Document

PRACTICE BASED COMMISSIONING PLAN 2010/2011 – 2011/2012

Our vision is to improve health, develop services and allocate resources based on our local

community health needs.

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1. CHAIRMAN’S FOREWARD 3-4 2. INTRODUCTION 5

3. FINANCE & PERFORMANCE 5

4. CONSORTIUM COMPOSITION 6

5. GEOGRAPHY & POPULATION 7

6. HEALTH NEEDS 8-9 7. HEALTH IMPROVEMENT TEAMS (HITs) 10

8. COMMISSIONING PRIORITIES 11- 23

Alternative Clinical Communication 12 Musculo Skeletal Service (MSK) 13 Inter – Practice Referral Minor Surgery 14 - 15 Paediatrics 16 Dermatology 17 A&E Redesign 18 Ophthalmology 19 Medicines Management 20 - 21 Consortium Development 22 Patient and Public Involvement 23

9. APPENDICES 24 - 35

NKCC 2010-2012 Implementation Action Plan 24 - 34 Executive team Membership & NHS Kirklees PBC 35 Support Team

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1. CHAIRMAN’S FOREWARD We have produced this plan on your behalf to reflect and build on the past years work of the consortium and to outline the future commissioning intentions for the next two years. There have been a number of key achievements of the consortium and we will continue to try to achieve improvements within the context of the current financial constraints being placed upon us. There has been a successful implementation of the Phlebotomy Business Case to all North Practices and I know this has been well received by practices and patients alike. This will continue to be monitored and refined and we hope all practices will continue to fully implement and support it. There has been ongoing evaluation of the primary care based vasectomy service which has seen over 100 cases in the past year. Continued support of this scheme by practices and its expansion to neighbouring consortium/practices will provide ongoing efficient provision of this service.

We continue to attend a range of HIT meetings contributing to the outcomes and overall commissioning aims of the PCT, as well as regular attendance and contribution to the commissioning college. Successful business case submissions around a Peer Review case, diabetes redesign, 24 hr BP and CVD primary prevention have all been worked on by the consortium and are awaiting prioritisation by the PCT. Use of freed up resources previously achieved has been put on hold by the PCT but we will continue to press for their utilisation.

We are working with other consortia and across the PCT on service redesign areas for example musculo skeletal (MSK), ophthalmology and dermatology. More locally we are doing further work on areas such as alternative communications, inter practice minor surgery referral schemes and other areas outlined within this plan. We are also working with colleagues across the PCT around larger areas of redesign such as A+E/urgent care provision and planned care improvements. Quarterly forum attendance by practices was at 86.96% with excellent evaluations overall and these will continue to be developed over the next 12months.

We are trying to develop and improve our executive member’s skills and expertise and have Implemented a series of facilitated half day events to support team development and prioritise objectives for 10/11. Members have attended local and national NAPC meetings and conferences as well as a more local series of meetings (Kirklees Way) to try to improve our knowledge and capabilities. Some areas we introduced have not been as successful as we would have liked, Staywell for instance. Improved communication with secondary care colleagues through attendance at the GP/MYHT liaison meetings has proved beneficial. We will continue to produce a quarterly newsletter and provide all our members with minutes of our regular executive meetings. We plan to change our annual visits to

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quarterly meetings with groups of practices linked to funding by the PBC Financial Incentive Scheme (F.I.S.) payments to better facilitate understanding of PBC issues and share best practice. With the forecast prescribing deficits in mind we introduced Scriptswitch this year and are pleased with the initial results of this, and are looking at other areas around prescribing such as the better care better value indicators, and specific areas around specials and care home prescribing. The next year will be a challenge for the consortium with the financial constraints imposed upon us and the QIPP agenda, and we will strive to achieve financial balance for the consortium. According to NHS Kirklees Director of Finance the PCT is moving towards the end of its current 5 year comprehensive spending review, with the last being 2010-11. During this period the levels of growth it has received have been relatively high compared with historic levels and these continue in 2010-11. As we move into 2011-12 and onwards, the levels of growth are anticipated to be much lower than in recent years and therefore this Commissioning Plan is produced in the context of a more difficult financial climate, and with greater uncertainty than in recent times. However, the financial position for 2010/11 is more challenging than at any time since the PCT was formed in 2006, mainly due to over spends on acute contracts. Consequently, there is a greater emphasis within the financial plan on delivering cost efficiencies than there has been in recent years. The PCT has formally stated that any new business cases submitted by the Consortium must be on an ‘invest to save’ basis and that for a business case to be supported, it must be able to demonstrate cost savings in the current financial year. Therefore, business cases with a ‘payback’ period which exceeds the time constraints of the current financial year will not be supported or approved by the PCT. We hope that this commissioning plan supports the drive for improved efficiency and productivity whilst maintaining or improving the quality of patient care next year and onwards. We will facilitate involvement of practices in the financial incentive scheme to try to improve our position across the consortium. We look forward to another successful year and working with you all on all the aspects of PBC work within the plan.

Dr David Kelly - NKCC Chair

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2. INTRODUCTION The context in which this plan and the consortium’s commissioning priorities have been identified is with reference to the World Class Commissioning (WCC) competencies and Quality Innovation Productivity and Prevention (QIPP) framework specific details regarding how each priority fits with QIPP can be found in Appendices Section 9.1: Implementation Action Plan. The consortium will continue to evaluate the priorities and objectives set out within this document to ensure that they remain relevant and achievable and appropriate action will be taken if the consortium executive team decides that this is no longer the case. The consortium will continue to participate in national, regional and local discussions in order to learn from others PBC experiences, including both successes and failures. This will include the continued attendance of Executive team members at the National Association of Primary Care (NAPC) Yorkshire and Humber Forum. The consortium is committed to understanding and building on this learning to ensure that where possible best practice is adopted. More locally Executive members will represent the constituent practices regularly at the Commissioning College and share minutes from these meetings. The consortium recognises the importance of training and development to support the implementation of this plan and the work of the Consortium as a whole. Training and development issues for the Executive will be assessed through the completion of self assessment against the World Class Commissioning (WCC) and the Executive team will continue to support their constituent population through their regular Forums. 3. FINANCE & PERFORMANCE

In addition to the areas outlined above two key drivers for the consortium in identifying its commissioning priorities for the next two years have also been finance and performance information. Due to the challenging financial situation that is facing NHS Kirklees there is a greater emphasis on delivering cost savings and any business cases need to put forward need to be on an invest to save basis in order to be considered and this context has influenced the content of this plan. The PBC Performance Analyst has helped the consortium to identify priority areas using benchmarked information and by working closely with the NHS Kirklees finance team and with other colleagues; within NHS Kirklees and this process will continue to ensure that the plans identified priorities remain relevant. Performance information will also be used to support the implementation of the plan objectives. The “practice based commissioner performance report” will replace the R.U.P/performance pack and will be produced at consortium level every six months and annually at practice level. The PBC performance team are in the process of evaluating all information that is sent to practices, ensuring that it is fit for purpose. This new report will help practices to focus on how they can improve the national performance targets.

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4. CONSORTIUM COMPOSITION The North Kirklees Commissioning Consortium consists of 23 GP practices with a total practice population size of 142,719. The table below details the member practices of the consortium. 1 Dr Ahmad and Partners Ravensthorpe Health Centre 2 Dr Ahmed and Partners Albion Street 3 Dr Barker and Partners Wellington House 4 Dr Bedford and Partners Mirfield Health Centre 5 Dr Bhat and Partners Savile Town Medical Centre 6 Dr Chandra and Partners Ravensthorpe Health Centre 7 Dr Gafoor and Partners West Park Surgery 8 Dr Gogna and Partners Broughton House Surgery 9 Dr Hassan and Partners Batley Health Centre 10 Dr Hicks and Partners Eightlands Surgery 11 Dr Houghton and Partners Kirgate Surgery 12 Dr Khan and Partners St John’s House 13 Dr Lee and Partners Undercliffe Surgery 14 Dr Lynch and Partners Grove House Surgery 15 Dr Medley and Partners Dewsbury Health Centre 16 Dr Mehrotra Windsor Medical Centre 17 Dr Fowers and Partners Blackburn Road Medical Centre 18 Local Care Direct School House Practice 19 Dr Rajpura and Partners Mount Pleasant Medical Centre 20 Dr Scrivings and Partners The Greenway Practice 21 Dr Unnikrishnan Ravensthorpe Health Centre 22 Malling Health Victoria Medical Practice 23 Dr Youd and Partners Brookroyd House

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5. GEOGRAPHY & POPULATION Geographically the area of the North Kirklees Commissioning Consortium lies across three localities in the North of the Kirklees area. The consortium practices fall into the three local area committee localities of Spen, Batley, Birstall and Birkenshaw and Dewsbury and Mirfield. This situation creates its own challenges as this means that the Consortium is not coterminous with one local area committee. Throughout 2009/10 the Consortium has been successful in developing links with Locality Managers, Local Authority and other community representatives and is committed to continuing this in 2010 - 12 to form effective and sustainable working relationships.

North Kirklees Commissioning Consortium Registered Practice Population (WYCSA 31st December 2009)

5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 1.0% 2.0% 3.0% 4.0%

00 to 04

05 to 09

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 to 85

85 to 89

90 and Over

% Females % Males

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6. HEALTH NEEDS Introduction The Consortium and its constituent practices cover three locality areas of Dewsbury and Mirfield, Batley, Birstall & Birkenshaw and Spen. The JSNA provides the Executive with useful insight in to the health needs of their constituent population and this has been used to influence the priorities for this plan. The key areas for concern identified below are primarily addressed through the consortium executive’s clinical support to ongoing work across NHS Kirklees. For example our Dewsbury locality has worst incidence for Kirklees for Diabetes and there is ongoing support for practices to help improve this situation through such initiatives as the PBC Incentive Scheme Care Planning and Diabetic Retinopathy Indicators and the Diabetes Health Improvement Team. Outlined below is a summary of the North Kirklees population health needs as identified in the Joint Strategic Needs Assessment (JSNA) 2009: Infant Mortality and Low Birth Weight These two areas were identified as key issues for all three of the localities making up our constituent population. Children and Young People The main challenges for children and young people are:

• Smoking tobacco (Spen/Dewsbury & Mirfield) • Drug Misuse (Spen) • Alcohol use (Spen) • Teenage pregnancies second highest for Kirklees (Dewsbury) • On average 5 year olds had 3 decaying teeth (Dewsbury) • Obesity (Dewsbury)

Women of child bearing age

• Smoking levels remain too high at nearly 1 in 4, and 1 in 4 are still smoking at the birth of their child, worse than previously (Spen). In Dewsbury this rises to 1 in 3

• Highest rate of obesity, 17% in Kirklees (Spen) Heart disease, stroke and high blood pressure

• Remains most common cause of death locally • Heart attack admissions highest in Kirklees (Spen) • Second highest rate in Kirklees for heart disease, particularly high in those

under 65, but improved since 2005 (Spen) • Nearly half of those over 65 had high blood pressure (Spen), this affected 1 in

4 people of all ages in Dewsbury • High rate of stroke in those aged under 65 in Dewsbury (worst in Kirklees) • Most severe impact on functioning in Dewsbury

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Pain • Most common condition • Highest levels in Kirklees in men aged under 65, 1 in 3 (Spen) • For the over 65s, over half suffered chronic pain (Dewsbury)

Obesity

• Highest rate in adults in Kirklees, over 1 in 5 and rising, figures were similar for Dewsbury with 1 in 5 being obese

• Being overweight or obese is now the ‘norm’ ie 57% of Spen adults, second highest in Kirklees

Asthma

• Rates highest in Kirklees for Spen, particularly those under 65, 1 in 8 Diabetes

• 1 in 11 had diabetes (worst in Kirklees, 7% in under 65s) (Dewsbury) Cancer

• Higher rates of lung cancer in Spen than in Kirklees overall, related to high smoking levels. In Dewsbury lung cancer is increasing in women, worse than nationally

• Breast cancer is the most common in Dewsbury, but reducing Smoking

• 1 in 5 adults still smoking in Spen, 1 in 4 in Dewsbury (highest in Kirklees) Alcohol

• 1 in 3 women and nearly half of men who drank alcohol, binged, the amongst the worst in Kirklees (Spen)

• In Dewsbury male drinking increased, but women report drinking less units less than recommended levels.

• High calorie intake, link to weight gain Depression/anxiety

• 1 in 4 in Dewsbury had depression, anxiety or a nervous illness (worst in Kirklees)

Food and Nutrition

• Lack of cooking skills (Dewsbury) Physical activity

• Highest rate in Kirklees of those not doing any physical activity 1 in 7 in Dewsbury (1 in 10 in Mirfield)

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7. HEALTH IMPROVEMENT TEAMS (HITS)

North Kirklees consortium has clinical leads working with the HIT teams to ensure that the consortium contributes and influences strategic development and leads on local development where appropriate.

Priorities for NKCC to attend actively

HIT Consortium Clinical Lead

Cardiology Dr Kelly

Alcohol (Alcohol Reference Group) Dr Kelly

Diabetes Dr Fowers

Intermediate care Dr Mehrotra/Dr Kohi

Long term conditions Dr Kohi

Urgent care Dr Kohi/Dr Mehrotra Dr Kelly

Planned Care Dr Chandra

Not actively attending representation when required via correspondence from the HIT Lead

Lead GP

Rheumatology Dr Singh

Dermatology Dr Kohi /Dr Singh

Obesity Dr Kohi

Pain Dr Kohi

Mental health Dr Naeem

Respiratory Dr Kelly/Dr Chandra

Stroke Dr Kohi

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8. COMMISSIONING PRIORITIES We have identified our commissioning priorities and targets after examining the health needs of our constituent population, recognising areas that are of concern to our constituent practices and considering NHS Kirklees priority areas and against the QIPP framework. The Consortium has identified specific priority areas over the following two years and these are summarised below:

1. Alternative Clinician Communication between Primary and Secondary Care

2. MSK Service

3. Inter-practice referrals minor surgery

4. Paediatrics

5. Dermatology

6. A&E Redesign

7. Ophthalmology

8. Medicines Management

9. Consortium Development 10. Patient and Public involvement

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8.1 ALTERNATIVE CLINICAL COMMUNICATION BETWEEN PRIMARY & SECONDARY CARE

LEAD CLINICIAN – DR KELLY

Aim

• To assess the feasibility of alternative methods of communication between primary and secondary care.

• To avoid unnecessary out patient appointments and reduce demand. To get quick consultant opinions without the need for a formal referral.

Issues

• Increased demand and activity in a number of specialities has led to increased costs in secondary care.

• The lack of effective and dedicated dialogue between clinicians can lead to patients being unnecessarily referred.

Current Position Case of need approved in principle and full business case to be developed. Proposal To facilitate innovative and dedicated alternative communication between clinicians for patients who would otherwise have needed referral to allow appropriate management and investigation to take place in primary care. This will initially look at developing alternative methods of interaction in pressurised specialities with high activity and costs. We will work with secondary colleagues to design an integrated scheme appropriately funded to improve patient care.

Expected Outcomes

• Assessment of feasibility to reduce OPD referrals in a range of specialities.

• Reductions in demand and cost in a range of specialities whilst improving quality and productivity.

• A timely response and better integration of care between primary and secondary care.

• It will help towards achieving 18 week targets.

• Improve knowledge base and clinical expertise.

• Facilitates positive relationships and clinical networks.

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8.2 MSK SERVICE LEAD CLINICIAN – DR KOHI

Aim

To analyse and understand orthopaedic/Rheumatology/Pain clinic activity from the Consortium

• Need to address the short term issues of demand management

• Where appropriate reduce levels of activity in secondary care through pathway redesign.

• To improve the quality of referrals

• Develop services in primary care and reduce the reliance on secondary services

Issues

• Demand has significantly outstretch capacity in secondary care ( MYHT)

• 18 week target not being achieved in orthopaedics

• Lack of primary care based services. Local MSK service needs to be expanded (? ICAT with direct listing)

Current Situation

• Local secondary care provider is unable to continue to offer the same level of activity in the future.

• Long waiting times

• Some patients are referred in to multiple pathways without the need to be referred at all, majority of these patients could be managed in primary care.

Proposal

To develop a service specification which will deliver a fully integrated, multidisciplinary MSK service in primary care. The vision is for all patients who do not need surgery or complex care can be managed in the community. For patients who do need surgery pre-operative work up will take place in the MSK service and than be directly listed for surgery in secondary care. Develop clinical networks between primary and secondary care which will enhance knowledge skill and expertise thereby improving the quality of referrals.

Expected Outcomes

• Care closer to home offered by MDT which will reduce the reliance on secondary care services.

• Shorter waiting times.

• Reduced Costs.

• Improved quality and efficiency for current and future services delivery.

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8.3 INTER PRACTICE REFERRALS MINOR SURGERY

LEAD CLINICIAN – Dr Chandra / Dr Singh Aim

• Assess feasibility of providing such a service.

• To utilise and refine the current skill base within Primary Care and to provide

• To assess the feasibility of extending the current DES to all NKCC practices

• To provide care closer to home for patients requiring minor surgical procedures.

• skin surgery within the Primary care setting.

• Aim to reduce the waiting time for these procedures.

• Aim to reduce the referral rate to secondary care. • To offer equity of service to all patients.

• To encourage and support accreditation of clinicians providing these services

Issues

• Some NKCC practices refer patients to secondary care for minor surgery when this service could be provided by member practices within primary care

• Introducing a primary care ‘inter practice referral pathway’ might increase demand and therefore costs

• Quality issues e.g. appropriate facilities available in primary care and accreditation of clinicians providing services

• Training costs.

• To ensure cancerous lesions are not being inappropriately removed within Primary Care.

• Address inequalities of service provision between practices.

• Wide variations in both take up, and levels of activity under the current DES.

Current Position

• Very difficult to quantify current activity that is referred to Secondary Care.

• Can measure current activity of that that is provided in Primary Care.

• Different levels of skill.

• Only a few NKCC practices participate in the Inter-practice DES Proposal

• Map current skill levels amongst clinicians performing procedures.

• Map qualifications

• Establish appropriate accreditation and clinical governance with evidence of expertise, skill level, adequate resources, future audit and monitoring arrangements.

• Standardised audit tool to assess activity and practice.

• Map current activity being paid for under the DES.

• Interrogate secondary care activity data and map activity which could be done in primary care.

• Produce an estimate of unmet demand.

• Careful cost analysis will be required to ascertain the financial feasibility of providing such a service.

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8.3 CONTINUED - INTER PRACTICE REFERRALS MINOR SURGERY

LEAD CLINICIAN – Dr Chandra / Dr Singh

Expected Outcomes

• Map activity in Primary and secondary care

• Establish the level of skills required for procedures.

• Produce and compare costing for both primary and secondary care

• To achieve the aims and objectives of the proposal

• Service will have to meet current commissioning criteria.

• Formalised accreditation process

• Formalise standards required for the facilities requirements to undertake the procedure.

• The need to set up a standardised audit to look at suitability of lesions removed

• Identify ongoing training requirements.

• Establish Peer review for all practices who participate in the DES scheme.

• Reduced waiting times for procedure

• Reduce costs by reducing secondary care activity

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8.4 PAEDIATRICS LEAD CLINICIAN – Dr Chandra Aim To analyse and understand the paediatric activity of the Consortium and where appropriate reduce levels of activity through service/pathway redesign. Issues Detailed review of the activity may find that these are accurate and valid and/ or beyond the scope of influence of the Consortium. Difficulties and / or time delays may be encountered in investigating the data – reliance on third parties for information in order to progress this. Current Situation Detailed analysis undertaken by the Performance Analyst has identified a high level of unplanned admissions in paediatrics. It was found that 19 % of these admissions related to gastroenteritis and respiratory infections. At NHS Kirklees and consortium organisational levels we are not achieving the breast feeding target and according to the Care Quality Commission (CQC,2010) breast feeding infants reduces the incidence of gastrointestinal and respiratory infections and may therefore reduce unplanned admissions. Paediatrics 70% of the unplanned admissions had a zero length of stay. Of this 70% 62% were admitted via A&E. Proposals

• Establish detailed set of benchmarking data to view consortium activity rates in both national and local context

• Work with Performance Analyst to gain an understanding of the possible reasons for breast feeding target not being achieved. Identify and trends/ potential areas for change

• Establish working group in order to progress this

• Work with others e.g. NHS Kirklees Maternity & Childrens Services commissioning team

• Define actions for the group to include mapping of patient pathways

• Dialogue with secondary care/A&E department Expected Outcomes

• Clear understanding of the reasons behind the activity.

• Improvement of the breast feeding target across the whole consortium.

• If appropriate areas for change are identified relevant action plan(s) to be developed clearly identifying next steps/ responsibilities and deadlines

• Regular monitoring procedures in place to ensure action plan is implemented

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8.5 DERMATOLOGY

LEAD CLINICIAN – Dr Kohi/ Dr Singh Aim

• To analyse and understand the increasing dermatology activity for the consortium

• To assess the feasibility of developing services within primary care to reduce pressure points in secondary care.

• To reduce secondary care activity where appropriate.

• To assess the feasibility of alternative pathways of care to achieve this aim.

• To work with the HIT team to understand the issues. Issues Increasing demand for Dermatology Services nationally. 30% increase on year. The reason for this is unclear. Alternative pathways will have to take into account the following;

• Suitable primary care facilities

• Adequate resourcing for a primary care provision

• Accreditation of clinicians

• How to manage unmet needs and therefore demands Current Situation

• Increasing demand at Local secondary care provider who are unable to cope with levels of activity

• Long waiting times

• Multiple referral pathways into MYHT causing duplication of referrals.

Proposals

• Map out current service to include patient pathways

• List of current providers to establish capacity and demand

• Look at referral pathways

• To assess the feasibility of developing a service specification to reduce the burden on secondary care.

• Develop clinical networks between primary and secondary care which will enhance knowledge skill and expertise thereby improving the quality of referrals.

Expected Outcomes

• Identify pressure points in dermatology.

• Where practical produce a service specification/alternate referral pathway, that takes into account the following;

- improved quality and efficiency for current and future services delivery.

- deliver care closer to home - provide value for money by reducing secondary care out patient costs

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8.6 A&E REDESIGN

LEAD CLINICIAN – Dr Kelly / Dr Kohi

Aim To look at a service redesign of A+E, the walk in centre and urgent care/assessment to improve patient access and reduce unnecessary secondary care activity and costs.

Issues

• High non elective admissions and short stays.

• High number of unnecessary secondary care admissions.

• Inability of A+E to achieve 4hr targets.

• A wide range of options for patients with urgent problems with duplication of activity.

Current Situation A disorganised and confusing array of entries into urgent care with a lack of full assessment, triage and investigation facilities within secondary care.

Proposals Redesign of A+E to incorporate a primary care run triage and assessment facility. Integration of the walk in centre functions within a redesigned service

Expected Outcomes

• Reduction in non elective activity.

• Allow A+E to achieve 4 hr targets.

• Reduction in activity and costs in secondary care.

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8.7 OPHTHALMOLOGY

LEAD CLINICIAN – Dr Kelly

Aim To look at a redesign of the ophthalmology service in conjunction with Dewsbury Doctors Consortium. To relieve pressure on secondary care and streamline and improve the service.

Issues

• High cost and activity speciality with pressure on achieving 18 week targets.

• Delays in access and no triage of referrals to prioritise activity.

Current Situation

• Long waiting times and struggling to achieve 18 week targets.

• Delays for patients with urgent problems due to pressures of demand.

Proposals To look at setting up of an alternative primary care based ophthalmology service. Options include a GPSI led service and a primary care unit to look at a specified range of ophthalmology conditions with appropriate integration and support of a community employed ophthalmology consultant.

Expected Outcomes

• Reduction in costs.

• Allow 18 week targets to be achieved in secondary care.

• To triage patients to the most appropriate service.

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8.8 MEDICINES MANAGEMENT

LEAD CLINICIAN – Dr Singh / Dr Chandra Aim

• To promote good prescribing practice amongst consortium practices.

• To effectively manage prescribing resources within allocated budgets without affecting the quality of prescribing.

• To minimise the risks to patients associated with medicine taking.

• To deliver national and local priorities on prescribing. Issues A prescription is the most common intervention made to treat patients in the NHS. There continues to be an increased demand for medicines due to changes in population demographics and the development of effective treatments for conditions where previously there was no treatment. Using the principles of evidence based prescribing, practices and consortia will be able to treat patients with effective medicines in the most cost effective manner. Current Situation The increasing complexity of prescribing in primary care means that the importance of ensuring that safe prescribing systems are in place becomes ever more important. The consortium will continue to monitor prescribing systems and take note of national safety guidance and information (e.g. NPSA and MHRA Patient Safety Alerts) to continually improve the safety of prescribing in the area. Proposals The consortium will encourage practices to work collaboratively with NHS Kirklees’ Medicines Management Team. The issues are outlined in the 2010-11 Medicines Management Action Plan. This plan includes elements of quality, safety and cost effectiveness.

• Quality and Safety: o ensuring NPSA methotrexate alert is fully implemented in all practices o reviewing prescribing of antispychotics to patients with dementia o reviewing patients prescribed unlicensed liquid specials o

• Quality and cost-effectiveness o Reviewing prescribing practice in the three therapeutic areas outlined

in the national Better Care, Better Value indicators – rennin-angiotensin drugs, lipid lowering agents and proton pump inhibitors.

o Reviewing prescribing of glucosamine, bisphosphonates and clopidogrel in line with NICE guidance.

o Reviewing prescribing of sip feeds, ‘Grey Drugs’ and other therapeutic areas included in local prescribing indicators.

o

• Practices will be encouraged to use the Scriptswitch prescribing decision support software to aid improvements in the quality of prescribing. Messages on the system will guide practices towards local formulary and cost effective prescribing options, provide reference to shared care guidelines (where available) and flag up relevant safety messages where appropriate.

• Practices will work with the PCT Medicines Management team to improve prescribing in care homes in line with the recommendations from the CHUMS study (Care Homes Use of Medicines Study).

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8.8 MEDICINES MANAGEMENT

LEAD CLINICIAN – Dr Singh / Dr Chandra

Expected Outcomes

• Safer prescribing systems resulting in improved patient safety. This has the potential to reduce admissions to hospital due to avoidable medicines related safety incidents.

• Improved patient outcomes through use of evidence based medicines.

• Improved utilisation of prescribing resources to ensure that increased demand for medicines can be met within the allocated budget.

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7.9 CONSORTIUM DEVELOPMENT

LEAD CLINICIAN – Dr Kelly Aims To ensure that NKCC is fit for purpose to lead the commissioning agenda for its constituent practices and recognises that there will be training and development required to support the implementation of this plan and the work of the consortium as a whole. Issues No clear baseline assessment to establish the above requirements. Current Situation The Consortium has attempted to meet the training needs of its Executive team and its constituent practices as and when they have arisen, no formal process has been in place for this to ensure that the needs of all levels of staff are consistently captured, prioritised and addressed. Proposals

• Training and development issues for the Executive will be assessed through the completion of the PBC self assessment against the World Class Commissioning competencies (WCC)

• Executive team will continue to support their constituent population through their regular Forums.

• To ensure that all the training needs associated with business cases are well thought out documented and reported to practices to help ensure successful implementation of the business cases.

• To carry out audits as appropriate to support change management work led by the consortium

• To utilise the opportunities created by the PBC FIS to ensure locality working to address local need

Expected Outcomes

• Completion of the PBC WCC self assessment

• A robust training and development plan is in place

• Forums to include clinical and non clinical training and information sessions reflected in the plan

• Support locality working groups as local indicator under the PBC F.I.S. suggested areas of work , significant Event auditing through peer support.

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8.10 PATIENT & PUBLIC INVOLVEMENT

LEAD CLINICIAN – Dr Singh Aim To ensure that all services commissioned by the Consortium are supported by appropriate levels of patient and public involvement. Issues Currently there is no formal process in place to ensure patients views are taken into account when commissioning services. Proposals

• To establish development plan to map out requirements and intentions to improve patient and public involvement

• To develop greater understanding of PPI measures already in place at practice level throughout the consortium

• To take active measures to promote greater awareness of PBC and the consortium

• When commissioning new services and/ or influencing service redesign fully take into account how these are informed by local knowledge and service user opinion.

• To work along side the PPI Team to test out locality approach to inform the continuing work of the consortium.

• Consideration to be given to other options to engage with PPI e.g. public event/ utilisation of software tools/ links with more community forums/ agencies Expected Outcomes

• Map of current PPI initiatives and ongoing work throughout the consortium at all levels

• Development plan for PPI is in place and is supported by robust monitoring mechanisms

• Identification of a range of appropriate methods of understanding service user perspective for the consortium and plans in place to develop/ utilise these as appropriate.

Section 9.1: The Implementation Action Plan Appendix 1

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Targ

et

Description Brief outline of rationale for choosing target – ref to JSNA/ NHS Kirklees priorities/ World Class Commissioning Competencies

QIPP Detailed actions required to achieve target

Completion date

Nominated lead / leads

Key Links

Establish working group. April 2010 Dr D Kelly Further Executive Team members to be agreed

Undertake literature search for best practice

Interrogate referral data by specialty.

To be determined

Identify clinical specialties and lead clinician

Start discussions with secondary care

Look for cost efficiencies Finance

8.1 To assess the feasibility of alternative methods of communication between primary & secondary care. To avoid unnecessary out patient appointments and reduce demand. To get quick consultant opinions without the need for a formal referral.

Helps address numerous disease areas as highlighted in JSNA. Improved efficiencies and access to clinical expertise.

Improve patient quality Innovate way of working Health prevention Improved productivity with potential to develop more streamlined access to consultant opinion.

Develop action plan and regular monitoring and reporting mechanisms to ensure timely feedback to the consortium.

8.2 To analyse and understand orthopaedic/rheumatology/pain clinic acitivity from the

Reduction in high activity level will help the consortium to stay within its

Improve quality of service received by patients. Increase productivity

Establish detailed set of benchmarking data working with Performance Analyst to ensure data is accurate and complete.

May 2010 Dr Kohi Performance Analyst


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Completion date


Key Links

Identify areas where changes may be influenced by the consortium to reduce activity levels.

Ongoing consortium & where appropriate reduce levels of activity, improve quality of referrals & develop services in primary care.

budget and may realise potential cost savings through pathway redesign. This area has been highlighted as a priority by NHS Kirklees for demand management. The consortium will support strategic direction.

reducing inefficiencies/ inappropriate referrals into secondary care.

Develop & monitor action plan with detailed objectives to achieve overall target.

July 2010 Dr Kohi Sue Richardson (MSK lead)


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Completion date


Key Links

8.3 To establish inter practice referrals for the primary care minor surgery DES.

Providing care closer to home, increasing equity of service for patients. Reducing secondary care referrals may help with budget management.

Quality issues are addressed for patients through care closer to home and potential to reduce waiting times. Innovation – promotes practices working closer together and developing expertise in primary care. Prevent unnecessary secondary care referrals and increase productivity by

Establish working group April 2010 Dr Chandra/ Dr Singh PBC Facilitator/ PBC Manager

Primary Care Contracting


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Develop action plan including assigned priorities to assess feasibility of expanding DES to all NKCC practices. Areas to cover in action plan to inc: - map current skill levels - map current activity levels - define what suitable for primary/secondary care -develop detail spec with clinical guidelines - robust accreditation processes - robust cost analysis to ensure financial viability

May 2010 Ongoing


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Establish working group June 2010 Dr Chandra PBC Facilitator/ PBC Manager

8.4 To analyse & understand the paediatric activity of the consortium & where appropriate reduce levels of activity through service/pathway redesign.

Reduction in high activity level will help the consortium to stay within its budget and may realise potential cost savings through pathway redesign.

Review of current situation, and establishing best practice will help improve quality of service provided. Develop & monitor action plan

with detailed objectives to achieve overall target.

August 2010 As above NHS Kirklees Maternity & Childrens Services Commissioing Team

Establish working group June 2010 Dr Singh / Dr Kohi PBC Facilitator/ PBC Manager

Dermatology HIT Performance Analyst

8.5 To analyse & understand the increasing dermatology activity for the consortium, where appropriate reduce levels of activity through service/pathway

Reduction in high activity level will help the consortium to stay within its budget and may realise potential cost savings through pathway redesign.

Review of current situation, and establishing best practice will help improve quality of service provided. Develop & monitor action plan

with detailed objectives to achieve overall target.

August 2010 As above


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redesign & assess the feasibility of developing services within primary care.

Nominated leads attend relevant established working group and feedback to the consortium and its constituent practices regularly.

Ongoing Dr Kelly Dr Kohi PBC Facilitator/ PBC Manager

Pat Andrewartha – Programme Manager –Urgent Care

Nominated leads to act as a communication link between consortium and the urgent care working group.

Ongoing

8.6 To look at a service redesign of A&E, the walk in centre and urgent care/assessment to improve patient access and reduce unnecessary secondary care activity.

Review of this service is one of NHS Kirklees priorities, reduction in unnecessary referrals to secondary care improves financial management for consortium and will support NHS Kirklees in aim to achieve financial balance.

Improving patient access will improve quality of service received.

Robust mechanisms to improve communication with constituent practices to be developed.

Ongoing


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Establish working group September 2010 Dr Kelly PBC Facilitator/ PBC Manager

Performance Analyst/ Finance/ Contracting

Develop robust action plan with clearly assigned responsibilities and time frames.

October 2010

8.7 To look at the redesign of the ophthalmology service in conjunction with Dewsbury Doctors Consortium (DDC).

Collaborative working to ensure best practice in development of primary care services in line with WCC competencies. JSNA highlighted diabetes and aligned healthcare issues as significant area of concern for our locality.

Aim to improve access to high quality service for patients and relieve pressure on secondary care will help NHS Kirklees to manage contract/budgets and improve productivity. Prevention – unnecessary referral to secondary care. Improving access may contribute to health prevention as will improved level of care.

Establish robust monitoring mechanisms to ensure that progress against the plan is regularly reviewed, reported on and communicated to the consortium.

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8.8

To promote good prescribing practice amongst all consortium practices. To effectively manage prescribing resources within allocated budgets.

Good prescribing practices support NHS Kirklees Medicines Management strategic plan and will help ensure that national and local priorities on prescribing are met.

Promoting best practice will improve quality of services provided to all.

Work closely with Medicines Management lead to establish clear actions to ensure practices are encouraged and appropriately supported by the consortium executive and PBC and Medicines Management team and progress is regularly reported on and communicated to all relevant parties.

May 2010 & ongoing

Dr Singh / Dr Chandra PBC Facilitator/ PBC Manager

Eric Power – Senior Medicines Management Advisor Finace

8.9

To ensure that NKCC is fit for purpose to lead the commissioning agenda for its constituent practices.

This will include completion of WCC self assessment tool to ensure consortium is fit for purpose and identify areas for improvement in line with WCC framework.

Will help ensure appropriate skill level of the executive team to fulfil its roles thereby improving quality.

Completion of the WCC self assessment tool.

May 2010 Dr Kelly Jackie Holdich – PBC Manager Jan Giles – Assist Director - PBC

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Development of a robust training and development plan

July 2010

Forums to include clinical and non clinical training and information sessions reflected in the plan


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Support locality working groups as local indicator under the PBC F.I.S. suggested areas of work.

8.10 To ensure that all services commissioned by the consortium are supported by appropriate levels of patient and public involvement.

Aligns with WCC competencies and is an aspiration of NHS Kirklees.

This will address and improve quality.

Map current PPI initiatives at all levels throughout the consortium.

October 2010 Dr Singh Jackie Holdich – PBC Manager

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Development plan for PPI is in place and is supported by robust monitoring mechanisms.

November 2010 & ongoing

Appendix 2

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Executive Team Membership

PBC Support & Contact Details

Name Job Title Contact Telephone

Nikki Gibson PBC Administrator 01484 464125 Jan Giles Assistant Director of

Commissioning & Strategic Development - PBC

01484 464086

Jackie Holdich PBC Manager 01484 464111 Sarah Crossley PBC Facilitator 01484 464119 Andrea Daley Performance Information

Analyst 01484 464053

Rob Willis Finance Manager 01484 464185 Andrea Issott Assistant Finance

Manager 01484 464045

Sarah Muckle Senior Public Health Consultant

01484 464205

Eric Power Senior Medicines Management Advisor

01484 464280

David Boothroyd Senior Contracts Manager 01484 464000

Please note all NHS Kirklees PBC support staff listed above are now based at Broad Lea House Bradley. All correspondence should be sent to the following address: NHS Kirklees

Broad Lea House Bradley Business Park Dyson Wood Way Bradley Huddersfield HD2 1GZ

Name Job Title Role Dr Kelly GP Chair Dr Kohi GP Deputy Chair

Dr Chandra GP Executive Team member Dr Naeem GP Executive Team member

Dr Singh GP Executive Team member Dr Mehrotra GP Executive Team member

Kath Greaves Practice Nurse Executive Team member Harry Farnhill Practice Manager Executive Team member John Pickford Practice Manager Executive Team member Lynn Batley Practice Manager Executive Team member

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