha.milford@nclondon.nhs.uk by 28th February 2013.

Kind regards,

Dr Jo Sauvage and Dr Katie Coleman

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IMPROVED ACCESS PILOT PROJECT

1 year duration (1 Apr 2013 – 31 Mar 2014)

My practice is interested in taking part in the Improved Access Pilot Project.

We wish to undertake (please choose one):

Component 1 (Dr First) ☐

Component 2 (Primary Care Foundation) ☐

We understand that as a practice we will need to engage with the full process,

including submission of data where required for a full year, as per the

specification.

Name of Practice:

Name of lead GP:

Signed:

Date:

Please return this form to Samantha.milford@nclondon.nhs.uk by close of play

28 February 2013

--------------for commissioner to complete----------------------------------------------------------------------------------------------------------

I hereby confirm that the commissioner will pay the practice for delivery of the service as per the

specification.

Signed on behalf of Islington CCG………………………………………………

Print name…………………………………………………………………… Date: ………………………..

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Negotiating for general practitioners

The government's proposed changes to clinical work in QOF: What they mean for you and your practice

The government announced in October 2012 that it intends to impose changes to GP contracts from April2013 following a

consultation period. The GeneralPractitioners Committee (GPC) has since received full details of the government's plans

and is currently analysing these proposals.

As part of the government's proposals, it intends to implement, from April2013 in England, all the NICE recommendations

for changes to QOF, without taking into account the detailed discussions held during 2012 between the GPC and NHS

Employers.

During this year's negotiations, the GPC agreed to include many of NICE's recommended new indicators and those

amendments which had a sound evidence base, which would benefit patients and which were practicalfor GP practices to

deliver in the context of other clinical priorities. However, GPC rejected some proposals because they were unworkable in

practice or because the workload involved was simply not practicable within the resources available next year.

This note outlines the clinical changes to QOF which the GPC feels are most concerning.

QOF indicators where services not universally available

We rejected some of NICE's recommendations on the grounds that they were unworkable as the services required are not

universally available across the UK, therefore effectively making the associated points impossible for practices in certain

areas.

Indicator Proposed point value

DM014: The percentage of patients newly diagnosed with diabetes, on the register, in 11

the preceding 1Aprilto 31 March who have a record of being referred to a structured

education programme within 9 months after entry on to the diabetes register

COPD006: The percentage of patients with COPD and Medical Research Council 5 (MRC) Dyspnoea grade >3 at any time in the preceding 12 months, with a subsequent record of an offer of referralto a pulmonary rehabilitation programme within the

preceding 12 months.

HF003: The percentage of patients with heart failure diagnosed within the preceding 15 5 months with a subsequent record of an offer of referral for an exercise based rehabilitation programme within the preceding 15 months

QOF is part of a national contract and all points should be relevant to all parts of the UK.These indicators were rejected in

negotiation because the four governments could not ensure 100% availability of the programmes across the UK.

The GPC does not believe that relying on exception reporting where the programmes are not available is enough to make

these new indicators acceptable.

With the increased public scrutiny of practices' annual QOF achievement, and the way the media has handled exception

reporting in the past, GPC does not want to see practices forced to justify exception reporting rates inflated as a result of

these changes.

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Workload implications

GPC rejected some of the NICE recommendations because the workload implications were so profound that they could

skew health care toward a certain section of the patient population at the expense of other patients.

A number of these focused on patients with hypertension, which is already a primary focus area for most practices.

Offering more or longer appointments for some patients simply to achieve QOF targets means fewer available

appointments for other patients in a practice.

For example, the new indicators which assess physical activity in hypertensive patients each year which will use an

exercise questionnaire:

Indicator Proposed point value

HYP004: The percentage of patients with hypertension aged 16 or over and under the 3 age of 75 in whom there is an annual assessment of physical activity, using GPPAQ, in

the preceding 12 months

HYP005: The percentage of patients with hypertension aged 16 or over and under the 3 age of 75 years who score 'less than active' on GPPAQ in the preceding 12 months, who also have a record of a brief intervention in the preceding 12 months

GPs will always encourage their patients to take more exercise when it is clinically appropriate, but many patients with

hypertension will not like having to complete an exercise questionnaire every year when it Is unlikely that the results will

change significantly from one year to the next.

Practices will have to spend time and resources filling in such questionnaires, to the detriment of other services they might

be able to offer. In light of the prevalence of hypertension in the population, this would result in nearly nine million

questionnaires administered annually across the UK, which would clearly have significant knock on effects to the rest of

the service without any discernible benefit.

The GPC also rejected a new indicator calculating the number of hypertensive patients under 79 with a blood pressure

reading under 140190. We not only rejected this because we believe it is the single biggest workload change to practices

but more importantly because of concerns that using QOF to hit such targets for a whole population risks increasing the

number of patients suffering from the adverse effects of polypharmacy, including potentially dangerous hypotension.

The GPC does not believe that relying on exception reporting would provide enough safeguards to avoid these risks,

particularly as the government is intent on raising upper thresholds to high and ever rising levels, as outlined in their

proposals for changes to GP contracts.

Indicator Proposed point value

HYP003: The percentage of patients aged 79 and under with hypertension in whom 45 the last blood pressure reading (measured in the preceding 9 months) is 140/90mmHg

or less

It is also clear that some other "tiny" changes to indicators will result in a large increase in workload for GP practices,

despite not delivering clear clinical benefits. For example, in the new BP screening target, there will be a requirement to

record the blood pressure of 85% of patients between 35 and 40 years of age.

Indicator Proposed point value

BP001:The percentage of patients aged 40 and over who have a record of blood 15 pressure in the preceding 5 years

GPC are not convinced that encouraging large numbers of well young people who would not otherwise make an

appointment to see their GP should be prioritised at the expense of offering enough appointments to those who are ill.

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Chasing these targets would impact on the appointment availability for those who genuinely need to see their GP or

practice nurse. It would mean significant extra work with no new resource to provide additional capacity to dealwith it.

As with several of the government's suggestions, we believe that any potentialsmall health gains from the introduction of

these new tasks would be massively offset by implications they will have for the delivery of other patient care.

Extra training

Another new QOF indicator would require diabetic dietary advice to be given by GPs and by diabetic nurses who have

done extra training. This may sound simple, but it could add significant extra costs for practices and require longer

consultations.

GPs already train for ten years (soon to be 11) to care for their patients, and routine chronic disease management is

already well within their capabilities. Both GPs and practice nurses are increasingly questioning the value of an increasing

number of days away from the practice spent doing supposedly mandatory training for areas in which they already have

the necessary skills.

Indicator Proposed point value

OM013:The percentage of patients with diabetes, on the register, who have a record 3 of a dietary review by a suitably competent professional in the preceding 12 months

Repetitive and inappropriate questioning

Two of the proposed new indicators refer to diabetic patients with a record of erectile dysfunction (EO). Although GPC

agrees that asking diabetics about ED may be appropriate in certain circumstances, there are concerns about having to

do this on an annualbasis. To repeatedly remind a man he has ED every year,when all treatment options have been

discounted, seems unnecessarily insensitive.

GPC therefore asked whether the Department of Health would consider extending the time frame and linking the indicator

to newly diagnosed patients. In the QOF subgroup, NHS Employers and GPC planned to add to the guidance that 'a

record of being asked' could include a leaflet, and to exclude patients with existing complaints of ED who had already

considered all treatment options. Unfortunately, it appears that these points will not be included in the new guidance.

Indicator Proposed point value

DM015: The percentage of male patients with diabetes, on the register, with a record 4 of being asked about erectile dysfunction in the preceding 12 months

DM016:The percentage of male patients with diabetes, on the register, who have a 6 record of erectile dysfunction with a record of advice and assessment of contributory

factors and treatment options in the preceding 12 months

Retirements

Finally, we are concerned that some process indicators such as CKD2 (patients with record of blood pressure),

EPILEPSY6 (patients on drug treatment for epilepsy with record of seizure) and BP4 (hypertensive patients record of

blood pressure) will be retired, yet the work will still need to be done but now without any resource to do them.

The proposalto impose all clinical QOF recommendations,without reference to our negotiations, means that these

important practical considerations are not likely to be taken on board, which will cause huge problems for both practices

and patients. It also risks undermining the confidence the profession and patients have in QOF as a whole.

If these changes are made to QOF, practices would do well to consider the value of each QOF point (worth £133.76 in

England in 2012-2013) and make their own decisions about whether it is worthwhile engaging in the associated work.

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The GPC will ensure the government receives all of these concerns as part of our response to its consultation.

Please do keep up to date with other related news and guidance on the website.

Road shows across the UK will take place in early 2013, alongside a GP survey to gauge the profession's views on the

government's proposed changes.

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1

MEETING: Islington LMC

DATE: 28 February 2013

TITLE: Transfer of anonymised GP practice data to London Borough

of Islington post-transition

LEAD DIRECTOR: Julie Billet: Director of Public Health for Camden & Islington

AUTHOR: Mahnaz Shaukat, Head of Health Intelligence

CONTACT DETAILS: Mahnaz.Shaukat@nclondon.nhs.uk

020 3317 3693

BACKGROUND

From April 2013 the Islington Public Health function will formally transfer to

Islington Local Authority (LA). In order to provide high quality advice to Clinical

Commissioning Groups on topics such as prevention of disease, management

of Long Term Conditions, health inequalities and lead on the production of the

Joint Strategic Needs Assessment (JSNA) the Public Health Intelligence team

will continue to require local access to NHS data as they currently do including

anonymised primary care data.

PREPARING FOR TRANSFER OF EXISTING DATA

The Islington Public Health Intelligence team hold a number of data sets used

to assess health needs which are being reviewed to ensure they can be legally

transferred to the local authority on the 1st April 2013. This includes

anonymised Islington primary care data. Nationally the guidance is that no

patient identifiable datasets can be transferred into the local authority unless

there is a clear legal basis. A legal basis is defined as explicit consent from the

patient, a section 251 agreement or an overriding public interest.

In 2011 all practices in Islington, with LMC support, consented for Public

Health Intelligence in the NHS to extract anonymised data from their practice

for the purposes of population health analysis. Public Health requires

continuous access to this historic data in order to enhance future analysis

using the GP dataset by providing time trend analysis and for data quality

analysis. As the data extracted from Islington practices is anonymised the

data can be legally transferred to the local authority. This anonymised

extraction was repeated in 2012, with LMC support and practice consent.

In 2012 all practices in Islington, with LMC support and an approved Section

251 agreement from the National Information Governance Board for Health

and Social Care (NIGB), consented for Public Health to extract patient

identifiable data to link with hospital admissions data to conduct analysis that

would inform strategies to reduce admissions. This extraction was completed

in February 2013. Public Health will link the primary care and hospital data and

then anonymise the dataset (i.e. remove NHS number, postcode, date of birth)

prior to transfer to the local authority on the 1st of April 2013.

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2

The Public Health team will be writing to all GP practices in Islington before

the 31st March informing them of the transfer of their practice’s anonymised

dataset (data extracted 2011, 2012 and 2013) to a secure IT environment

within Islington Local Authority unless there is an objection.

RECOMMENDATIONS/ACTIONS REQUESTED

The LMC is asked to:

NOTE the new operating environment for Public Health from April 2013.

SUPPORT the transfer of anonymised GP data to Islington Local Authority for

continued analysis.

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1

MEETING: Islington LMC

DATE: 27 February 2013

TITLE: Publishing Islington GP practice overview profiles on the

new ‘Evidence Hub’

LEAD DIRECTOR: Julie Billet: Director of Public Health for Camden & Islington

AUTHOR: Baljinder Heer, Senior Strategist

Dalina Vekinis, Senior Public Health Information Analyst

CONTACT DETAILS: Baljinder.Heer@nclondon.nhs.uk

020 7527 1233

BACKGROUND

As part of the wider changes to the NHS, Public Health analysis and production of profiles

and reports will continue after the move to the Local Authority from April 2013 in order to

provide high quality advice to Clinical Commissioning Groups, leading on the production on

the Joint Strategic Needs Assessment (JSNA) and other needs assessments. Currently, all

Public Health Intelligence profiles are available on the NHS Islington intranet

(http://nww.islington.nhs.uk/phi), accessible by all NHS staff. However, this site will cease to

exist from March 31, 2013 so a new place for publication is needed.

ISLINGTON PRIMARY CARE DATA ON THE EVIDENCE HUB

A new ‘Evidence Hub’ is being developed to fulfil the statutory requirement for a Joint

Strategic Needs Assessment, and as a suite for publication of other key needs analyses

and evaluations for NHS priorities and analyses of wider determinants of health that cut

across Council departments. The site is due to be launched in March 2013 and can be

found at: http://evidencehub.islington.gov.uk/. It is live and viewable to the public but is not

searchable in search engines such as Google or Bing.

As you are aware, Islington’s Public Health Department have, with individual practice

consent, extracted Primary Care data and have used this in order to carry out population

level analysis (practice and borough level) to produce to inform strategy and

commissioning.

As the historic profiles will need to be referenced going forward, we propose that the new

Evidence Hub become the common site to publish Public Health Intelligence profiles and

outputs. This includes those that use the Public Health GP dataset. This will also allow

them to be easily accessible to Islington CCG, Islington GPs, Public Health colleagues,

Joint Commissioning and others. Future outputs using the anonymised primary care

dataset will also be housed on the site.

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2

The Evidence Hub will comprise of two ‘layers’: open access and restricted. The open layer

will be ‘public’ access. The restricted layer will only be accessible to Islington CCG,

Islington GPs and Public Health. Profiles will be housed on one of these areas, depending

on the content and type:

� Overview profiles: profiles providing in depth analysis on a particular topic or

condition, e.g. Stroke/TIA, will be available as open access. These types of profiles

include:

- Overview figures for Islington, benchmarked against other London areas

- Previously published or openly available statistics (including QOF achievement)

- Breakdown of indicators by individual GP practice:

- Using previously published statistics

- Using the anonymised PH GP dataset for analysis not previously available

- Commentary and recommendations for action based on findings of analysis

� Practice profiles: profiles providing practice-specific analysis on a particular topic

or condition, e.g. Long term conditions, will be available as restricted access via a

secure login and compliant with data protection regulations. These types of profiles

include analysis of the type:

- Numbers per practice for specific indicators related to the topic

- Short commentary by section as guidance around the data presented

- Comparisons with the Islington average, where applicable

- Most data will be from the anonymised PH GP dataset, with other figures from

previously published sources.

In addition to the Public Health Intelligence profiles, Factsheets are in development, some

of which contain practice level graphs from the anonymised PH GP dataset naming

practices. These will be available as open access on the Evidence Hub.

No outputs that are deductively disclosive, or data and analyses that could be potentially

identifiable, will be published on the open access area of the Evidence Hub. This is

compliant with Freedom of Information regulations, as any published data can be requested

by the Act, as long as it is not disclosive.

This transfer of publication has been discussed at the previous Health Intelligence Advisory

Group meeting, with the recommendation that approval from the LMC should be sought. Dr

Clifton Woolf is the LMC representative of the group, with Dr Katie Coleman and Deb

Snook the General Practice representatives of the CCG.

RECOMMENDATIONS/ACTIONS REQUESTED

The LMC is asked to:

APPROVE the request to publish Public Health Intelligence profiles to the Evidence

Hub, in their current form, to the appropriate access level as detailed above. This

applies for historic profiles as well as future profiles.

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APPROVE the request to publish Factsheets that use anonymised primary care data

onto the Evidence Hub.

NOTE that if approval is not granted for publication in their current form, Islington’s

Public Health Intelligence team can redact graphs which label GP practices,

recommendations and commentary on Public Health Intelligence profiles and publish

on the open access section of the site. However, the profiles will be published on the

secure layer of the site as originally published (i.e. with graphs and recommendations).

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