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Kingston Primary Care commissioning strategy Kingston Medical Services

Kathryn MacDermott Director of Planning and Primary Care Kathryn.macdermott@kingstonccg.nhs.uk kmacdermott@nhs.net

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Contents

1. Introduction .................................................................................................................................... 3

2. Key health priorities ........................................................................................................................ 3

3. Right Care / Commissioning for Value ............................................................................................ 5

4. Commissioning principles ............................................................................................................... 6

5. Delegated Commissioning of Primary Care Medical Services ........................................................ 7

6. The PMS Review .............................................................................................................................. 8

7. What this means for Kingston Primary Care Commissioning Strategy ........................................... 8

8. April 2016 Start Positions ................................................................................................................ 9

9. Primary care investment ............................................................................................................... 12

10. The commissioning intention .................................................................................................... 13

11. The implications for PMS practices ........................................................................................... 13

12. The impact of the London mandatory and optional KPIs ......................................................... 13

13. The implications for Primary Care commissioning ................................................................... 14

14. Immediate next steps .................................................................. Error! Bookmark not defined.

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1. Introduction

This strategy aims to set out the approach to commissioning primary care medical services in Kingston. Its aim is to support the delivery of the Kingston Primary Care Strategy and the vision of: “We want to deliver the highest quality primary care measured by health outcomes, patient experience and staff morale” This commissioning strategy is written in the context of Kingston CCG taking on delegated commissioning of primary care medical services and the opportunity presented to Kingston CCG through the PMS review. This strategy will set out our approach to delivering a model of primary care in Kingston known as Kingston Medical Services and sets out the KPIs/outcomes that we wish to commission, the timescales for commissioning changes and the investment to be made in primary care.

2. Key health priorities

The Public Health England Health Profile for Kingston upon Thames for 2015 and the Kingston Joint Strategic Needs Assessment tell us that:

The health of people in Kingston upon Thames is generally better than the England average.

Deprivation is lower than average, however about 12.3% (3,700) children live in poverty.

Whilst Kingston generally does well across most measures of health, the JSNA identifies three areas where Kingston is worse than the England average:

The rate of sexually transmitted infections is higher

The rate of statutory homelessness is higher

The rate of excess winter deaths is higher In addition, there are health measures which if not monitored closely may become worse over time. These are the measures where Kingston is not significantly different from the England average. These measures include alcohol specific hospital stays, smoking prevalence, incidence of malignant melanoma (skin cancer), incidence of TB, hip fractures in

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people aged 65 and over, infant mortality and under 75 mortality rate due to cardiovascular disease. Whilst Kingston is healthier overall than the national or London population, these figures mask some stark differences between local areas;

Cambridge Road Estate is in the most deprived 20% of areas in England;

The differences in the life expectancy between people living in the most deprived and the least deprived areas of Kingston are 4.8 years for men and 2.9 years for women.

The three leading causes of deaths contributing to the difference in life expectancy are cardiovascular disease, cancers and respiratory diseasei:

Cardiovascular disease (CVD) causes o 27.5% of deaths at all ages o 21.8% of deaths in people aged under 75;

Cancers account for 26.8% of all deaths in Kingston but are responsible for 44.4% of deaths in people aged less than 75;

Respiratory disease (which includes pneumonia, bronchitis, emphysema and chronic obstructive pulmonary disease)cause 13.9% of all deaths and 6.9%% of deaths in people aged under 75;

All three major causes of death have preventable risk factors which include smoking, diet, exercise and excess alcohol consumption. Actions to address these are prioritised in the Kingston Annual Public Health report 2015 and will involve primary care working in partnership with Royal Borough Kingston and Your Healthcare to maximise the outcomes for the Kingston population. Delivery of the Primary Care Strategy in 2016/17 will require investment will be targeted at increasing access to GP and nurse appointments, working with the primary care providers in networks and GP Chambers to support the redesign of key pathways and enable activity shift to primary care settings, delivery of the London specifications: Accessible, Coordinated and Proactive, development and delivery of the Kingston Primary Care commissioning strategy and local contract, and improving primary care detection and management of:

CVD

Diabetes

Dementia

Mental Health

COPD

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3. Right Care / Commissioning for Value

A key principle of any commissioning is to secure the best possible outcomes within available resources. Part of the commissioning cycle involves looking at what is already provided and making commissioning decision on whether the current service or pathway represents the best outcomes for patients. The Right Care and Commissioning for Values tools indicate opportunities for both

improving quality and improving the value for money in what we commission (spend) in a

number of areas. The illustration below shows the areas that the Right Care analysis

indicates we could improve in both quality and spend. Each of these areas that can be

influenced by primary care and are included in our Primary Care commissioning strategy:

Royal Borough of Kingston public health analysis of the prevention opportunities suggests

that we should be prioritising both primary (preventing disease) and secondary prevention

(detecting disease early) in the following areas:

Diabetes prevention & detection

Spend & Outcomes

Circulation

Endocrine

Mental Health

Outcomes

Respiratory

Cancer

Circulation

Endocrine

Genito Urinary

Spend

Musculoskeletal

Endocrine

Circulation

Trauma & Injuries

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CVD prevention, detection and management

Hypertension detection and treatment

Dementia detection and management

Cancer screening & prevention

Smoking cessation

Obesity prevention

Physical activity promotion

Alcohol reduction

Mental Wellbeing Promotion

NHS Workforce Health promotion

The key messages we have taken from all of the above analyses include:

There is work to do with primary care improving the detection and optimal management of LTCs, particularly diabetes, cardiovascular disease including atrial fibrillation and hypertension, and dementia, and respiratory disease (particularly asthma)

Reinforces the need to invest in primary care to support the redesign of ambulatory care pathways

Mental health is a recurring theme with opportunities for improvements in outcomes, quality and savings, reinforcing the need for the current training in primary care on mental health, highlighting the need to redesign the whole pathway

Screening and early detection of cancer could be improved

A deep dive is required on Musculoskeletal for adults and children to understand the divers for higher spend, hospital attendances and outcomes

A deep dive into complex patients is required to understand the appropriate interventions to make the largest impact

4. Commissioning principles

Kingston CCG has recognised that the combination of delegated commissioning and the PMS review gives us a unique opportunity to increase the equity of access and quality of services across Kingston. KCCG has already agreed:

Investment in general practice in Kingston will increase

No practice will be destabilised due to the PMS review

We will commission the services that have the maximum impact on our population health

We will raise access & quality across all Kingston practices

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5. Delegated Commissioning of Primary Care Medical Services

Kingston CCG (KCCG) membership voted overwhelmingly in favour of delegated commissioning as we believe that the opportunity to assume full responsibility for commissioning general practice medical services enables us to shape the way in which primary care develops and empowers the local health and social care system to improve out of hospital services for the local population and supports the shift in investment from acute to primary and community settings. Delegated Commissioning arrangements give CCGs full responsibility for commissioning general practice services. Delegated responsibilities will include:

Contractual GP performance management

Budget management

Complaints management

Design of local incentive schemes as an alternative to QoF and DESs

Delegated commissioning arrangements will exclude any individual GP performance management. NHSE will also be responsible for the administration of payments and list management

We recognised that the opportunities that come with full delegation arrangements include:

GPs in CCGs to have direct leadership to influence the development of investment in general practice

Ability to design local schemes to replace QOF and DES contracts based on local knowledge

CCGs will have more power to drive the five year forward view agenda

Greater freedom for how primary care finances are used

Local decisions closer to patients’ needs

Ability to use innovative commissioning to implement local priorities

Better care for patients via joined up working

Tailored services to meet the local needs of the patient population

Local patients have greater opportunities to input and influence

As of the 1st April 2016 KCCG will be responsible for commissioning primary care medical services. We believe that this gives us a unique opportunity to make a difference for local population outcomes. Legally NHSE will retain the residual liability for the performance of primary medical care commissioning.

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6. The PMS Review

There is a national mandate to review the services and standards currently commissioned through Local Personal Medical Services (PMS) agreements to ensure equity of provision across all general practices. Kingston CCG is in a unique position in South West London with 11 of the 26 practices in Kingston being PMS practices. This has meant that significant additional investment has been made in general practices in Kingston, supporting additional services and standards to just under half of Kingston’s population and provided a unique pool of learning of best practice and innovation. We believe that the PMS review represents a significant opportunity to review and learn from the existing PMS services and standards and commission those services that meet our population health needs and represent best practice across all practices in Kingston. This change in commissioning approach – commissioning best value care that meets out population need across all Kingston practices is achievable as Kingston CCG has committed to invest in primary care to bring all practices up to the highest standard possible.

7. What this means for Kingston Medical Services

We will invest in general practice to deliver high quality care for the whole of the Kingston population. The investment will be focussed on ‘outcomes’ not ‘process’. The Primary Care Commissioning Strategy will draw on one local ‘primary care investment fund’ to support delivery of the Kingston Medical Services model. The local fund will be targeted at GMS practices in the first instance and is called GMS+. We recognise that both GMS & PMS practices in Kingston have been innovative. The commissioning strategy aims to embed the learning and best practice across all general practices. This will mean that we decommission services that no longer represent best value and will instead commission services that better meet population health need. We recognise that Kingston general practice is already delivering good quality primary care services. The aim is to move to the highest quality for the whole population as soon as possible without destabilising general practice(s). The yard stick by which this commissioning strategy will be measured is “we will ensure fairness, equity and transparency in the way general practice services are being commissioned”.

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8. April 2016 Start Positions

KCCG has had a PMS Review Task & Finish Group in place since the year start that has included key stakeholders and been supported by NHSE London appointed consultants. The key piece of work that the independent consultants have produced is the financial methodology and model that has enabled us to understand the start position for the PMS practices on 1st April and allows us to model the impact of commissioning and decommissioning decisions on the existing and new KPIs. The methodology has been developed and tested over a number of weeks and we are now confident that the data included in the model and the values arrived indicated are robust.

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Table 1: 2016/17 Start Positions

Table 1 above demonstrates the start point for both PMS and GMS practices on the 1st April 2016. For the GMS practices the start position reflects the GMS contract value only. For the PMS practices the start position includes all current local PMS KPIs, the London Mandatory and optional KPIs. Table 2 overleaf illustrates the impact of the London offer on the existing PMS budget.

Expected position as at 1st April 2016

CCG No

Total Raw

List size as at

01/01/16

Total

Normalised

Weighted

List size as at

01/01/16

Total

Contract

value after

adjustments

Total GMS

Baseline

£76.51 pwp

(plus London

supplement

@ £2.18 prp)

Total PMS

Premium Value

- difference

between PMS

baseline and

GMS price (incl.

London

supplement)

Total GMS

MPIG

Average Price

£ pwp (incl .

London

Supplement,

before OOH

deduction)

Average GMS

baseline Price

equivalent £

pwp, incl.

London

Supplement

Average PMS

Premium Price

- difference

PMS £ pwp and

GMS

equivalent £

pwp (incl.

London

Lowest £

per patient

Highest £

per

patient

PMS Practices 11 99,215 86,482.98 8,982,297 6,833,101 2,149,196 0 £103.88 £79.03 £24.86 £103.61 £104.31

GMS Practices 13 100,269 88,287 7,277,562 6,973,428 0 304,134 £82.25 £78.95 £0.00 £78.65 £94.15

APMS 2 3,144 2,383.36 0 0

Kingston Totals 26 0 0 202,628 177,153 16,259,859 13,806,529 2,149,196 304,134

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Table 2: Breakdown of the cost of the PMS offer based on the London Offer and Local KPIs

The introduction of the London ‘offer’ for PMS practices means that the London KPIs must be met first from the existing PMS budget. The cost of meeting the London offer for the PMS practices is £659,768.26. This means that as a commissioner KCCG will be decommissioning a number of the existing PMS KPIs to be able to deliver the mandatory KPIs across PMS practices, as per the new PMS contractual requirements. Table 3: Breakdown of how the current PMS cost is built up

Cost of Offer to PMS Practices£262,908.26

£396,860.00

£1,881,004.82

£2,540,773.07

Unallocated Premium -£391,577.32

£2,149,195.76

Total Mandatory

Weekend Additional Capacity

Total Local Initiatives

Total Allocated

London Optional (£pwp)

£0.00

Plus

£2.18

Local Initiative (£pwp)

£21.75

Weekend Additional Capacity (£pwp)

£4.59

Mandatory (£pwp)

£3.04

Core Price (£pwp)

£76.51

Plus

London Supplement (per raw patient)

£2.18

£105.89

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9. Primary care investment

Kingston CCG held two engagement workshops with its PMS and GMS practices, and provided monthly updates to the Council of Members. The key messages from the workshops included:

• Overwhelming agreement to the strategy of investment in general practice • Awareness of historical inequity • A desire to move forward • Move away from the language of PMS & GMS to ‘Kingston Medical Services’ (KMS) • A challenge on the pace of change • Recognition that the current suite of PMS KPIs will change • Recognition that performance against KPIs will be more rigorously monitored • Recognition that the CCG commissioners retain the right to ‘flex’ the contract held

with practices accordingly Clinical commissioners in Kingston are committed to the transformation of primary care as part of delivering the out of hospital, proactive and preventative strategies. We recognise that significant change is needed and that this offers us a unique opportunity to invest in primary care and build a suite a local KPIs / outcomes that enable the transformation of primary care locally. KCCG has agreed to pump prime investment of £1m in 2016/17 into the GMS+ fund. £0.5m is recurrent monies and £0.5 non recurrent. The challenge will be to achieve the transformation supporting the delivery of the Out of Hospital strategy, to shift activity from the acute setting to primary / community. Table 4: The Primary Care Investment plan

We are looking to ‘pump-prime’ GMS+ in 2016/17 bringing forward equalisation by a year. This is not free money, this represents significant investment in the transformation of primary care and we will need to work collaboratively to ensure this is recurrent investment. Kingston CCG has agreed to use its £2.50 per head (£500,000) to create a GMS+ fund to start on 1st April 2016. Kingston CCG has added an additional £500,000 to the 2016/17 GMS+ to pump prime transformation and equalisation.

2016/17 2017/18 2018/19

GMS Investment £1,011,826.65 £1,533,885.66 £2,067,841.67

GMS ‘Premium’ £11.34 £17.00 £22.63

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10. The commissioning intention

Whilst Kingston CCG will be investing in general practice we will not be offering the full suite of existing local KPIs to all practices. There are two reasons for this position:

(1) Outcomes: We need to demonstrate that the local investment in general practice is targeted at those areas that make the most difference to our local population

(2) Affordability: The cost of meeting the mandatory London KPIs for the PMS practices comes out of the existing PMS budget. This effectively means that as commissioners we will need to decommission a number of the existing PMS KPIs to be able to deliver the London offer KPIs across PMS practices.

Kingston CCG has started the process of reviewing the existing local KPIs to determine those KPIs that deliver the outcomes required whilst representing value for money. This is a current and ongoing engagement programme with Kingston practices.

11. The implications for PMS practices

As commissioners we recognise that the additional services that the PMS practices have been able to provide to the Kingston population have clearly added value to the primary care landscape in Kingston and we wish to draw on that learning and innovation. As part of the national PMS review mandate KCCG has had a PMS Review Task & Finish Group in place since the year start that has included key stakeholders and been supported by NHSE London appointed consultants. The key piece of work that the consultants have produced is the financial methodology and model that has enabled us to understand the start position for the PMS practices on 1st April and allows us to model the impact of commissioning and decommissioning decisions on the existing and new KPIs. The methodology has been developed and tested over a number of weeks and we are now confident that the data included in the model and the values arrived indicated are robust.

12. The impact of the London mandatory and optional KPIs

Kingston PMS practices will be contractually required to deliver the London mandatory as part of the new PMS contract. This means that for the PMS practices the current PMS premium is firstly allocated to meeting the London KPIs and then allocated to locally selected KPIs.

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KCCG as a commissioner is currently in conversation with Kingston general practice reviewing the existing PMS KPIs with the aim of identifying the KPIs that would offer the maximum benefit going forward.

13. The implications for Primary Care commissioning

The global sum for PMS practices currently stands at £2,149,196. This is equivalent to £24.85 per weighted patient. The introduction of the London offer for PMS practices will cost £659,768.26. This is made up of the Mandatory KPIs costed at £3.04 pwp and the Weekend Additional Capacity with an average cost of £4.59 pwp. Meeting the cost of the London KPIs reduces the start figure of £24.85 to £17.22 per weighted patient. The proposed commissioning strategy is to commission the London mandatory at scale to ensure 100% coverage and maximise value for money. The existing locally selected KPIs are under review and a suite of new KPIs will be selected based on outcomes and value. This suite of KPIs will be offered as a menu that all practices can chose from up to the value of £17.22 per weighted patient. A system on intra-practice referrals to ensure that all patients have access to all services will be established with appropriate pricing mechanisms.

14. Kingston Medical Services KPIs

KCCG has established a Local KPI Task & Finish Group to review the existing KPIs and establish a suite of new KPIs. The group has agreed a set of criteria through which the existing KPIs are evaluated and new KPIs selected. The criteria are being tested and comments are welcome:

1) What is the clinical evidence supporting the KPI? 2) What is the size of the population to be covered? 3) What is the evidence of the financial savings to be secured? 4) How will the KPI be measured? 5) Does the KPI promote prevention? 6) What would happen if the KPI was not offered?

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To date the group has agreed two KPIs that have been offered out to all practices:

1) Weekend Additional Capacity – booked in advance appointments 2) Screening, Immunisations & Vaccines

The Local KPIs currently in development include:

1) Paediatric same day appointments 2) Respiratory (children’s) pathway 3) Prevention (focus on cancer screening) 4) Prevention (diabetes)

Areas under consideration for development include:

Back pain / pain management

Risk stratification & links to KCC

Quality to be defined)

The existing PMS KPIs that have been reviewed include:

KPI Value Recommendation

Advanced Quality KPI £3.50 for first 2 years and £3.00 thereafter to maintain Award

Decommission.

Anticoagulation Clinic £1.50 Decommission. Look to replace with a KPI focussed on AF case finding.

Urology and Male LUTS £1.00 Decommission. Look to replace with a KPI focussed on a Prostrate follow up pathway.

Sports Injury Clinic £1.00 Continue in the short term. Look to expand and include within a community MSK service.

Audiology £0.50 Commission. Look at possibility of primary care based audiology service and decommissioning of activity at KHFT.

Engagement with Community Pharmacist

£0.50 to £1.50 (list size dependent)

Decommission.