The professional voice of general practice in Lambeth 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

LAMBETH LOCAL MEDICAL COMMITTEE MEETING

PART I

To be held at 1.00pm on Tuesday 21 February 2012 at

Room ST01 & 2 ground floor, 2-8 Gracefield Gardens, Streatham London SW16 2ST

AGENDA

1.0 1.1

Apologies: To receive apologies

2.0 2.1

Declaration of members’ interests 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 3.1 Minutes of previous LMC meeting on 20 December 2011 (page 3-7) 4.0 Reports of meetings attended by LMC members as LMC representatives 4.1 Londonwide LMC update

To receive an update from the LMC office 4.2 To receive an update from the Chair including:

• Report back from the SE Cluster meeting held on 7 February 2012 4.3 To receive updates from LMC representatives attending local meetings:

• GP Contract Steering Group • Practice Manager Forum • Medicines Management Committee • Lambeth Clinical Commissioning Collaborative Board

5.0 Items for decision: 5.1 Motions for the LMC Conference

6.0 Items for discussion: 6.1 Integrated Care in Lambeth & Southwark – Application for funding from the Guy’s & St Thomas’

Charity (page 8-71 6.2 Once for London principles - to receive the agreed principles for:

- List Maintenance (page 72-79) - Enhanced Services (page 80-96) - PMS Contract Review (page 97-110)

6.3 Sessional/Salaried GPs issues

To discuss any issues

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7.0 Part Two agenda To discuss the agenda

8.0 Items to receive: 8.1 • GPC News - January 2012

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13667 • Important information on safeguarding practice premises and income

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13619 • The M Word issue 6

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13476 • GP commissioning – latest news

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13460 8.2 LEAD: To receive a list of forthcoming LEAD events (page 111-112)

9.0 LMC newsletter To identify items for the next newsletter

10.0 Dates of future meetings: 10.1 LMC/BSJLC meetings:

• Tuesday 24 April 2012 • Tuesday 26 June 2012 • Tuesday 21 August 2012 • Tuesday 23 October 2012 • Tuesday 18 December 2012

Cluster meetings:(Chair and Vice-Chair only)

• Tuesday 3 April 2012 • Tuesday 15 May 2012 • Tuesday 17 July 2012 • Tuesday 2 October 2012 • Tuesday 4 December 2012

11.0 Any other business: At least 24 hours notice should be given of matters to be raised under this item

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LAMBETH LOCAL MEDICAL COMMITTEE MEETING

Part 1 Held at 1.00pm on Tuesday 20 December 2011 at

Gracefield Gardens, Streatham, SW16 2ST

LMC Members: Dr Di Aiken Dr Azhar Ala Dr Arun Gadhok Dr Miriam Ish-Horowicz Dr Nigel Konzon Dr Jenny Law (Chair) Dr Himanshu Patel Dr Lee Winter Ms Lyn Eustace

Londonwide LMC Representatives

Dr Eleanor Scott Ms Ariadne Siotis Mrs Jenny Foley

MINUTES

1.0 Apologies

Apologies were received from; Dr Tyrrell Evans Dr Emma Rowley-Conwy and Dr Neil Vass.

2.0 Declarations of Members’ Interests None.

3.0 Minutes and maters arising The minutes of the meeting held on 25 October 2011 were

agreed as an accurate record.

4.0 Reports of meetings attended by LMC Members as LMC representatives

Dr Scott reported that the principles for Once for London policies had been agreed for List Maintenance, Enhanced Services and PMS. The next tranch would be on appraisal and premises polices.

4.1 LMC update 4.1 & 4.2

Chairs update LMC Membership Dr Law welcomed Dr Ish-Horowicz to the committee and also congratulated Dr Gadhok on becoming the new Vice-Chair. Report back from SE Cluster meeting held on 29 November Dr Scott and Dr Law reported that the following SE Cluster policies had been agreed: GP Locum Reimbursement, CRB Checks and Premises cost reimbursement which was subject to further discussion at the Capital Strategy Estates working group. They also informed the committee that the Revalidation Policy

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had been withdrawn, and minor surgery would be discussed at the working group. Dr Law informed the committee that the LMC made the point that locum doctors should not be treated differently with regards to CRB checks. Dr Law also informed the committee that with regards to the GP Premises Cost Reimbursement policy, Mr Sturgeon had made it clear that if practices were not in possession of a proper lease, they would not receive rent reimbursement. Dr Law also explained that issues about a transfer of an estate from leasehold to freehold was not received very well at the Cluster meeting. Dr Konzon asked if practices would get financial support for lease agreements. Dr Law pointed out that there was a strong bid for Cluster to provide money for DDA and other premises improvements. Ms Siotis indicated that Londonwide LMC office was looking at a paper by Mr Sturgeon which would be used for lease arrangements. Ms Siotis indicated that she would be circulating the final versions of the policies to LMC Members shortly. Dr Law also reported that Cluster would be producing an IT Policy as there were different approaches across all six areas.

4.3 GP Contract Steering Group Information Governance Toolkit Dr Law informed the committee that practices were expected to sign up to the new Information Governance toolkit. However Cluster would not be providing any training and therefore practices would have to use outside organisations if they required training to be provided. Dr Law asked about using the on line toolkit if the areas that needed to be completed were highlighted. The committee agreed to raise this with the BSU and CCG in the part two meeting. EMIS Web Dr Law also reported that EMIS Web had still not been rolled out to practices. Dr Gadhok indicated that practices had received an email asking which system they would prefer. Sharps boxes Dr Law reported that local authorities would no longer be collecting sharps boxes. However it would be acceptable for the boxes to be brought to practices for collection once a form had been completed. PMS Review Dr Law informed the committee that the GP Contract Steering Group would also be the PMS negotiating group. The PMS group would include: Dr Law, Dr Konzon, Dr Gadhok, Mr Sturgeon, Ms Baker, Ms Hornick and Ms Freeman and Ms Siotis from the LMC office.

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SELDOC shifts Dr Law reported that there had been problems filing SELDOC shifts and that a reminder letter had been sent to practices from Ms Baker. Dr Law urged members who were contracted, to check and put themselves forward to cover shifts.

4.2 Practice Managers Forum (PMF) Ms Eustace pointed out that the information that was sent to practices by the BSU with the spreadsheet did not explain what the spreadsheet was for.

4.3 Medicines Management Committee (MMC) Dr Aitken informed the committee that there had been two MMC meetings since the last LMC. The first meeting on 31 October was a joint meeting with Southwark with a view to merging in the future. Dr Aitken indicated that there had been good representation from the acute trust but that Southwark was not sure if they wanted to have joint meetings. Dr Aitken reported from the MMC meeting on 7 December, that guidance on vitamin D had been circulated to practices and pharmacies to ensure more cost effective medicines were used for treating any deficiencies. Dr Aitken also informed the committee that the CCG schedule on prescribing budgets had been circulated and showed that practices were overspent. The MMC was advised that anti malaria prescribing should only be given on the NHS when no other malaria medication worked. Dr Aitken also reported that the problems with ScriptSwitch had been due to human error.

4.4 Lambeth Clinical Commissioning Collaborative Board (LCCCB) Dr Law advised the committee that Dr Ala had agreed to be the LMC representative on the LCCCB as Dr Evans had stood down.

5.0 Items for decision 5.1 LMC Conference – Tuesday 22 and 23 May 2012

Dr Law and Dr Gadhok agreed to be the LMC representatives for the Conference.

6.0 Items for discussion 6.1 The letter from Andrew Lansley regarding the future role of

LMCs was noted.

6.2 The LMC Briefing – Managing conflicts of interest was noted.

6.3 Sessional/salaried GPs issues No issues were raised.

7.0 Part two agenda 7.1 - Virtual Ward (VW) proposal

The committee agreed to raise their concerns about: • the patients on the VW and who would be responsible

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and accountable for them.

• case management by the community matron • sub-contract, a legal agreement would need to be drawn

up which Ms Baker was in the process of getting Capsticks to prepare. Dr Kay supported this. However clarification was needed as this was outside of core primary care.

• Issues about indemnity

Dr Ala indicated that a VW doctor in Wandsworth worked from 9-5 and had access to EMIS Web. The patient would be on the VW for 5 days and the case management would be for 12 weeks with the GP being responsible. Dr Ala added that the community matrons had already been appointed for the pilots in Lambeth and Southwark. Dr Law indicated that she felt pressured to agree the proposal, and would strongly appreciate support from the LMC not to sign up to the proposal. Dr Scott pointed out that Capsticks advice was that GPs would remain medico-legally responsible for their patients. They were also advised that involvement of GPs with the VW should be undertaken as a LES. Dr Winters indicated that the VW proposal would solve the hospital problems but would not fit any of the needs of the GP and agreed that the proposal should be rejected. The committee agreed that until the legal status had been clarified, the LMC was not prepared to have further discussions on the proposal and agreed to state this in the part two meeting. - PMS Contract Review The committee agreed to raise the following concerns:

• The tight timescale and the threat of further money being deducted for QIPP savings if there was any delay in meeting 1 April 2012 deadline.

• Dr Winters would ask about the GMS contracts and how the review will affect them.

• Julian Alexandra’s approach in dealing with practices. 8.0 Items to receive: 8.1 The following items were noted:

• GPC News November 2011 http://www.lmc.org.uk/news/news-detail.aspx?dsid=13471

• Urgent care number (111) and directory of services – latest news http://www.lmc.org.uk/news/newsdetail.aspx?dsid=13367

• Scam alert – CQC registration and the Health Care Research Association (HCRA)

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13167

• Dr Michelle Drage comments on NICE guidance, NHS shared business services and contract overpayments

http://www.lmc.org.uk/news/news-detail.aspx?dsid=13171

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8.2 LEAD The LEAD scheduled was noted.

9.0 LMC Newsletter 9.1 No specific items were identified.

10.0 Dated for future meetings: 10.1 The following dates were noted:

11.0 Any other business 11.1 There was no other business.

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Contents

Chapter Page1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Introduction and summary

A new system for integrated health and social care

The new care pathway for older people

Finance – impact, investment, benefits and flows

Information technology

Workforce

Next steps – long term conditions

Programme support

Evaluation

Income and expenditure

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8

17

32

41

52

54

59

60

62

Appendices:

1. A new system2. Redesign process3. Service specifications4. Finance5. Information technology6. Evaluation proposal

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1. Introduction and summary

1.1 Context

Part-funded by the Guy’s & St Thomas’ Charity, an Integrated Care Pilot (ICP) has been established during 2011 within King’s Health Partners and working across Lambeth and Southwark. The ICP’s work to date, building on existing initiatives where appropriate, forms the basis of this application for substantial funding over a three year period. It sets out proposals that will move beyond the confines of a pilot and to a scaled programme operating across both boroughs. This will take the health and social care system increasingly towards far greater integration.

This application describes a vision of a sustainable integrated system offering high value care for the citizens of Lambeth and Southwark. This will involve the redesign of services and the system and will redefine the way in which professionals engage with each other. It will fundamentally change the way in which people are able to take charge of their own care and conditions.

It sets out a proposal requesting total funding from the Guy’s & St Thomas’ Charity £10.60m over a three year period as part of a system-wide change programme. The proposed phasing of the programme and funding is described elsewhere in the document.

From the programme’s third year onwards the changes made will be self-financing and the transformation seen will mean that every year in Lambeth and Southwark:

15,900 unnecessary days currently spent in hospital are avoided for older people (a reduction of 14%);

118 older people are supported in a way that means they do not have to go into residential care homes (i.e. 18% fewer residential care packages) and;

Savings of £13.9m per annum are released across the system.

This is a start and these figures describe one part of the impact of what will be a broader set of changes. Beyond this and during the same three year period we will take forward a range of service improvements. At the same time we will change clinical and professional behaviours to the extent that patients are able to take charge of their own health and care if that is what they want. We will change the way in which the system is managed and unleash the potential that exists in new or better use of technology.

We will do this by integrating care and re-incentivising the system -driving up quality and doing so at lower cost, improving the value of the care we provide to the people of Lambeth and Southwark.

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In common with other health systems we face mounting pressure and costs as people live longer and their health and social care needs grow more complex. The resource available to support the provision of local services is falling in real terms and the care provided through our services too frequently is perceived by patients as being of poor quality.

Public and patient expectations are rising but all partners agree that at present the care we collectively deliver is fragmented, that communication is often poor and that people’s ability to navigate the system is severely constrained in our local services. At the same time we know the South EastLondon system faces a funding gap of c£500m over the next three years. The status quo is not a sustainable option.

Our headline objective of increased value will be delivered across the whole system by:

Joining care up around people, across providers

Identifying and managing people’s care needs better and intervening earlier

Ensuring care is provided in the most appropriate setting, particularly at times of acute crisis

1.2 A new commitment to the people of Lambeth and Southwark

If this level of radical change is delivered we believe that we can develop a new compact defining what local citizens can expect from their contact with our services:

The offer – integrated care will mean local people can expect to��.

3be healthier, and have their health managed proactively with fewer health emergencies3be treated for mental and physical health needs in a coordinated manner, improving their safety, recovery and wellbeing3be cared for by a single team, rather than feeling ‘passed around’ the system 3only need to give their information once, as patient information will be shared between professionals (with consent) 3have to visit hospital specialists less often, as specialist advice will be available in the community and primary care and community staff will have the skills and support to care for them3be more empowered to manage their own healthcare, and will be able to easily access their own healthcare information and health advice3feel they can get the support they need when they need it – for example, a range of diagnostics in one visit or rapid home care support if appropriate

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We have a particularly significant opportunity to build on the strengths that exist within King’s Health Partners and develop exciting new approaches to the holistic provision of physical and mental healthcare.

1.3 The approach

The ICP has worked across the whole system of health and social care – the three Foundation Trusts (FTs) that make up King’s Health Partners (Guy’s & St Thomas’ Hospital, King’s College Hospital and South London & Maudsley); primary care in Lambeth and Southwark; the London Boroughs of Lambeth and Southwark; and clinical commissioners in both boroughs.

The programme has been designed to support and drive complementary processes of service and system redesign, with core workstreams under both headings:

Service RedesignOlder PeopleLong Term Conditions (COPD, Diabetes, Severe Mental Illness, Cardiovascular Disease and HIV)System RedesignIT and InformaticsFinanceGovernanceWorkforce

This dual focus will be crucial to the delivery of sustainable change. History suggests that to redesign services without challenging the way the system operates creates the risk that the changes will not be embedded and may not survive long beyond the end of the transformational period.

Similarly system change, which again must involve challenging long-established cultural and behavioural traits, would be likely to prove similarly unsustainable if detached from operational reality or being built around anoutdated service model. System change alone could rapidly become unduly focused on transactional processes.

In practice our work on system redesign will come together in our first phase in support of our first service priority: the care of older people.

Two principles underpin our activities. First services must be co-designed in the context of a shared set of objectives and, second, the system must be constructed in a way that supports practitioners in working effectively together. With regard to the principles of effective co-design we will learn from the process of Experience Based Co-Design that has been used so successfully in cancer services locally.

We will only succeed if local people and those providing services and managing the system are driving the change process together.

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1.4 System change

From April 2012 a health and social care Federation will be established in Lambeth and Southwark, binding providers together on a voluntary basis but through a hard contractual framework around agreed pathways of care. A federated model represents the degree of change and movement that the local system can tolerate at this point in time. During the course of the next few years our expectation is that new opportunities and ways of working will begin to emerge, not least as patients become more involved in the design of services.

The role of patients and service users will be central. A Citizen Board is being built into the programme’s governance to ensure a strong voice for local people in the design and operation of services and the system. From the grassroots up we will nurture a dynamic culture of co-production and empowerment. Patients will have the formal opportunity to become partners within the Federation and increasingly to shape the way their care is provided.

We are challenging existing funding flows, with the ambition of moving to a world in which discussions around finance correlate much more closely with real costs in the system. We are focusing systematically on incentives, both financial and non-financial. During the lifetime of the pilot we will seek to develop new forms of tariffs and mechanisms for funding and payment.

International evidence from Valencia to the US Veterans Administration to Singapore highlights IT as representing both a barrier to integration and possibly our single greatest opportunity in leveraging change. This applies equally in South London and our approach is one which focuses initially on getting the most out of our existing systems while thinking ambitiously about what might be possible in the future.

From April 2012 a portal-based solution will be in place to extract key data and support case management. Existing software for risk stratification will be enhanced and access to core systems will be extended along pathways. This means that Multidisciplinary Teams working in the community will have better access to information that will support them in identifying patients who are at risk and enable them to be clear on their status and recent activity. During the course of 2012/13 we will seek to procure a more ambitious solution, providing real time information and supporting more proactive interventions.

The Department of Health published its report on the outputs from the Whole System Demonstrator pilots on telehealth on 7 December, confirming that “if used correctly” telehealth has the potential to drive substantial reductions in hospital activity and a 45% fall in mortality rates. Bringing together the opportunities around telehealth and telecare locally we propose to take this forward at scale through our work on long term conditions.

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1.5 Service change

The first phase of this programme is built around proposals to transform the care of older people, by coordinating care around individuals and maintaining their independence and health. By the start of the third year of implementation these changes will result in a sustainable reduction in demand of 14% of hospital bed days and 18% of residential care placements.

These proposals were developed through a robust whole-system design process, bringing together commissioners and providers, clinicians and other care professionals from all parts of the system. The discussions were shaped by the advice of a User Group, established with the support and guidance of Age UK.

This has resulted in the development of detailed specifications, building on work within related local initiatives (e.g. the Virtual Ward pilots in parts of Lambeth and Southwark). These changes will be implemented from April 2012.

Our next area of focus will be Long Term Conditions. Following a robustprioritisation process, five conditions have been identified – Diabetes, Chronic Obstructive Pulmnary Disease (COPD), Cardiovascular Disease (CVD), Serious Mental Illness (SMI) and HIV. This list correlates strongly with the needs of the people living in our communities and the opportunities to develop new approaches to chronic care are exciting and significant. The level of local need in areas such as Diabetes has been recognised through the Charity’s support of the Modernisation Initiative (MI). Prevalence of HIV and SMI in Lambeth and Southwark, however, is the highest in Europe and highlights both the need and the potential for groundbreaking activity.

It is in our work on Long Term Conditions that the effective deployment of assistive technology will have the greatest impact and our use of telehealth and care locally will be taken forward in tandem with the development of new models of chronic care.

In three years we will have implemented these changes at scale, working with those in need and intervening early and proactively. We will have established and embedded principles of co-production and patients will have been supported to take charge of their conditions and their lives.

1.6 Programme plan

Significant work is in hand in preparation for the go-live of the new pathway for older people in April 2012. This involves the coming together of a number of strands and streams of work and builds on initiatives such as the piloting of the Virtual Ward. Plans are in place to support these processes:

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Primary Care Interventions Agreed

Social Care Redesign Agreed

Training and

Comms Plans

Finalised

RRoll Out of All Primary and Social Care Service and

Training Requirements

Example text

PROGRAMME TIMELINE �INTEGRATED CARE FOR OLDER PEOPLE

MAR 2012 APR 2012FEB 2012JAN 2012DEC 2011WORKSTREAMWORKSTREAM

CLINICAL &

SOCIAL CARE

PATHWAY

REDESIGN

ENGAGEMENT

INFORMATION

TECHNOLOGY

METRICS

GOVERNANCE

WORKFORCE/

CONTRACTS

”FIND”*1 Requirements

Captured”FIND” - Negotiation and Implementation of additional

resources

PUBLIC – response to proposals

GP – Practice and Locality Visits for 1st wave sign up

PUBLIC – Ongoing Service feedback

Ongoing GP Visits to advise on subsequent signup

Feedback from Wave 1 Practices and LocalitiesIT Governance Reference GroupInterim Case Management Tool developed based on exiisting systems

Deployment and Training Roll Out

Risk Stratification –

PHMCC aligned to ICPDeployment and Training Roll Out

Telemedicine - feasibility and costings assessment Roll Out following costings agreement

Initial Quality and Outcome Indicators Agreed

Collection and Reporting Systems FormalisedSystems Implementation

Agree to establish Federative Structure with new Board. BOARD BOARD

Assessment of training requirements, organisational design options and resource deployment with follow on adjustmentsto and appropiate drafting of, all related contracts

W/F change Implementation

”FIND”*1 - Negotiation and Implementation of additional resources

*1 – “FIND” – new services for Falls, Infection, Nutrition &

Dementia

The programme is also looking ahead to the full implementation of the pathway for older people in Lambeth and Southwark, the implementation of a full IT solution and the development of proposals for Long Term Conditions.

1.7 Funding requested

This submission describes and draws on detailed work undertaken to date, supported in part by funding from the Charity of £250k.

A detailed breakdown of the funding requested, timing, funds available from other sources and the cost of each element of the proposal is set out elsewhere in this paper and in the supporting appendices.

The ICP Programme Board commends this proposal to the Guy’s & St Thomas’ Charity’s Strategy Committee for consideration.

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2. A new system of integrated health and social care

2.1 Introduction

Our current system is fragmented, decision-making is disjointed and relationships are nurtured and maintained despite the system rules rather than because of them. We plan to change this by moving to a less transactional way of doing business, by establishing principles of shared decision-making and through an unrelenting focus on value to the system and to the individual patient or citizen. We will do this in a way that puts the patient at the centre of the decision-making process and, where necessary, challenges established culture and behaviour.

We are putting in place the governance that we believe will work in Lambeth and Southwark at this point in time. The nature and complexity of the relationships in our system mean that trust will need to be built, in some cases from a relatively low base. Our belief is that the most effective way of building that trust is by forging new relationships, between practitioners and between practitioners and the local people who use our services. During the course of the next three years and beyond we will test different models and seek solutions that lead to genuinely patient or user-centred services.

Given this context we are developing arrangements for system governance that:

Support new partnerships without threatening autonomy.

Establish a Federation of health and social care providers with an overarching Integrated Care Board structure, working in partnership with commissioners and responsible for the shared delivery of care along agreed pathways.

Provide clear structures for shared decision-making in support of the Board, operational oversight and risk management, based on principles of equality, transparency and proportionality.

Introduce clear processes to drive continuous improvement in qualityand a detailed understanding of the financial implications of the system’s actions.

Is underpinned by a robust delivery model and contractual framework, in which incentives are aligned and mechanisms are in place to manage operational, clinical and financial risk.

We are committed to developing new ways of working with local people and communities and will ensure patients are fully and formally engaged. We will build on the User Group format that has supported our work on Older People and, as our design process for Long Term Conditions takes shape we will look

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to draw on the best elements of established local initiatives – particularly the Lambeth Living Well Collaborative and Diabetes Modernisation Initiative - in developing a new approach to co-production.

2.2 Lambeth and Southwark Care Federation (LSCF)

The principles that have supported our work – set firmly in the context of inner South London in 2011/12 – are set out below.

Integrated Care in Lambeth and Southwark���

...will not mean vertical integration between primary and secondary care or the creation of a new organisational structure3will develop ways of working that place the citizen in charge of their care3must be based on principles of equal partnership3will involve shared decision-making in the best interests of the system and local people3will involve the realignment of incentives throughout the system, challenging existing funding flows and developing new models in partnership3will be supported by transparency and openness between partners

The Federation will have no legal standing and will not involve changes to organisational form. Rather it will involve a contractual agreement between autonomous providers, coming together to provide care along agreed pathways and in a way that can drive rapid change in the way that strategy is developed, operational issues resolved and decisions made at a system level.

It is likely that the LSCF will involve a grouping of the willing in the first instance – community services, general practice, one or more acute FTs and one or more Local Authorities. We envisage that this will scale up to the point of full coverage across Lambeth and Southwark over a period of 12-18 months. For the first time GPs, Local Authorities and NHS organisations will work together through formally established processes to make decisions with local people in the best interests of the local system.

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2.2.1 The role of patients and local people

At its heart the ICP is about protecting and improving outcomes and people’s experience of services in a deeply challenging fiscal environment. This is a significant challenge and success will be partly dependent on the extent to which it proves possible to forge a new sense of shared purpose with the local population.

There are three main elements to the approach to working with and accessing the views and expertise of local people:

Patients will have the opportunity to become a partner within the federated model;

Co-production and empowerment will be nurtured, building on the learning from the Lambeth Living Well Collaborative and their work with NESTA and working up from the level of the encounter between clinician and patient;

A Citizen Board will be established as part of the formal governance of the programme, ensuring a strong voice and influence for local citizens.

The invitation to become a partner will be exercised through an initial documented conversation with the patient’s care coordinator and will mean that the patient understands and is able to influence:

What we are trying to achieve and what their role can be;

What the implications might be for them and what they need to know (for example in the way information relating to their care might be used);

Who is responsible for coordinating their care and how they can work with them to ensure they get the care that is right for them.

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There is an explicit objective for Year One to make progress in giving patients access to and increasingly ownership of the information relating to their care. Through systems of regular two-way communication a live dialogue with local people will be built and an increasingly powerful asset base can be created as local communities are mobilised.

These structures will be built in from the spring and the approach will be developed as part of the programme’s development work on long term conditions.

2.2.2 Contractual framework

There are a number of contractual vehicles which could be used to support a federated model. The primary contractual relationship required to support the approach is between the main providers - acute and community health services, general practice and social care. This could be formalised through aFederation Contract, based on Alliancing principles. The Living Well Collaborative is likely to move to an Alliance Contract shortly.

Other options include the establishment of a new legal entity or organisation (an ICO) and a Prime Contractor route. The first of these has been ruled out, while the second has generally been judged less attractive at this stage. This is largely on the basis that both could be perceived as a form of acute takeover. These issues are being worked through as part of ongoing detailed discussion and as part of the 2012/13 business planning and contracting round.

This could also have implications for the nature of the main contract between commissioners and providers for non-elective care and will be set firmly in the context of that broader negotiation. Over time a more joined up approach could have the potential to support a significant reduction in transaction costs to the system.

A more detailed breakdown of the contractual options is set out at Appendix 1b.

A Memorandum of Understanding (MoU) will be held by each of these providers, simply and transparently setting out the system’s requirements of them (i.e. what they will need to do) and the risks that they are accepting. Risk must be proportionate, reflecting the fact that this will involve partnerships between large Foundation Trusts with general practice and social care and that capacity to take on risk will vary. An agreement will be required to put elements of funding at risk to support the establishment of a risk pool to support the developments that are necessary elsewhere in the system. KHP Co is a vehicle that already exists and that could be used for this purpose – effectively acting as the bank.

The ambition for the next three years is to develop the trust and relationships through the LCSF that will support an exploration of different forms of governance, in partnership.

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2.2.3 Benefits and risks

The primary incentives to integrate around and along end to end pathways are clearly the potential for an improvement in the quality of local services and the patient’s experience of joined-up care. There are also a series of financial and operational incentives and drivers for change of this kind:

Primary Care Better access to information from hospitals

Better access to specialist advice

Better relationships with social care

Support in identifying high-risk patients

Financial incentives (Local Enhanced Service)

More investment in services in the communitySocial Care More investment in services in the community

Potential to reduce number of expensive packages

Better relationships with local hospitals and GPsSecondary Care Reduction in levels of loss-making activity

Opportunity to expand tertiary or other activity in reallocated beds

Opportunity for smoother urgent care pathway

Potential for positive impact on performance in ED

Improved discharge and length of stayCommissioners Move to commissioning for pathways

Simpler set of relationships – with the system

Less adversarial environment

Could test market in due course if appropriate

These incentives are described in more detail in Chapter Four. If properly aligned these incentives, supported by a different approach to the management of risk and contracting, have the potential to drive significant changes in behaviour within the system. In subsequent years we will look increasingly to introduce and develop new forms of tariffs (e.g. Year of Care) and ways of working, particularly through our work on long term conditions.

It will also be important that some of the risks to delivery are acknowledged equally clearly. These could range from the state of readiness of services in some parts of the community, to the ability of the acute sector to redeploy or close capacity, to the willingness of individual GPs to change some of their ways of working.

All these issues will be explicitly identified, worked through and addressed in the development of contracts and the establishment of our new system governance.

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2.3 Integrated Care Board

An Integrated Care Board (ICB) will provide system leadership, supported by strong operational and strategic support structures:

The Integrated Care Board will be made up of:

GPs in their capacity as providers, nominated by their locality or CMDT,

Director of Clinical Strategy, King’s Health Partners,

Chief Executives of the three NHS Foundation Trusts,

Directors of Adult Care, London Boroughs of Lambeth and Southwark,

Lambeth and Southwark clinical commissioners.

Voting rights will be established, but in such a way that no one part of thesystem has a majority and that unanimous decisions are encouraged. Decisions will be made and issues resolved in line with the objectives supporting the establishment of the Federation. A robust dispute resolution process will be agreed for use if necessary.

GP membership will be made up of the nominated representatives of those areas in general practice that have formally joined the Federation. Membership will be for a minimum of one year

The Board’s role will be one of system oversight and leadership and it will be supported through strong supporting structures.

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Operations Group Design Group Finance Group

Oversight of implementation and system quality and effectiveness. Direct relationships with both the Board and the CMDTs.

Strategic oversight of implementation to ensure consistency with design principles. Responsibility for ongoing development work across all workstreams.

Oversight of funding flows and measurement of impact. Ensures consistency of financial planning andmanagement. Shared responsibility with Design Group for development work on tariffs and incentives.

Membership:

KHP CAG Leaders –clinical and management;Director of Operations –Community Services;Nominated GPs;Senior nurse practitioner;Deputy Directors – Adult Social CareNHS commissioners

Membership:

Directors of Commissioning;KHP Directors of Strategy;Director of Operations –Community Services;Director – Diabetes Modernisation Initiative

Membership:

KHP Directors/Deputy Directors of Finance;Directors of Finance, NHS Lambeth and Southwark;Social care finance leads

2.3.1 Community Multidisciplinary Teams (CMDTs)

It is proposed that CMDTs are established, most likely working at the level of a locality and building on the model that is currently being taken forward through the local piloting of the Virtual Ward in Lambeth and Southwark.They will be made up of staff already in the system with targeted recruitment where appropriate (Appendix 3 sets out the detailed proposals).

The core of the CMDT will mirror the system-level governance and will comprise community nursing, the GP and the social worker, with specialist advice available from geriatricians or other acute physicians as appropriate. The case manager – most likely either a community nurse or a nurse in primary care – will have a key role and will hold the relationship with the patient. Support will be needed for both patients and case managers in shifting the balance in the relationship to a point where the patient and/or their carer are able to take an active lead in their care. The case manager will then need to be able to represent the patient’s perspective within the CMDT.

Supported by risk stratification software and information drawn from other systems, the team will come together monthly to focus on the needs of individual older people, and at each of its meetings (or perhaps bi-monthly) it will also discuss the quality of care being provided in that locality.

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It will:

Consider its performance, and compare it to the performance of other localities in its regular meetings

Review outcomes for patients living in that locality and comparethem to other localities

Review the contribution of individual providers or teams in that locality, drawing comparisons within the locality and outside it

Make decisions about how to improve quality and effectiveness within individual local providers, in line with the agreed care pathway

Feed any suggestions for pathway change to improve system value to the Operations Group.

Active participation in the CMDT will be a requirement of joining the Federation. Face to face meetings will work best as relationships within the team are developed, though tele and video conferencing may well make the management of the discussions increasingly efficient over time.

The role of the Operations and Finance Groups will be crucial to the effective running of the new system – they will hold the ring on implementation and monitoring and oversee the circular flow of key items of information from CMDTs to the ICB and back again.

The Design Group will retain strategic oversight of the development work on new pathways and new forms of incentives and governance, as well as seeking assurance that implementation processes remain true to the programme’s objectives.

.2.3.2 A quality system

A quality monitoring system is fundamental to the success of integrated care,to ensure that key commitments set out in contracts are observed but more importantly, to drive improvement within and across providers. The quality system will be overseen by the Operations Group and both its contents (the quality indicators it monitors) and the way it operates will be key. Principles of the proposed system are:

Quality SystemContents: what is monitored

The system will monitor outcomes where possible, as well as the aspects of processes which are necessary to achieve those outcomes:

Overall system outcomes, reflecting the performance of the system

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as a whole:- patients’ views of care - whether activity has shifted to community settings compared to

target levels- whether overall costs have reduced

Individual provider group contributions (e.g. the contribution of all GP practices combined):- outcome measures, where that outcome can be attributed to the

action of a single provider type (a limited number)- process measures, where those processes need to be achieved

within individual provider types in order to give good system outcomes (e.g. the proportion of screening assessments delivered against target)

Individual provider contributions (e.g. the contribution of individual GP practices) in relation to process measures at that provider.

Examples of proposed quality measures can be seen in Appendix 1a.These quality measures have been gathered in discussion with providers and commissioners, and the framework are being rigorously refined and tested in the run up to implementation in April 2012.

Process: how the system works to drive improvement

All providers, and clinical frontline as well as managerial staff within those providers, need to be engaged in the quality system for it to support improvement. Information has to be made available at a level of detail relevant to those people. Various levels of engagement are therefore proposed, the main areas of focus being the Operations Group and the local CMDT.

The purpose of quality monitoring should be two-fold: - to support and challenge performance in individual providers

- to drive changes in pathway redesign, if there is evidence that the current design is not giving good value

The Integrated Care Board will meet for the first time in shadow form in February 2012 and the Operations, Finance and Design Groups are in place. The new systems will be formally established from April.

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3. Services for older people

The implementation of the proposals to be introduced for older people under the ICP’s first phase – developed through codesign between local professionals and older people – will transform the care of older people and their experience of services, by coordinating care around individuals and maintaining their independence and health. By the start of the third year of implementation it will result in a sustainable reduction in demand of 15,900 hospital bed days (14.4% of current demand) per year and 118 (18% ofcurrent) residential care placements.

3.1 The challenge

Older people can have complex needs and often receive care and support from a number of parts of the health and social care system. This can result ina poor experience not only because of fragmentation, but because separate professionals working with them may not identify their full needs, or act in concert to keep them as healthy and independent as possible.

3.1.1 Older people in Lambeth and Southwark

There are 49,500 older people aged 65 or over in Lambeth and Southwark, 7000 of whom are aged over 85. This is within a total population of around half a million. While, therefore, the proportion of older people locally is low compared to the UK average, these older people have relatively high levels of need and interaction with health and social care (see Box 1). The current balance of care for older people is not preventative, and tends towards higher-intensity and high-cost interventions (Figure 1). Given the high level of need in

Mrs Ibrahim is 83. Over the last two years she has fallen occasionally. She has ended up in A&E twice, once with a broken arm. She put this down to just getting old, but it has dented her confidence and she does not like to go out now, so her mobility has got worse. She lives in a small house with an upstairs toilet and her husband does all the shopping. Last month she fell again and broke her hip. After emergency surgery she spent five weeks in hospital. She has not recovered well with therapy and now she and her family are talking to social services about placing her in a care home. She is staying in hospital for longer while this is sorted out. She and her husband are very upset but he would not be able to cope at home.

Mr Buckley is 78 and lives alone at home. He has type 1 diabetes and a history of Urinary Tract Infections (UTIs) but these have been managed through antibiotics prescribed by his GP. One morning his neighbour contacted his GP, because Mr Buckley seemingly had another UTI but this time with a high fever; he was also confused. Mr Buckley was admitted to hospital for a course of IV antibiotics lasting 5 days but returned home after two weeks because he was assessed as needing home care and had to wait for the package to be in place.

Mrs Okoye is 81 and lives with her daughter. She has mid-stage dementia and is on medication, but her daughter who works part time is finding it increasingly hard to care for her. She has been to hospital twice over the last year for different reasons. Then she was admitted again with a chest infection following on from flu, and was in hospital for three weeks, and lost a lot of weight. Her daughter now says she cannot cope any more and wants her mother to go into a home.

We want to change things for Mrs Ibrahim, Mr Buckley and Mrs Okoye and their families.

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what is a relatively small ‘target’ population, there is a real opportunity to help people improve their outcomes. We will do this by focusing on their needs better, intervening more appropriately, and rebalancing the way we provide care across community and higher-intensity settings, to be more effective and efficient.

Box 1: Older people in Lambeth and Southwark:28,000 (57%) of older people (aged 65+) live in social housing 23,600 (48%) have a limiting long-term illness and 8900 (18%) need help with mobilityThey account for 29,000 ED/A&E attendances a year at local hospitalsThere are 15,000 emergency admissions involving an overnight stay every year, of which 1,420 last more than 30 days21% of emergency admissions for older people are within 30 days of a previous emergency admission (compared to about 5% for the population as a whole)The later in the day that older people attend A&E, the more likely they are to be admitted1055 older people live in care homes and 1040 receive intensive home care for more than 15 hours a week

______________________________________________________________Figure 1: The current balance of care is not preventative or coordinated and results in high use of hospital and institutional care

results in 110,000 hospital emergency bed-days and 238,000 residential care bed-days per year for older people______________________________________________________________

Poor proactive identificationof need and largely uncoordinatedintervention, increasing likelihood ofdeterioration:

Crises often result in admission:

Very limited

screening in

a few

practices

No

access to

specialist

opinion

and MDT

workup

unless

admitted

Protracted

discharge

process

Little capacity

to respond in

the

community so

people are

admitted

enablement

function for

some

(500 per

year)

Single-

discipline

interventions

and limited

matron case

management

(1200 per

year)

Limitedopportunity tomaximiseindependencebeforelong-term care isfinalised:

People

in acutecrisis

People

who canstay at

homeAllolderpeople

Poor proactive identificationof need and largely uncoordinatedintervention, increasing likelihood ofdeterioration:

Crises often result in admission:

Very limited

screening in

a few

practices

Very limited

screening in

a few

practices

No

access to

specialist

opinion

and MDT

workup

unless

admitted

Protracted

discharge

process

Protracted

discharge

process

Little capacity

to respond in

the

community so

people are

admitted

enablement

function for

some

(500 per

year)

Single-

discipline

interventions

and limited

matron case

management

(1200 per

year)

Limitedopportunity tomaximiseindependencebeforelong-term care isfinalised:

People

in acutecrisis

People

who canstay at

homeAllolderpeople

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3.1.2 Older people’s views1

Local older people strongly support the aims identified through the ICP. They do not want to be admitted to care homes or hospital; they are worried about cleanliness, infections and dignity. They would rather be assessed quickly –and return home for treatment in the community if possible. If they do have to go to hospital, they want far better communication after discharge, with a named person proactively contacting them, and better access to temporary support from a nurse or social care at home. At the moment there can be a sense of being ‘dumped in the community’.

They value continuity of care and communication with the same professionals, people who know them (so they aren’t patronised, and don’t have to keep repeating themselves), and people they trust. They would like better access to specialist health advice and more time with someone to talk, for example about the side-effects of medicines or more general concerns.

They also think there should be far better liaison between physical and mental health; they recounted a number of experiences of late diagnosis of dementia, and untreated depression.

3.2 The new care pathway

A professional group of 40 people was established, to:

‘design a holistic pathway of care for older people that not only improved people’s experience but also increases the value of the system – i.e. achieves better outcomes for the same or less cost’.

An older people’s reference group of around 25 people, run with the support of Age UK, met a number of times to test and feed back on the professional group’s proposals. Following an intensive and iterative design process (seeAppendix 2) a generic pathway was set out. This would address the needs of older people holistically, through integrated teams and processes including physical and mental health and social care (Figure 2). The new system will put increased emphasis on preventative interventions delivered in the community which will reduce the reliance on residential and hospital care.

1Gathered through a series of 5 user workshops run by Age UK, and a series of one to one

interviews with older people including seldom heard groups and housebound people

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______________________________________________________________Figure 2 The new Older People’s care pathway has a far greater focus on prevention and coordination and will lead to the need for fewer hospital and care home admissions:

Results in 95,000 emergency hospital bed-days and 195,000 residential care bed-days per year______________________________________________________________

The pathway consists of a range of interventions that are inter-dependent in order to be effective, but which broadly form three parts:

1) Better maintenance of health through earlier proactive identification of need and case management which coordinates care around people.

2) Lower likelihood of inappropriate admission to hospital in times of acute need because there is an alternative acute response involving better access to specialist triage, diagnostics and assessment, and enhanced rapid response care in the community

3) Increased independence, lower need for long term placement in care homes and less time in hospital, due to simpler discharge pathways and an expansion of enablement and rehabilitation to those living in the community, not just hospital discharges

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3.2.1 Interventions and service models

Interventions under each part of the pathway are as set out in the coloured boxes on the next page.

Detailed service models for each of the interventions are set out in Appendix 3. These are being developed collaboratively with local professionals and older people, and are subject to further development in early 2012.

Service models also include proposals relating to falls, dementia, infections and nutrition. These were identified as specific clinical areas of focus where we can have most impact, based on the numbers of older people affected, their current outcomes, the great number of hospital bed days involved in care currently, and likelihood of being able to improve things locally.

The Community MDT (CMDT), described in Chapter Two, is the ‘unit of delivery’ of much of the proactive community-based care that will make a difference, and participation in the CMDT will be a condition of participation in the LSCF. Its role will be to:

Review high-risk individuals identified by risk stratification software;

Identify other patients who may be at risk, based on softer information;

Set out actions for the MDT in relation to individual patients, including reviewing individuals’ care packages where necessary, ensuring advance care plans are in place, and preparing for transitions of care;

Review its performance regularly and proactively agree interventions and next steps in support of the new pathway for older people.

3.2.2 A targeted approach based on need

The integrated care pathway is applicable to all people aged 65 and over. It is important to note, however, that interventions will not be made available on the basis of age; rather they will be targeted towards those who need them, in order to be effective. For example, there will be a differential approach to screening and case management with half the population of older people (24,750) screened, but 8000 per year receiving some form of care coordination through a case manager (Figure 3). The full range of anticipated activity in preventative and alternative services is set out in Figure 4.

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Interventions under each part of the pathway:

Part 1: Better maintenance of health through proactive identification of need and intervention

A targeted proportion of older people will be screened (in primary care) to pick up currentlyunrecognised problems

An older person’s home care worker (home care workers visit the most dependent people in their own homes regularly) will be trained to spot deterioration, and have a clear contact for raising concerns

People will be treated to prevent falls, infections and poor nutrition, and those with dementia will have better care due to increased support for GPs from community mental health teams

Up to 10% of people will be supported by a case manager, who will coordinate their careThe people most in need will be discussed (and their care will be delivered) by a Community Multidisciplinary Team including social care and mental health

People will have specialist input to their care if needed because the CMDT can access geriatricianadvice when needed

Those people nearing the end of life will have opportunity to talk about their care wishes (Advance care planning) and this will be recorded

People living in care homes will have better quality care because there will be increased support for care homes to manage risks and follow care plans, especially out of hoursThe people most at risk of admission will be identified by software, so they can be prioritised for intensive case managementPeople’s care plans will be shared across organisations, and case managers will be able to track whether the care is being delivered, using new software

Part 2: Lower likelihood of inappropriate admission in times of acute crisis due to an alternative acute response:

People will get a faster response to requests for home visits, because their practice will ring back within 20 minutes to identify those people most in need. This is with the intention of getting people to A&E earlier in the day if they need, which gives a higher chance of investigations being completed before eveningThey will go to A&E only when it is appropriate, because GPs can seek urgent telephone advice from geriatricians about treatment and whether to send someone to hospital

The hospital will be able to see GP records, so people’s needs can be seen in the context of full case history, current medications etc – which is safer

People will get rapid access to geriatrician led multidisciplinary assessment, with bookable hot clinics and also triage from A&E, which will give them faster access to expert holistic assessment currently seldom available without admission

If people need acute/complex nursing, for the treatment of infections with IV antibiotics, catheter care, subcutaneous hydration etc, this will be available in the community to help avoid admissionPeople not needing admission will be safely returned home with rapid response support (nursing and social care in the community until 9pm) before longer-term new care packages kick in. The carers of people with dementia will be able to access rapid respite care in times of need

GPs and case managers will receive alerts if their patients have attended or been admitted to hospital

Part 3: Increased independence, lower likelihood of admission to care home and less time in hospital:

People’s discharge from hospital will be faster and smoother due to a standardised discharge process with a single set of documentationAll those people needing an increased package of care (whether hospital discharges or living in the community) will first have a period of enablement at home (therapeutic home care supported by qualified therapists), to maximise their independence - after which time a long term care package would be finalised if still needed.

People will have rehabilitation more responsive to their needs, because existing rehabilitation pathways will be simplified.

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3.3 Impact and benefit realisation

3.3.1 The difference for older people

The major outcomes of the new care pathway will be a marked and measurable improvement in people’s experience as well as their individual health outcomes, both of which we will track. The operation of the new integrated system will make a real difference to individuals in our communities like Mrs Ibrahim, Mr Buckley and Mrs Okoye and their families, by changing the way the system responds:

From�. To�

one that identifies needs too late, when crises have arisen

one where individual professionals or families struggle to get the best outcomes for older people

one that is all too quick to admit patients to hospital or place them in care homes, because there is little alternative

one that identifies needs early and puts proactive prevention and advance care planning in place

one where an identified individual (case manager or care coordinator) acts on the older person’s behalf and is supported by a team of other professionals to deliver holistic coordinated care

one that promotes alternatives if they are better for the older person.

This means that far fewer people will need to spend time in hospital, or need to receive long term care from social services. The projected impact on non-elective and social care activity is as follows:

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The difference for Mrs Ibrahim, Mr Buckley and Mrs Okoye is clear!

Mrs Ibrahim is 83. Over the last two years she has fallen occasionally. She has ended up in A&E twice, once with a broken wrist�

Because she had been to A&E twice, the new ‘risk stratification’ system flagged her as high risk, but in any case her GP had spotted the recurring problem because of the automatic alerts he got from the A&E. She got a new care coordinator – her practice nurse, who made sure the GP referred her to a falls clinic. Mrs Ibrahim was found to have a cardiac arrhythmia which caused the blackouts, and is now getting treatment from her GP. She also received a course of physiotherapy and now attends a weekly exercise class. Her nurse care coordinator reviews her annually.

Mr Buckley is 78 and lives alone at home. He has type 1 diabetes and a history of UTIs but these have been managed through antibiotics prescribed by his GP. One morning his neighbour contacted his GP, because Mr Buckley seemingly had another UTI but this time with a high fever; he was also confused�

Mr Buckley attended the new geriatric assessment unit and was referred to the rapid response nursing team who provided IV antibiotics in his home starting the same day. He has a course of antibiotics lasting 5 days, and intensive home care support is put in place during this period. It isthought he is likely to need ongoing support at home so is referred for a 6-week period of enablement, after which he does not need further support and is living independently at home.

Mrs Okoye is 81 and lives with her daughter. She has mid-stage dementia and is on medication, but her daughter, who works part time, is finding it increasingly hard to care for her. She has been to hospital twice over the last year for different reasons. Then she was admitted again with a chest infection following on from flu�

After recovering in hospital she is referred for a 6-week period of enablement in her own home, with staff specially trained to work with people with dementia. Because she has attended hospital three times she is also allocated a care coordinator – acommunity matron, who: works with the community mental health team and her GP to ensure her dementia medications are reviewed; ensures that social workers carry out a carer’s assessment; ensures her daughter knows about the rapid response respite service, which she can call for support; and puts Mrs Okoye in touch with an African Elders charity. She isthen handed over to her practice nurse to coordinate her care, and the nurse among other things makes sure Mrs Okoye has her flu vaccination next winter. Mrs Okoye continues to live at home with a package of support from social care, and has more social contact because of the charity’s bi-weekly lunches. Her daughter feels supported by the case coordinator and the knowledge that she can call on rapid respite if she needs to.

Screening &identification

of need

Coordinatedcare from

thecommunity

MDT

Screening &identification

of need

Coordinatedcare from

thecommunity

MDT

Rapid

medical

triage,

diagnostics,

assessment

Enhanced

rapid

response in

the

community

Enhanced

intermediate

care/

enablement

Rapid

medical

triage,

diagnostics,

assessment

Enhanced

rapid

response in

the

community

Rapid

medical

triage,

diagnostics,

assessment

Enhanced

rapid

response in

the

community

Enhanced

intermediate

care/

enablement

Enhancedintermediate

care/enablementfunction

Coordinatedcare from

thecommunity

MDT

Coordinatedcare from

thecommunity

MDT

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3.3.2 The difference for local organizations

Through the implementation of the new pathway for older people we will see a sustainable reduction in demand of 15,400 hospital bed days (14% of current demand) per year and 118 (18% of current need) residential care placements2.

3.3.3 Reduction in need for acute care

The professional design group set out the likely impact on hospital admissions (Table A)3. Applying these percentages to the most recent year’s activity (October 2010-September 2011) generates an 8.6% reduction in admissions,with up to 9.7% of bed-days avoided. The group also considered the likely impact on length of stay for those people still admitted to hospital (Table B). This gives a further 4.7% reduction in bed-days relating to older people’s emergency care in hospital. The combined bed-day reduction is 14.4%, i.e., in total 44 less beds will be needed across GSTT and KCH, assuming fullcoverage of the population of Lambeth and Southwark (Table C)4.

3.3.4 Reduction in need for social care long term placement and care packages

There will be a reduction in the need for placement in residential care homes and for domiciliary care packages because:

Early intervention will mean people are healthier and more independent

Those for whom a care package or placement is indicated will first have a period of enablement in their own home, to increase their independence before care packages are determined (part 3)

The professional consensus on the likely impact of these changes is set out in Table D. The result (Table E) is up to 118 (18% based on current caseload) fewer people living in residential care, and up to 114 (4.5%) fewer people on the domiciliary care caseload, again assuming full population coverage5.

2Because interventions are interdependent and most cannot be effective by themselves, the

impact of the proposed integrated care interventions as a cohort has been modelled.3

To do this they looked at reasons for admission and case severity at a detailed HRG level, amenability to interventions, and the extent to which good practice was already being delivered in Lambeth and Southwark (i.e., identifying those areas where there was less room for impact). See appendix.4

Note: Although admissions of older people are increasing at 3-4% per annum, current growth in bed days is 0% pa or less (c-1%). Therefore, all other things being equal, ICP activity reductions should enable closure or reallocation of beds rather than simply helping to manage increasing demand.5 While the ICP should reduce demand for nursing care homes, it was regarded as too speculative to project an impact,. There are, however, likely to be further savings in this area.

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Table A: likely impact of ICP interventions on admissions

Table B: likely impact of ICP interventions on length of stay (LOS)

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Table C: Resulting ICP impact on hospital bed-days and beds

Table D: Likely impact of ICP interventions on social care activity

3.3.5 Impact over time

Our goal is to achieve at least the ‘upside’ impact, which is both realistic and ambitious:

Realistic, because we used the more conservative professional estimates of impact in our modelling; because of the strong professional consensus about achievability and because of the extent

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to which the design is grounded in local context and existing care pathways.

Ambitious, on the basis of the strong professional view that these changes will represent a significant improvement over the current position, reflected in the commitment of local senior leaders to put their organisations’ money at risk to achieve these changes.

Our assumption is that we will achieve this impact or more, over a period of three years (with at least full upside impact in year three). Working assumptions on the trajectory of change are as set out in the table below, and take into account both increased impact as the pilot spreads geographically within Lambeth and Southwark and impact as change beds in.

Table EYear Impact Reduction in

hospital bedsReduction in residential home placements

1: 2012/13 20%+ 9 total 242: 2013/14 50%+ 22 total 59 total

3: 2014/15 100%+ 44+ total 118 total

Real reductions in beds and placements are achievable. Reductions in residential care placements are within the level of placements currently purchased by spot placement (rather than block contracts). In acute care, the great majority of beds are in general medicine and geriatrics, so through focused bed management clusters of closeable beds will be identifiable.

3.3.5 Benefits realisation

Many redesign programmes become dependent on ‘pump priming’ funding because there has been no active plan for monitoring and delivering benefits.In order to achieve benefits we will need to set out explicit advance plans forreducing acute bed numbers and residential care placements. This is in recognition of the fact that supply (i.e. availability of beds/places) can influence professional decision-making.

The ICP will make a significant difference to individuals whether or not beds are shut, and we will track this change. Across the population of older people in Lambeth and Southwark, we will monitor for:

An improvement in people’s views about the coordination and management of care

A reduction in admissions to hospital and in bed-days needed, particularly for target conditions

A reduction in placements in residential homes and domiciliary care packages

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These headline indicators of benefit will be monitored as part of the Integrated Care Federation’s quality system as set out in Chapter 2 and Appendix 1a,and as part of its evaluation (Chapter 9 refers). This will form part of the basis of the circular flow of information through the Operations Group to the Board and back down to CMDTs at locality level.

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4. Finance – cost savings, investment, flows and long-term approach

The programme’s first phase (older people) will generate system savings of £13.9m or more in year three, through a 14.4% reduction in hospital emergency bed days and an 18% reduction in residential home placements. Of these savings, £6.96m are readily available for investment in alternatives (as they reflect marginal costs, revenue savings or existing commitments). To establish the new care pathway for older people and achieve these savings, we propose shifting and re-investing costs of £6.78m annually (with additional start-up costs of £149k in 2012/13).

4.1 Changing financial flows: principles and approach

Providers in the current system are funded in a range of different ways (block contracts, cost-volume contracts, pay-per-activity), and each separately agrees a contract with commissioners. This does not encourage providers to think about the knock-on financial effects of their actions on different parts of the pathway or the system, or encourage commissioners and providers to plan together to reduce total costs along the pathway, across providers.

Through our new arrangements for system governance we propose to move swiftly to a position where decisions are made in the best interests of the system as a whole, but with transparency around the cost implications for its constituent parts. System sustainability will be a central theme through decision-making discussions.

Through the Integrated Care Pilot we have developed plans to support the creation of a system of health and social care that gives better outcomes and experiences for people, but at more sustainable costs – ie, lower per capita costs. This is a ‘higher-value system’.

To achieve this we need to be sure that we:

invest in effective alternative interventions

do not invest more money than we expect to save in those ‘traditional’ services where activity will reduce (in terms of annual costs)

remove capacity in the ‘traditional’ services to ensure savings are made (see previous section on benefits realisation) and

continuously monitor activity and costs to ensure we are achieving our goals, and if not, adjust the pathway to ensure effectiveness

To ensure that providers and commissioners continuously act to create higher value, we need to design a system that incentivises participants to come together to plan change, and that encourages participants to change, by sharing risks and the potential for gains.

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4.1.1 Our approach

We are taking a phased approach to change in the financial system. In the first instance, we are focusing on the cost-shift needed to support redesign along the older people’s and long term conditions pathways.

Our initial focus has been to support providers in reducing the actual costs of providing care along the pathway for older people. The costs that can be reduced within acute and residential care have been identified from analysis at the level of individual older people (see appendix 4a). It so happens that there is an in-built incentive for all organisations to shift older people’s activity in this way6:

Provider type Incentive

GPs Increased investment including an outcomes-linked paymentCommunity services Increased investment

Mental health services Increased investmentAcute care Reduction in extremely loss-making activity and potential to

increase revenues through backfill with other activitySocial care Reduction in costs of residential placements and investment in

community alternatives, net savings accrued

These aligned incentives may not exist for other pathways, and it will be important that we ensure the health and social care system is motivated to work together on coordinated cost reduction without facilitation. In essence this means that this will need to become the default way of working within the system, removing the need for programme support over time.

The central theme of our next phase of work, therefore, will be the transformation of financial flows locally. Our goal will be to do this in a way that fundamentally changes behaviours, so that different organizations are automatically incentivised to come together to plan change and reduce overall costs in the health and social care system.

4.2 Financial impact of the older people’s pathway

It should be noted that all cost and investment figures in this section assume that the new pathway and system changes will be operational across the whole of Lambeth and Southwark.

4.2.1 Acute trust cost savings

Bed-day reductions set out in the previous section have the following impact in terms of costs and revenue:

6 At the moment, if KCH and GSTT were contracted under the Operating Framework, theywould receive on average £861

6in income for each of these admissions. The actual costs of

providing this care (in full, including fixed costs) are £5708 per admission, or, if one considers only marginal costs, £2322 per admission. The activity is therefore greatly loss-making.

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Financial impact in year 3 of the pilot: Upside Base caseTotal acute savings – full costs of providing the care including fixed costs e.g. capital overheads.

£8.26m £5.71m

Of which, the ‘easily releasable’ marginal costs of care saved

7£3.29m

e.g. ward staffing, drugs£2.33m

Income loss due to reduced admissions (assuming trusts are contracted under the Operating Framework)

£792k £559

Therefore net marginal cost saving-income loss £2.49m £1.77m

Costs based on 10/11 PLICS data from GSTT and 10/11 Q4 PLICS data from KCH, and activity projections based on Oct 2010-Sept 2011 activity from both trusts. An annual underlying increase in admissions of 3% is assumed, with 1.5% annual tariff deflation. Further details are available in Appendix 4a.

4.2.2 Health commissioner savings

Acute health commissioners will make savings due to the 8.6% avoided admissions described in the previous section. Currently both GSTT and KCH are funded under a block contract for emergency activity. It is assumed, however, that future activity will either be paid for under the Payment by Results tariff or preferably that a new cost/volume contract will be agreed, with appropriate upside/downside risk arrangements. In either scenario it is assumed that commissioners will make savings due to avoided tariff payments or through negotiation of a lower cost/volume contract value which takes into account ICP activity projections.

Financial impact in year 3 of the pilot: Upside Base caseGross commissioner savings under the operating framework (100% of tariff)

£3.44m £2.44m

Of which savings ALREADY made due to emergency readmission penalties. ~23% of ICP-related avoided admissions fall into this category

£797k £580k

Of which, additional commissioner savings (ontop of readmissions penalty savings)

£2.64m £1.86m

4.2.3 Social care cost savings

Reductions in residential care placements and domiciliary care packages set out in the last section have the following financial impact:

Financial impact in year 3 of the pilot: Base case DownsideGross social care savings due to reduced demand

£2.953m £428k

Of which, savings due to reductions in residential care

£2.344 £586k

Of which, savings due to reductions in domiciliary care

£610k -£157k

7NB Our definition of ‘marginal’ is very tight and does not include, for example, therapy costs

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There are likely to be additional benefits from reductions in nursing care placements due to the programme’s focus on prevention. This has not been modeled because it was not felt that the figures were sufficiently robust.

It should also be noted that there will be increased investment in certain aspects of social care as part of implementation: these are treated separately below under ‘Investment needs’.

4.2.4 Funds that can readily be made available for investment

It is assumed that the funding envelope available for investment consists of contributions from all partners reflecting the readily releasable cost savings, totaling £7.0m:

Funding available per annum:Acute marginal cost savings minus income loss £2.49mCommissioner cost savings, taking account of impact of readmission penalties

£3.44m

Social services contribution; a proportion of total potential £1.03m8

8£868,456 of this annual figure has already been committed by councils in the 2011/12

financial year (Lambeth: £ 474,840; Southwark: £ 393,616) and councils have plans to increase spend on reablement to £1.097m by year 3 of the pilot.

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savings (already-committed spend relating to increased enablement packages; for detail see appendix)Total £6.96m

4.2.5 Additional financial benefits to participating organizations

Acute Foundation Trusts have additional opportunity to release the full costs of care (up to an additional £4.8m). These benefits can be realised if the Trusts can backfill released bed capacity with new activity. Currently both GSTT and KCH indicate this may be possible. It is highly likely that this activity will be more profitable than older people’s emergency care, in which case the Trusts would benefit additionally from increased revenue. If trusts cannot backfill the beds with additional activity, over time and as additional pathways come under the Federation’s remit, they should be able to start addressing and releasing more of their semi-fixed and fixed cost base.

Social care budgets will contribute £1.02m of their £2.95m savings. The additional savings will be made available to social care budgets in recognition of the considerable budgetary pressures existing within Local Authorities currently. As mentioned previously, there will be additional savings from avoided nursing home placements though these have not been quantified with certainty as yet.

Health commissioners will additionally benefit from reduced admissions to neighbouring Trusts that receive emergency admissions of Lambeth and Southwark older people. These people will receive our community interventions, but the acute impact will be felt outside of the current ICP partnership involving GSTT and KCH.

More funds could therefore potentially be made available for investment, from social care, acute and commissioner budgets. It has not been assumed, however, that these extra funds could be made available over a three year period, not least on the basis that those organisations who will be making contributions to the investment pot should retain some incentive to do so.

4.3 Investments

4.3.1 Investment needs

We need to ensure that we:

invest in effective alternative interventions

do not invest more money than we expect to save in those ‘traditional’, hospital-based services where activity will reduce

The intention is to invest in the range of interventions set out by the Design Group, where funding is clearly required. Once in place, the effectiveness, cost and impact of each intervention will be closely monitored. The pathway and levels of investment in any part of it may change over the life of the

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programme, to increase effectiveness. Any major changes in investment patterns will be brought to the Integrated Care Board for decision, via the Finance Group.

The total investment needs for the first phase of the programme, including part of the admission avoidance envelope, are £6.78m (recurring) as set out in Table A, with additional start-up costs of £149k in 2012/13. Service models and cost assumptions for each intervention listed can be found in Appendix 3.They will be developed over the coming month, so investment proposals may shift slightly in light of learning.

It is important to note that some of these interventions have already received investment through the admission avoidance programme. Appendix 4bdescribes how this has been taken into account.

4.3.2 Funding flows over the next three years, to support the pathway changes for older people

The funding envelope for integrated care is released as a result of reduced activity in acute and social care. Our assumption is that the full impact of the programme’s first phase will be achieved by the start of year three.

Pump-priming investment will be needed in order to achieve these savings downstream. We will seek to achieve a proportionate contribution from the integrated care partners in years 1 and 2, reflecting changed activity profiles and existing commitments, and as an expression of intent. The programmewill also seek funding from external sources such as commissioners and the GST Charity to ensure the right level of investment can be achieved.

The Operating Framework for the NHS, 2012/13 has maintained past arrangements regarding non-payment for emergency readmissions. It is our assumption that the interventions described in this document will have a strong call on readmission monies held by commissioners (reasons are set out in Appendix 4b).

Proposals for funding flows over the three years of the pilot are therefore as follows:

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Table A

£m 2012/13 2013/14 2014/15PCTs - from readmission monies

and/or avoided admissions 2.85 2.85 3.26

social care* 0.87 0.87 1.03

acute trusts 0.50 1.25 2.49

GST charity 2.72 1.82 0.00

total funds required for investment** 6.93 6.78 6.78

* £0.87m has already been committed from social care budgets in 2011/12'**including one-off start-up costs in 12/13

Once again it will be essential that robust arrangements for financial monitoring and reporting are in place in advance of implementation.

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Table B: Intervention costings

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4.4 Financing integrated care: next steps and transforming financial flows.

The immediate next step for our finance workstream will be to start developingthe financial case for our second phase (the management of long term conditions) in a similar way to the work completed for older people. Again, professional consensus on impact will be sought and it is envisaged that demand for elective admissions and outpatient care will reduce, as well as that for emergency admissions. These reductions in activity will be mapped to costs, taking into account any cost assumptions already made for the cohort of emergency admissions of over-65s (first phase of the pilot).

4.4.1 Transforming financial flows

In our first steps to introduce integrated care we have not changed the financial system and all organisations retain their individual current funding and contract flows. They are, however, incentivised to participate in the new care pathway and we envisage the situation will be similar for long term conditions.

Through our next phase of work we will transform financial flows locally in a way that will fundamentally change behaviours, so that participants from those different organisations are automatically incentivised to come together to plan change and reduce overall costs in the health and social care system.

In consultation with local partners, we will develop proposals on ‘year of care’ funding which will:

Take populations (not diseases) as its focus (e.g. older people)

Consider the full costs of care for those populations including mental health, acute and community health, social care, primary care enhanced payments and possibly prescribing (probably excluding GMS and PMS)

Allow for comorbidities

Identify cohorts of patients with similar needs/costs across the system

Build a cost model that will enable us to move towards a combined capitated funding proposal

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5. Information technology

5.1 Our current position

IT and informatics arguably represent both the most consistently evident barrier to effective integration and an enormous opportunity to drive change and improve people’s experience and lives.

It is worth noting that in many respects we start from a position of strength in Lambeth and Southwark. Individual systems are robust and developments have taken place in support of effective joint working across primary and secondary care, particularly through initiatives such as the routine emailing of discharge summaries. Nevertheless IT remains a source of frustration in many quarters, particularly when it comes to the lack of access to important pieces of information about what may have happened to a patient elsewhere in the system:

Most patients have little or no sight and certainly no ownership of their records;

Communication of what happens to a patient in hospital back to the GP is inconsistent (or GPs may not be aware of how to access that information);

Key elements of some patients’ history will not be visible to a clinician in clinic in a hospital;

Bringing information together across health and social care can be difficult, often on the basis of difficulties relating to information governance.

Our ambition is to provide holistic care and to make the right interventions at the earliest stage possible. The challenge for this programme is how it canbest facilitate the implementation of strategies that are emerging across the system, to support decision-making on the basis of all aspects of the case involved and to put the patient at the heart of the discussion. The issues around IT represent a microcosm of the broader challenges of integration –resulting too often in a poor patient experience, professional frustration and inefficiency.

Mary is 73 years old and has very high blood pressure for which she is on a range of medication. She also has issues with her thyroid with some suspicion that a recent growth may be malignant.

Following her first visit to her GP she had blood tests in the surgery and she was referred on to the hospital. On arriving at hospital she was told that they would need to take blood tests. Confused, she asked why the tests which she had had done a few days previously would not do. She was told that the hospital had not received the results.

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She was subsequently referred on to another consultant in a neighbouring hospital at which point further tests were ordered, on the basis that the team she was now under would always want to do their own.

From the point of referral onwards the GP lost sight of what was happening and Mary had to bring her up to date on her next visit.

While Mary’s case may be unusual, it highlights the impact on patient experience of the lack of the technology to share information and the extent to which that can cause different parts of the system to work in isolation and for trust to break down.

This lack of cohesion between systems is problematic at the level of the patient. It also acts as a significant barrier to developing a robust understanding of performance and quality along pathways and as a constraint to research activity.

In our work to develop new pathways for older people and people with long term conditions there is a clear theme around supporting patients and carers in taking charge of their own conditions and staying healthy at home. The evidence that technology has a significant role to play in support of this agenda is now compelling. There is some use of telehealth, care and medicine locally and again there are examples of good and innovative practice, for example the work between KCH and the Paxton Green surgery around maxillofacial patients. With the possible exception of telecare, however, these technologies have not been implemented systematically or at scale.

5.2 What we are planning to do

Our ambition during the course of this programme’s lifetime is to transform the way in which technology supports and drives integration in Lambeth and Southwark. We are aiming to deliver:

Availability of the basic information relating to individual patients to support effective joint working and decision making within CMDTs;

Live interoperability between systems, over time allowing real time feeds;

The development of a platform that can support integration but that can also support a range of other agendas;

Large-scale empowerment of patients, both through people owning the information in their records and the effective use of assistive technology.

We propose to do this through three staged initiatives:

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Firstly, internally and working with existing suppliers we have identified a range of low cost solutions that can come together to support the go-live of the older people’s pathway in April;

Secondly, as the pathway design nears completion work has begun on the development of a robust specification for a medium-term solution that provides real time access to systems;

Thirdly, with the benefit of the headline findings from the Department of Health’s Whole System Demonstrator Programme we are developing proposals to take telehealth and telecare to scale across both boroughs.

Mary is 73 years old and has very high blood pressure for which she is on a range of medication. She also has issues with her thyroid with some suspicion that a recent growth may be malignant.

Following her first visit to her GP she had blood tests in the surgery and she was referred on to the hospital. On arriving at hospital she was told that they would need to take blood tests. Confused, she asked why the tests which she had had done a few days previously would not do. She was told that the hospital had not received the results.

She was subsequently referred on to another consultant in a neighbouring hospital at which point further tests were ordered, on the basis that the team she was now under would always want to do their own.

From the point of referral onwards the GP lost sight of what was happening and Mary had to bring her up to date on her next visit.

While Mary’s case may be unusual, it highlights the impact on patient experience of the lack of the technology to share information and the extent to which that can cause different parts of the system to work in isolation and for trust to break down.

In the future each part of the system are kept up to date on her progress, improving her experience and reducing the waste of multiple tests. Her GP and members of the CMDT are able to make informed decisions with Mary about her care, whereby she is provided kit and support so she can measure her own blood pressure with results to be transmitted electronically. A number of her consultations are then carried out by telephone, removing the need for multiple attendances at outpatients.

This application covers all three of the phases described above. The full costs of the IT component of the bid are set out in Table A and total £2.77m over the three year lifetime of the programme. The costs in Year One are£1.71m. It is proposed that £0.61m would be drawn down at the beginning of 2012/13 to support the go-live of the pathway for Older People and the procurement, deployment and management of systems for telehealth and telecare. The remaining £1.1m is an indicative figure, developed through our

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market research of established suppliers and solutions and focused on our second stage solution for information-sharing. It is proposed that we would return to the Charity with a detailed specification for discussion and that the £1.1m or the appropriate sum would only be drawn down following the conclusion of that discussion, later in 2012/13. It should be noted that the profiling of this spend is also indicative at this stage.

We propose to take this work forward as set out below:

This work is set firmly in the context of the broader strategic agenda on IT and complements parallel processes and initiatives:

The process that is ongoing within GSTT on its IT Strategy: Delivering the Digital Healthcare System and Culture and particularly the work on a clinical desktop;

KHP’s Grand Challenge on research informatics;

The process being led by the South East London PCT Cluster on the IT requirements of the new Commissioning Support Organisation.

The leads for all these initiatives are members of the ICP’s IT Reference Group and their teams have been involved in the development of these proposals. Further details on proposals for IT are set out in Appendix 5.

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5.2.1 IT requirements to support the implementation of the pathway for older people

In supporting the implementation of the older people’s pathway our approach has been to make best use of existing systems and to extract best value from existing contracts. Many of the barriers to information sharing have less to do with technology and are more about a reluctance to change. In fact many of our systems are sophisticated and there is good practice and innovation in discrete areas and organisations – our challenge is to make the connections that can bring information together in support of a CMDT’s operation.

The redesign process for the older people’s pathway identified the following core requirements:

Underpinning requirements Description

A tool that identifies patients most at risk

and that can foster closer working,

screening and MDT support models.

Expand risk algorithms to include new data

that supports better identification of patient

deterioration

Work towards a shared, live and

read/writable record across settings,

including diagnostics, care packages, care

plans etc

Support workflow monitoring so that

community teams can track actions /

interventions

Exploitation of telehealth and telecare

technologies to support patient self

monitoring, management

Embrace telemedicine and the ability to

underpin virtual models of working e.g.

Virtual case conference

System to support the calculation and

reporting of KPIs for the pathway, including

information from GPs, community, social

care, mental health and Acute.

Reports for both programme and individual

Performance monitoring

Telemedicine / assistive technology

Shared Care Plans

Risk Stratification

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MDT level, with the ability to undertake

comparison

A range of internal developments are in train, along with agreements to a number of enhancements with the supplier of the risk stratification software that is already in place across Lambeth and Southwark.

Crucially these actions will support the operational effectiveness both of the CMDT and the system as a whole from April onwards:

A simple “checklist” to support case management, accessible through a common web-portal;

Viewable access to core systems will be expanded, particularly to staff working in community services;

The United Health risk stratification tool will be enhanced to include fields relating to packages of social care, mental health care plans and data from community services;

The N3Collaborate will be adopted to facilitate virtual meetings, providing a secure and cost-effective platform for telemedicine and supporting daily Virtual Ward rounds and regular case conferences.

At its simplest the CMDT will be able to make use of technology to help identify those people in the community who are most at risk; they will have access to a portal-based tool to support case management; and they will have access to the core systems that they need to have access to.

The IT will also be in place to support the circular flow of information through the Operations Group and Board and back to the CMDT – the Quality System described in Section Two.

Information governance is a central consideration and processes are in place to ensure that all these developments are in line with good practice, with a consent-based model of “opting in” the most likely way forward. One option would be to build this into the offer of partnership to the patient described in Chapter 2.

The two-stage approach proposed for taking this forward will substantially improve the way information is shared across the system at relatively low cost.

Costs associated with this work can be found in Table A and more detailed requirements are set out in Appendix 5.

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5.2.2 Vision for the future

Within the ICP and across KHP and the local health and social care system we are developing an increasingly coherent and ambitious vision of the way in which informatics can transform our local system into one that is demonstrably world-beating. To drive integration and support the early stages of the delivery of that vision it will be critical that the right IT systems and support are in place.

There are various elements to our approach, moving quickly beyond the pragmatic solutions we are putting in place to support the early implementation of the pathway for older people:

We need to be able to share clinical operational data live in a way that supports increasingly proactive and informed decision-making (there are clear links here to the agenda around workforce development and support);

Whole system integration should be driven purposefully – between primary, secondary and social care but also in terms of patient access;

Having got hold of the data we need to be able to store it in a way that complements and supports parallel processes around research.

During the course of 2012/13 we will need to move from a pragmatic set ofinterim solutions to a more sophisticated, longer-term position, capturing at least the following:

Pragmatic state Desirable state

A shared ‘view-only’ of care plan which is relatively* live but that can't be written in; single professions write into their systems and the propose solution amalgamates a view across the system

Available across the community team (community health, mental health and social care), general practice, ED/hospital

Supports minimum dataset

Has basic workflow monitoring

Shared, live record that can be written in, used by the community team for care planning and delivery

Available across the community team (community health, mental health and social care) general practice, ED/hospital SELDOC and LAS

Includes latest diagnostic, meds and care package information, advance care plans and End of Life Care(EoLC) plans where applicable

Has workflow monitoring

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functionality

Minimum indicators and reporting present

functionality

Reporting on quality, MDT and Locality reporting, benchmarking etc

Significant research has been undertaken:

Discussions have taken place within the English system with areas where progress is known to have been made – particularly Trafford, Birmingham and Torbay.

Market research has allowed us to develop a good understanding of the capability of the various solutions and suppliers and to generate the indicative costings set out in this application.

We have undertaken some international research and have looked at the Veterans Administration’s (VA) VistA system – both as an indication of what is possible when IT is made an integral component of a broader focus on integration and as offering a different commercial model through its Open Source availability.

Again it will be important that this thinking is taken forward in a way that

supports and complements the broader local strategy for informatics. An

explicit part of this second stage in the process will be a focused exploration

of the ways in which patients can own their records and the information about

them that is currently held in different parts of the system.

With the completion of the pathway for older people and the development of

our high-level IT requirements (see Appendix 5), we are now in the process of

developing the specification of a solution for KHP, Lambeth and Southwark.

On the basis of our discussions and work to date we believe the indicative

costs set out in Table A are realistic and grounded.

Our proposal is that we take this work forward, explore the different

commercial models that might be available and – at the point where we

believe we are ready to formally go to the market - we will seek to formally

reengage with the Charity. As previously indicated, the indicative costs set

out (£2.0m) will give a good initial sense of the likely scale of that funding

request. This figure has been factored into the global application but we

would anticipate further formal engagement with the Charity’s

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Committees following completion of our specification and before

funding for Year One (2012/13 - £1.1m) could be drawn down.

5.2.3 Assistive technology

There is a growing evidence base to support the scaled implementation of

telehealth and telecare and this will form a central theme within our work on

long term conditions. The Department of Health recently (December 2011)

published headline findings from the evaluation of its Whole System

Demonstrator (WSD) Programme – the largest randomised control trial (RCT)

of telehealth and telecare ever undertaken. It involved 6191 patients and 238

GP practices across three sites – Newham, Kent and Cornwall.

WSD Early Headline Findings:

If used correctly telehealth can deliver a 15% reduction in A&E visits, a

20% reduction in emergency admissions, a 14% reduction in elective

admissions, a 14% reduction in bed days and an 8% reduction in tariff

costs. More strikingly they also demonstrate a 45% reduction in

mortality rates.

This is consistent with findings from a number of reviews and pilots around the world (for detail see Appendix 5):

Canadian systematic review of the telehealth evidence for heart failure, COPD and Diabetes (2008)

Scottish Telecare Development Programme (2006-11)

US systematic review (9 RCTs, 967 patients) of the telehealth evidence for heart failure

Cochrane systematic review (11 RCTs, 2710 patients) of the telehealth evidence for heart failure (2010)

The DH publication helpfully included definitions as the various terms are often used interchangeably:

Telehealth (remote care) – Electronic sensors or equipment that monitors vital health signs remotely, e.g. in your own home or while on the move. These readings are automatically transmitted to an appropriately trained person who can monitor the health vital signs and make decisions about potential interventions in real time, without the patient needing to attend a clinic.

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Telecare – Personal and environmental sensors in the home that enable people to remain safe and independent in their own home for longer. 24 hour monitoring ensures that should an event occur the information is acted upon immediately and the most appropriate response put in train.

There is a third and related theme around telemedicine and this will form an important element of the early implementation of the new pathway for Older People, supporting the effective functioning of the CMDT as described earlier.This will principally be taken forward through the rollout of video conferencing,building on work that is already underway. Some progress has already been made locally and we need to build on this with a sense of purpose and scale.

The Scottish Telecare Development Programme drove efficiencies of £78m through an investment of £20m. There is a growing consensus, supported by emerging central guidance, that the time for small scale pilots of telehealth and telecare has passed (as referenced in the Operating Framework 2012/13and in subsequent guidance).

On this basis we propose to take a stepped approach to developing a scaled rollout of a blend of telehealth and telecare across Lambeth and Southwark. We propose to take this forward as an integral element of our approach to managing long term conditions. In the first instance we will look to identify a commercial partner and work with a targeted population of 300 patients. Through this process we will test the case for a further rollout of a holistic approach to telehealth and telecare across the 3000 patients who may be able to benefit from assistive technology in Lambeth and Southwark.

Table A - IT breakdown costings

Year One Year Two Year Three

LOW COST SOLUTIONS

Risk Stratification 20 12 12

Check-list case management 60 0 0

N3 Collaborative 20 12 12

Contingency (Diabetes) 15 15 15

Total cost 115 39 39

MEDIUM-TERM SOLUTION (information sharing)

Procurement & Legals 50 0 0

Hardware & Software Costs 650 0 0

Technical setup and deployment 350 100 100

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(including installation of software,

information sharing agreements,

support and training)

Data feeds and extracts (14) 140 140

Licences (250 – 700 users) 150 150

Development 50 100 100

Total estimated cost 1100 490 490

TELEHEALTH / TELECARE

Device deployment / management

(fully managed and leased, cost of devices

and communications, support and training)

432

Local technical configuration 15

Patient Involvement 10

Economic Evaluation 40

Total cost 497 0 0

TOTAL COST 1712 529 529

In taking this agenda we will seek to build on existing relationships with the industry, exploring new forms of partnerships and commercial relationships. This will form a key component of our second phase of implementation.

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6. Workforce

The workforce is the greatest resource at the disposal of the health and social care system in Lambeth and Southwark. It also accounts for around two thirds of expenditure. For us to extract the maximum benefits from integrated care it will be important that we support our local workforce over time in taking on new roles and activities.

There are two core elements to the range of our activity on workforce:

Organisational development and cultural change and

Training and personal development

Both are significant and both will feed a third challenge around the recruitment and retention of high quality staff in primary and community care locations in the often pressurised circumstances of inner South London.

6.1 Organisational development

As CMDTs become active there will be an immediate task to develop the team members’ understanding of integrated care and what it will mean for them and their practice. For silo working to be eradicated it will be important that the whole team has an understanding of the whole pathway and not just their part of it. The goal should be a service that feels seamless to the recipient, particularly around the boundaries between primary, community, social and acute care. Roles and responsibilities will need to be very clear and strong feedback loops will be required.

A range of potential schemes have been identified:

Exchange programmes for staff from hospital and community settings

Mentoring/coaching across primary care and community, social care and hospitals

Action learning sets for CMDTs working across care pathways

Facilitated workshops using a range of methods, e.g. simulation exercises

Leadership development programmes identifying champions to cascade training within their teams

This work will be taken forward with the support of identified expert resource from within the KHP Transformation teams.

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6.2 Training

A robust programme of training and development will be required for different staff to undertake procedures (e.g. intravenous drugs and therapy) that they may not have previously been trained to do. Clear visibility of this development will also be necessary to reassure clinicians currently undertaking such procedures that the right level of capability is in place in the proposed new settings. This process has already begun through the preparatory work for the Virtual Ward pilots and will need to be continued systematically if more care is to be delivered in the community, GP surgery or the patient’s home – away from acute settings.

Again some internal resource will be available for training and educational leads across the system are engaged. A combination of change teams and staff development units will support a series of facilitated workshops, providing support and training on service redesign and LEAN techniques.

The table below sets out the funding that will be necessary to support additional training and OD funding. Training with new IT systems is included within the section and costings relating to IT.

Investment required in OD and training (excluding IT)

Who What Estimated costGP leads in all Lambeth and Southwark practices

Relevant Primary Care ICP interventions 1.5 days per practice x 91 practices

£134,740

Practice nurses Health checks training £10,000Homecare workers Early warning changes in

condition £24,000

Virtual ward teams Enhanced clinical skills £25,000Commissioners Facilitated workshops £3,000Multidisciplinary team Action learning sets and

coaching£50,000

Multidisciplinary members identified as champions

Leadership development training

£30,000

Contingency What is not yet known £30,000

Total £291,740

Discussions are planned with King’s College London on how best to embed integrated care into training and education curriculae.

History of previous change programmes nationally has been that the needs of the workforce are addressed too late – it will be essential that this programme engages proactively with staff and supports them through any changeprocess. It is highly likely that additional training implications will emerge through our work on Long Term Conditions and these will be reflected as we develop our second phase.

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7. Next steps – long term conditions

7.1 Context

Along with the demographics of an ageing population, perhaps the most significant challenge facing health services in the developed world – and the greatest call on their resources – lies in the management of long term conditions (LTCs). Around two thirds of NHS resources are spent on care provided to people with LTCs.

The needs of populations vary and in Lambeth and Southwark certain trends are particularly strong. There is a strong consensus that if these needs are to be responded to effectively and if costs are to be maintained at a sustainable level, a different approach is needed. Initiatives on LTCs to date have been largely disease-focused and much progress has been made around individual pathways and services. There is now an opportunity within the ICP to develop a holistic and connected approach to chronic care, building on the substantial elements of the approach to care of older people that are transferable.

Five areas have been identified for focus within the Integrated Care Pilot’s (ICP’s) Long Term Conditions workstream. These were identified through a prioritisation process across KHP and both sets of commissioners with criteria that included local prevalence, need and commissioning priorities. The potential for substantial impact and the level of buy-in and enthusiasm from professionals were also factors.

Long Term Conditions - ICP Priority PathwaysDiabetesChronic Obstructive Pulmonary Disease (COPD)Cardiovascular Disease (CVD)Severe Mental Illness (SMI)HIV

Two principles have also been agreed by the ICP Programme Board:

That the programme’s work on LTCs should contain a strong cross-cutting theme on the relationship between physical and mental health and

The approaches and systems developed should support a focus on the broader health and social care needs of the individual and particularly on co-morbidity.

The ICP’s work on LTCs needs to make use of existing structures wherever possible and, therefore, elements will be jointly led, for example with the Diabetes Modernisation Initiative or the Lambeth Living Well Collaborative.The co-creating principles existing in both are well-established and can form part of the basis for the development of a strong and distinctive approach to LTCs and co-production in Lambeth and Southwark. These proposals are

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being developed in partnership with both the DMI through its ongoing work and the LLWC as it develops its own proposals.

7.2 Scope

The ICP’s scope is about both service and system redesign and the approach to the Frail Older People workstream has focused intensively on the pathway for that group of people, in addition to the systemic aspects of the drive to integrate. This has worked well as that pathway has not received the amount of developmental attention that has been seen in some other disease-specific areas in recent years.

A review of work on the pathways prioritised by the ICP demonstrates that considerable work has already been undertaken and can be built upon:

Diabetes – The subject of a substantial, Charity-funded Modernisation Initiative in Lambeth and Southwark with pathways that are well-developed and understood.

COPD – A redesigned pathway has been developed in the last year through a commissioner-led process and is now close to being agreed with providers. The Charity has also supported previous initiatives, building on Pursuing Perfection.

CVD – A similar approach to that taken with COPD, probably a few months away from agreement with providers.

SMI – Different approaches to those taken with the pathways for physical healthcare but again they are well-understood.

HIV – A different service model, currently hospital-focused to a large extent but with exciting opportunities.

This suggests that there is little to be gained by reopening or disturbing discussions around the detail of pathways that in some cases are either underway through separate processes or have just been finalised.

The ICP is unlikely to add value through detailed redesign of disease-specific pathways but that it should instead:

Focus on the application of the system changes and integrated ways of working to these areas, moving to the Community Multidisciplinary Team (CMDT) model and seizing opportunities around technology and finance;

Do this in a phased manner, making use of existing work, structures and experience wherever possible and maximising opportunities in areas such as assistive technology;

Develop and maintain an overview of the pathways, providing assurance that the approach to chronic disease management in Lambeth and Southwark is consistent and holistic and advising on enhancements or adaptations where it is not;

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Through this process identify the processes and interventions that are common across a number of pathways but that could be done once and consistently;

Develop a focus on outcomes and an approach to pathway benchmarking that will generate a clear picture of relative performance within Lambeth and Southwark and potentially between Lambeth and Southwark and other areas.

This workstream provides a significant opportunity to take the advances made through the ICP’s workstream for older people to scale. It should also be possible to:

To develop and implement a South London approach to the provision of chronic care

To develop an approach to benchmarking of pathways and outcomes

To develop innovative approaches to support the effective integration of physical and mental healthcare, building on and complementary to proposals such as the one on Medically Unexplained Symptoms currently under development within the Psychological Medicine CAG.

All of this will be set firmly in the context of the ICP’s overarching objectives around the provision of care in the most appropriate setting, improved outcomes and experience of services and must be based on a strong economic case.

7.3 Objectives and methods

The task on LTCs through the first phase of the programme’s activity, during the first six months of 2012/13, will be to size the value opportunity associated with rapid rollout of the types of approach developed for older people across a much wider population.

As with Older People this will be achieved through a blended approach and aset of five activities:

Workstream Method Objective/Opportunity

1. Development of financial case for Phase Two. Similar multidisciplinary professional approach to Older People, but with less focus on pathway redesign. Impact of agreed interventions on activity and mapped to costs, taking care to avoid

Facilitated workshops

Public health analysis

Detailed modeling of activity and finance

Development of approach to co-production

Substantial reductions in elective care and outpatient appointments, as well as in unplanned care

Improved outcomes and patient experience

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double-counting.

2. Development of generic approach to chronic care where appropriate, focusing on co-morbidities and links between pathways. Impact of streamlined, holistic approach mapped to costs and outcomes.

Pathway review to identify common issues and interventions

Focus on primary prevention

Co-production

Facilitated workshops

Financial modeling.

Substantial improvements in patient experience

Longer-term modeling of impact of preventive interventions

Consistent and complementary interventions across pathways = efficiency

3. Scaled deployment of assistive technology. Focus for LTCs on telehealth and telecare, modeling impact on activity and finance(Chapter Five refers).

Factored into development work relating to pathways and interventions.

Work with industry to identify creative solutions and partnerships.

Simulation suite.

National evidence to support potential for substantial reductions in activity across the board.

Significant potential for positive impact on people’s lives – to be worked through with user groups.

DH evaluation of demonstrator sites suggested potential 45% reduction in mortality rates.

4. Development of pathway metrics, creating the potential for benchmarking quality, performance and efficiency across pathways.

Development of benchmarking partnerships with Academic Health Science Systems around the world (e.g.UCLP, Toronto, Singapore).

International upper decile performance for the populations of Lambeth and Southwark.

5. Development of support systems for self care and management, building on work already underway within the local system and particularly in the DMI.

Interactive development process with users and carers integral to the design and running of the process.

Facilitated workshops and structured discussions.

Simulation suite.

Financial modeling.

Measurable impact on patient experience and quality of life.

Improved outcomes.

Financial case for self management.

It is proposed that the outputs from this work would form the basis of the programme’s second phase, moving to a staged implementation in the second half of 2012/13. The design work will be taken forward under the

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remit of the system’s Design Group and will be taken forward in a way that complements the work of other programmes and initiatives.

This activity, brought together with the full implementation of the redesigned service for older people and the system changes described in this application, will represent a further comprehensive and ambitious component to our broader change programme. If successful with this application we would propose to report back to the Charity on our progress with the development work on Long Term Conditions in October 2012.

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8. Programme support

It has been agreed that implementation of the redesigned system and services should be the responsibility of the operational and transformation teams within the various organisations. The role of the programme team, therefore, would remain one of design, oversight and project support. It is proposed that the team is hosted by one of the partner organisations.

The majority of the roles set out below would be designed to act as project managers and change agents, working alongside operational teams and aligned with established transformational resource and programmes within the system.

Programme Team Annual Cost (£k)

Senior ManagementClinical Chair (0.5 wte/4 GP sessions per week)Director (1.0 wte, AfC 9)Deputy Director (1.0 wte, AfC 8d)

5511090

Programme Support and OversightProgramme Manager (1.0 wte, AfC 8c)Programme Coordinator (1.0 wte, AfC 5)

7835

Programme Management – Service RedesignProject Manager/Change Agent - Frail Older People (2.0 wtes, AfC 8a)Project Manager/Change Agent – Long Term Conditions (2.0 wte, AfC 8a)GP backfill

130

130

100

System ManagementPerformance Lead (1.0 wte, AfC 8b)Project Lead/Change Agent – IT (2.0 wte, AfC 8a)Project Lead – OD and Transformation (1.0 wte, AfC 8a)Finance Lead (1.0 wte, AfC 8b)

70130

65

70TOTAL 1063

The proposal for the ICP is ambitious and complex. Robust programme management and processes will be crucial to delivery. Each of the health and academic partners has made an ongoing financial commitment of £50k to the programme’s core budget.

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9. Evaluation

It is of fundamental importance that the Integrated Care Pilot can robustly demonstrate its impact in improving the value of the health and social care system locally.

While the ongoing performance information system will inform much immediate operational decision-making, a more thorough and controlled evaluation is necessary, to robustly assess the extent of impact once confounding factors are taken into account, and provide richer analysis of the process of change.

The focus of the evaluation should be two-fold:

Outcomes: It must assess whether integrated care has achieved its intended outcomes in Lambeth and Southwark

Process: It should additionally assess the model of operation of integrated care and the way that it has been introduced, to identify problems and barriers and how these could be resolved

Outcomes to be monitored should include:

Whether the system has improved outcomes (including looking at admission to hospital and placement in care homes)

Whether the system has improved people’s experience of care

Whether costs are lower, taking into account pathway per-capita costs and levels of demand

Potential measures include:

Admission rates for older people compared to trajectory and compared to a control group

Hospital bed-days for older people compared to trajectory and compared to a control group

Admissions and bed-days for our ‘target’ conditions compared to trajectory and controls

Admission rates to care homes compared to trajectory

People’s (and potentially carers’) experience of care, in particular their experience of screening, case management and the new urgent care pathway

Total pathway costs including the actual costs of alternative services provided and cost reductions in acute, residential and domiciliary care

Per-patient pathway costs

A process evaluation of the model of operation of integrated care and its introduction should identify the extent of change and what has helped and hindered the process of change. It should record findings at the various levels at which integrated care is intended to achieve change, and test change ‘inside’ and ‘outside’ the formal integrated care governance structures that are introduced.

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Methodologically, the evaluation (overall) should:

Take a formative approach, ensuring frequent (at least 6-monthly) and rapid feedback during the course of the pilot, to ensure learning can be incorporated – both in terms of feeding findings on outcomes into the quality (performance) system, and in terms of sharing learning on the process and operation of the integrated care system itself.

Develop a sensitive and appropriate approach to control groups. This is likely to constitute a before-after approach, because it will be hard to define a concurrent control group in Lambeth and Southwark (some of our interventions, for example geriatrician-led assessment alongside ED, will affect all the population even if more local interventions e.g.screening in general practice, only affect some). Furthermore any external control group of patients outside Lambeth and Southwark are highly likely also to be subjected to admission avoidance initiatives.

Be sensitive to potential unintended consequences of integrated care in terms of outcomes and activity and monitor for these.

Take account of the fact that the integrated care pilot will expand geographically and change in scope (for example, introducing new care pathways) as it progresses.

Provide assurance on the robustness and objectivity of the evaluation, by, for example, involving external experts or developing methodology aligned with other AHSC evaluations of integrated care.

An outline proposal from King’s College London is included in Appendix 6.

We intend to put the evaluation of the integrated care pilot out to tender. The evaluation specification and selection of evaluators will be agreed by the ICP Sponsor Group. Applicants will be encouraged to seek collaborations and apply jointly, in order that all aspects of the specification can be fully addressed and that a degree of external (non-KHP) participation is achieved, to increase external perception of impartiality.

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10. Income and expenditure

This section sets out the proposed profile of income and expenditure across a three year programme. The detailed breakdown of the spend is set out elsewhere in the application, principally in the appendices.

The total cost of the implementation of the programme is £26.39m over a three year period, of which £10.60m is requested from the Guy’s & St Thomas’ Charity.

The profile of expenditure, high-level breakdown and proposed sources of funding is as follows (£m):

Year 1 Year 2 Year 3 TOTALInvestment in services for older people (by source):

BSUsSocial CareGSTT/KCHGST Charity

2.850.870.502.72

2.850.871.251.82

3.261.032.49

-

8.962.774.244.54

Sub-total 6.94 6.79 6.78 20.51

Information technology

Workforce

External support –analysis and modeling

Programme team and support (£300k contribution from partners)

Logistical costs andaccommodation

Engagement andcommunications

1.71

0.29

0.25

0.760.30

0.03

0.03

0.53

0.10

0.10

0.760.30

0.03

0.02

0.53

0.10

-

0.760.30

0.03

0.01

2.77

0.49

0.35

2.280.90

0.09

0.06

Total funding requested from GST Charity

5.79 3.36 1.43 10.60

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Total funding from other sources

4.52 5.27 7.08 16.87

Total programme funding (Phase One)

10.31 8.63 8.51 27.45

Support in the order of £5.79m is requested from the Charity in Year One(2012/13) of the programme. If successful in this application we would propose to draw down £4.69m in the first instance, with the balance on the provision of further assurance following the completion of our detailed specifications for new IT solutions (Chapter 5 refers).

Following the completion of the development work on Long Term Conditions we would then seek to initiate Phase Two of the programme during the course of 2012/13, focusing on those pathways and further system changes.

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‘Once for London’

Pan-London Operating Principles for Primary Care

List Maintenance

72

Once for London

The Once for London Project

• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical,

dental, pharmacy and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning

of primary care services to:

– Support continuing improvement in the quality and productivity of primary care services as part of QIPP

– Ensure fairness, equity and transparency in the way general practice services are being commissioned across London

– Embed best practice approaches across all commissioning organizations

• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we

commission key primary care services. Initially this work programme will focus upon:

– For general practice - List Maintenance, Enhanced Services and PMS Reviews

– For dentistry - End of Year Process, Performance Approach and Contract Changes

• The expectation is that this programme of work will synchronise with transition towards a single operating model for

primary care commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and

other contractor groups within London both implementing national operating models and influencing the shape of these by

sharing local operating principles.

Developing the Operating Principles

• A set of task and finish groups have been established to ensure that there is wide collaboration from across London.

• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors,

LMC, LDC, FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and

knowledge to develop a unified approach to a basket of key QIPP challenges.

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73

Operating Framework for List Maintenance

Primary Drivers for Undertaking List Maintenance:

London is a world city, with a diverse population and many health issues. However, London has some of the worst health

outcomes in the country in some key areas, and poor performance in prevention activity. Gross inequalities exist across the

capital, both in the quality of preventive services and in health outcomes. London is an extreme outlier for all indicators based on

GP registrations.

The accuracy of a practice’s registration list is important for:

– the efficacy of ill-health prevention / screening programmes and total population capture

– the assessment of performance and clinical outcomes which are often compared on a ‘per patient’ denominator

– the appropriate use of public funds, as allocations are made on a £ per patient basis

Improving GP list accuracy would:

– reveal the true picture of London prevalence of ill health and public health performance – showing that London is not

the outlier it is currently presented to be;

– ensure the design of effective interventions to reach local priority groups and impact on priority programmes;

– contribute to the delivery of regional and local QIPP Health & Wellbeing outcomes;

– have a positive impact on many clinical outcome measures for example, cancer, long term conditions, heart disease,

communicable disease, respiratory disease.

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74

Operating Framework for List Maintenance

Why do inaccurate lists occur?

• The patient list is a changing register reflecting population movement. This is particularly true in London where turnover of

patients is high and can be marked for some practices serving a transient population.

• Ongoing and effective maintenance of lists is essential to ensure that they are accurate. However, even with the most

effective list maintenance procedures in place, a practice list can hold 3-8 % of inaccuracy due to patient turnover alone.

• It is estimated that in London the level of list inaccuracy can range from 3-35 %. Whilst some of this is accounted for by

population turnover, high levels of list inaccuracy have also resulted from:

– list maintenance being one of many competing priorities for improvement

– low awareness of the importance of list maintenance and the link to both service outcomes, public health and the use

of public funds

– attention not being given to this over time but list maintenance has become more critical as a result of QIPP

� Practices have an important role to play in maintaining accurate lists. Practices with robust systems in place to verify and

record patient details at the point of registration ,as well as regular systematic checking of details when patients contact the

practice, have more accurate lists.

• Commissioners, patient registration authorities and GP practices will be effective in reducing list inaccuracies sustainably, if

they work collectively to addresses these factors.

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75

Stage 1 of a List Maintenance Exercise

Commissioner identifies

cohort of patients and

sends details to the practice

for verification (see page 7)

After 4 weeks a second

letter is sent

Pa

tien

t

Re

spo

nd

ed

Pa

tien

t

Re

spo

nd

ed

No

Response

No

Response

Pa

tien

t

Re

spo

nd

ed

Pa

tien

t

Re

spo

nd

ed

No

Response

No

Response

After 4 weeks an FP69

activated on the

practices IT system

List action taken by the

patient registration

authority

List action taken by the

patient registration

authority

See STAGE 2 overleafSee STAGE 2 overleaf

FP

69

Activ

eF

P6

9 A

ctive

Practice identifies any patients that have a

record of contact with the practice in the last 15

months, removes them from the cohort and

returns list to the commissioner. Practices will

have 4 weeks to do this after which time the

letters will be sent out.

Contact would include an appointment,

telephone consultation, collection of a

prescription or any other interaction which has

been noted in the patient record.

First letters sent to

patients that have had no

contact with their

practice in the last 15

months

5

76

Operating Framework for List Maintenance

Stage 2 of a List Maintenance Exercise

FP69 Active

If the practice still believes the

patient is an active registration,

they have 6 months to establish

contact with the patient directly

to confirm their registration

requirements.

Practice declares patient

resident and eligible for

general medical services

from the practice

List action taken by the

patient registration

authority

Pa

tien

t

Co

nta

cted

Pa

tien

t

Co

nta

cted

Pa

tien

t

No

t

Co

nta

cted

Pa

tien

t

No

t

Co

nta

cted

Patient deregistered by

the patient registration

authority

6 month long pause,

Commissioners do not hold attendance

information. Advance screening of the

cohort by practices should minimise the

removal of any vulnerable patients on

chronic disease registers, as the 15

months time frame coincides with many

of the QOF recall standards for patients

with chronic diseases.

Commissioners should not request any

more than a verified list from the practice

– practices should not be required to

produce screen shots or other

documentation.Return to sender

The patient registration

authority will inform the

practice of any letters which

are “returned to sender.”

The practice would then be

responsible for contacting

the patient and establishing

their new/correct address.

They should then inform the

patient registration

authority so that the FP69

can be removed.

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77

Operating Framework for List Maintenance

Pan-London Operating Principles:

• List maintenance processes should be designed with the proactive engagement of commissioners, registration authorities,

LMCs on behalf of GP’s and practice managers.

• List maintenance should be undertaken as a continuous rolling programme for example working through the list

alphabetically over a one to three year period.

• A rolling programme could also include phased targeting of specific patient cohorts

Examples of this approach include:

i) choosing a patient cohort that supports a screening programme e.g. childhood immunisations, flu or cytology

ii) addresses with apparent multiple occupancy

iii) practices with particular circumstances which dictate a local bespoke approach to maintaining accurate lists e.g.

University practices

• A ‘one hit’ approach in which a single practice is targeted should be avoided except in exceptional circumstances. This might

include for example; due diligence when transferring a full list to a new practice. In all cases this should be carried out in

consultation with the LMC.

• When responding to FP69 flags in the practice IT system, a practice declaration will be sufficient - additional evidence such

as screen-shots would be unnecessarily bureaucratic and may breach patient confidentiality. The practice is responsible for

ensuring all declarations made are accurate and should be made aware that these can be challenged where any

inconsistencies are highlighted through cluster-wide audit.

• A list maintenance exercise is not designed to address performance failures. Where there are reasonable grounds for

believing that list inflation is particularly high at an individual practice then concerns about this should be handled separately

and in accordance with the performance management directions. Good performance management guidance has been

agreed pan-London (weblink to be inserted).

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78

Operating Framework for List Maintenance

Minimising inconvenience to patients

• Advance screening of the proposed cohort by practices means that less patients will be inconvenienced by having to respond to

the letter. It will also reduce postal costs associated with the exercise.

• The commissioner should ensure that where the registration authority disputes the practice declaration, the practice is made

aware of the reason why, and is advised of any list actions that have been taken.

• The commissioner should maximise awareness in the patient population of list maintenance procedures an effective patient

communications strategy should be in place. The strategy should be tailored to local needs and build upon examples of what has

worked well for example:

– Branded NHS envelopes are more likely to be opened as they are clearly related directly to the patients health

– Alerting patients to registration checks well in advance – as part of the registration conversation, through display notices in

a practice

– Making the process clear to patients through any letters and posters for example - what the letter looks like, what to do

when you get one, the steps in place to minimize de-registration errors, what to do if there is a de-registration error, what

to do if a letter arrives for someone not living at that address.

– Communications tailored for different languages and consideration of other support for patients who’s first language is not

English

– Letters to be addressed to named patients and not the occupier

NHS London will work with patients and community groups to develop recommended templates which provide clear simple

accessible messaging on all patient correspondence

• Commissioners should ensure that practices have access to training and IT support to undertake validation - identifying FP69’s and

flagged patients on the practices system

• Practices have a crucial role to play in ensuring that their staff access the training, are familiar with the FP69 process and are

proactive partners in the list maintenance process.

• List maintenance is also an opportunity to improve other aspects of patient registration including the accuracy of patient

information held on the register. Practices should verify the details of patients contacting the practice on a systematic basis as

part of routine on going maintenance.

• Practices should always re-register patients who have been removed under this process, but who are still resident , with a

minimum of inconvenience to the patient.

8

79

‘Once for London’

Pan-London Operating Principles for Primary Care

Local Enhanced

Services

80

Once for London

The Once for London Project

• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical, dental, pharmacy

and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning of primary

care services to:

– Support continuing improvement in the quality and productivity of primary care services as part of QIPP

– Ensure fairness, equity and transparency in the way general practice services are being commissioned across London

– Embed best practice approaches across all commissioning organizations

• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we commission key

primary care services. Initially this work programme will focus upon:

– For general practice - List Maintenance, Enhanced Services and PMS Reviews

– For dentistry - End of Year Process, Performance Approach and Contract Changes

• The expectation is that this programme of work will synchronise with transition towards a single operating model for primary care

commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and other contractor groups

within London both implementing national operating models and influencing the shape of these by sharing local operating principles.

Developing the Operating Principles

• A set of task and finish groups have been established to ensure that there is wide collaboration from across London.

• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors, LMC, LDC,

FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and knowledge to

develop a unified approach to a basket of key QIPP challenges.

2Draft Work In Progress81

Local Enhanced Services

Context and Background

• LESs are a key commissioning tool for delivering care closer to home and to shift services out of hospital.

• This document sets out a range of pan-London operating principles for the commissioning of enhanced services. These principles

will provide a framework for local bodies to make best use of local enhanced services mechanisms.

• PCTs have commissioned a broad range and number of enhanced services. There is great variation in the number, scope, format and

type of Local Enhanced Services (LES) within each cluster as well as across London.

• The benefits and outcomes of many LESs have not often been systematically evaluated for value for money, impact and strategic fit.

A number of PCTs are completing reviews of enhanced services as part of Primary Care QIPP programmes.

• Enhanced services can make up to 20% of practice income. The historical variation in PCT commissioning , reporting, auditing and

payment arrangements for different enhanced services can be counterproductive and a significant burden for both commissioners

and providers.

• Directed Enhanced Services (DES) remain outside of the scope of this document as they have national specifications which cannot

be altered and which must be offered to all practices. Commissioners may wish to replace a National Enhanced Service (NES) by

developing a LES to make it more locally applicable.

• The document is structured around 4 parts of a cycle that all commissioners of enhanced services need to explore as key elements

of the commissioning and contracting process.

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4

Key Enhanced Service Commissioning Principles

•This document provides principles for Clusters, CCGs, Public health and LMCs in the commissioning of Local Enhanced Services

•LESs are a key commissioning tool for delivering care closer to home and to shift services out of hospital.

•LESs should be locally led and developed in consultation with the Local Representative Committee (LRC)

•LESs should have clear notice periods, termination dates and the facility for annual review.

•Clinical engagement in audit and outcomes should be a key part of this process.

•Commissioners should give due consideration to the provision of reasonable notice periods and appropriate contract lengths to facilitate budgeting

and planning. Many LESs will be annual contracts, but where a LES may require the purchase of equipment or employment of additional staff, a LES

may be commissioned with a contract length of 2 or 3 years as appropriate.

•LESs should be outcome based as far as possible and the costs required to provide a service covered by the income which the LES provides.

•Commissioners should systematically review their LES portfolio for value for money, impact and strategic fit. It may be that there are opportunities

to decommission some services of limited value & strengthen the specifications and outcome measures of those that remain. Commissioners should

consider opportunities to consolidate their LES into a fewer number to deliver measurable health outcomes within a financial envelope .

•Enhanced services should add value and offer a measurable enhanced level of care and not duplicate services provided under other contractual

provision

•For reasons of equity, commissioners should give due consideration to cover any gaps in service so that complete population coverage is achieved.

Non-specialist LESs should normally be offered to all practices which satisfy accreditation criteria. Where specialist skills or equipment are needed to

provide a LES (such as minor surgery or anticoagulation therapy) , it may be that a cohort of appropriate practices are commissioned to provide the

service to the local population. Commissioners could also consider opportunities to achieve economies of scale through a network of practices

combining to employ particular staff (such as an additional nurse to provide immunisations and vaccinations) or share a piece of equipment.

• The data requirements for LESs should be as simple and straightforward as possible. They should not be onerous to produce or analyse. By involving

general practice IT system suppliers early-on, it is possible to develop a set of enhanced service read codes. This places a marker on all enhanced

service activity so that searches can be conducted to provide information for audit requirements.

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5

Governance arrangements

It is likely that the new NHS architecture will present commissioners with challenges to ensure there are clear and transparent governance

arrangements.

Commissioners must ensure that there are robust and transparent governance arrangements to manage any potential conflicts of interest

within Clinical Commissioning Groups (CCGs) in the LES commissioning and provision process, to ensure that services commissioned are

genuinely enhanced and that a robust pricing process has been followed which ensures that LES provide value for money.

We do not know the precise nature of roles and responsibilities for enhanced services commissioning post transition but transparent

governance mechanisms will need to be in place to demonstrate probity and stewardship.

It is expected that the LMC will have a key role to play in establishing them and that public and lay representation will be involved in this

process.

Deciding if a LES is the best contractual vehicle for the service

As part of the process of defining a service need, understanding the options for provision will enable commissioners to decide whether a

local enhanced service contract is the right approach.

Considerations such as the time of day and number of days a week the service would be best provided and the skills required may lead the

commissioner to consider a range of providers for whom an alternative contractual vehicle would be more appropriate.

For example ,local community services or pharmacists may be best placed to provide some services rather than GP practices.

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6

Governance Arrangements

Governance Arrangements

Framework for

Local Enhanced

Services

Development

Stage One:

Identify the outcomes to be achieved by the service you are commissioning and the service specification that will deliver it.

Stage Two:

Agree an appropriate financial model for the service

specification

Stage Three:

Deciding which providers should provide the service

Stage Four:

Review and Evaluation

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7

Stage One:

Identify the outcomes to be

achieved by the service you are

commissioning and the service

specification that will deliver it.

Stage One: Identify the outcomes and service specification required by the service

Having identified a health need, the commissioner should consider the outcomes that they wish to

achieve, the service required to address it and the service specification to support it.

Service specifications for enhanced services should be based on clearly defined and measurable

service outcomes, outputs and processes depending on the service commissioned which should be expressed in clear KPIs.

In order to facilitate impact assessments, service specifications should contain outcome measures where possible. They may also contain some output

measures where appropriate. A smoking cessation LES, for example, will pay for the number of smoking cessation consultations held (‘outputs’) , as

well as the number of quitters achieved (‘outcomes’).

The specification should be appropriately quality assured to fit with the local enhanced services portfolio, including testing quality, effectiveness and

efficiency of a specification.

LES services specifications should include:

•What the LES aims to achieve and how that will be evaluated

•Any eligibility and exclusion criteria

•Service outline

•Pricing for the service

•Data requirements and payments schedule

•Length of contract prior to service review and audit

•Monitoring arrangements and audit process (PPV arrangements for example)

•Length of notice required for termination of agreement or variation of agreement (it is recommended that this should not be less than 3 months)

•Arrangements for patient participation/feedback where appropriate

The commissioner should consult with the LRC on all aspects of the specification

For a LES model template see appendix 1

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8

Stage One:

Identify the outcomes to be

achieved by the service you are

commissioning and the service

specification that will deliver it.

Length of contract

Due consideration should be given to the period of time that the service will be commissioned

before review and evaluation. Where a service requires, for example, the purchase of equipment or

employment of additional staff, commissioners may consider an agreement of two years

or more appropriate as providers may need to make significant investments to provide the service.

This should be clearly outlined in the LES specification and SLA/contract.

Notice period for variation and termination

Similarly, the notice period to be given to providers for variation or termination of a LES should be considered on a case by case basis and should usually

be no less than 3 months. When considering notice periods ,commissioners should take account of the requirements of providing the service and the

ability of providers to make necessary operational adjustments within a reasonable time frame, as well as the health and clinical outputs and outcomes.

Considerations similar to those given to contract lengths will need to be given to LES notice periods as those which require the employment of

additional staff, for example, are likely to require longer periods of notice than those where the operational impact on providers is less significant.

Commissioners may also want to include the period of notice providers need to give should they no longer want to provide a LES.

Contract length, notice periods , termination and variation arrangements should be clearly outlined in the service specification and contract/SLA and

are subject to consultation with the LRC.

Contract monitoring

The contracting body should carry out suitable audit ,such as undertaking regular reviews of payments and activity. Anomalies/changes in patterns of

provision should be queried and where there are ongoing concerns , a post-payment verification check may be appropriate. Contract monitoring should

also provide assurance on compliance with service delivery and achievement of outcome measures.

Commissioners should carry out systematic post payment verification at a sample of practices as a matter of routine. Arrangements for contact

monitoring/PPV should be made clear in the service specification.

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Draft Work In Progress 9

Stage 2: Agree a financial model for the service specification

Recorded activity

Recorded activity for local enhanced services should be based on clearly defined, valid and measurable

service outcomes, outputs and processes which should be reflected in the service specification and

payments.

For example, where a practice provide chlamydia screening , the LES may reward the number of screenings carried out

Smoking cessation may include ‘outcomes’ (i.e. the number of quitters) , as well as ‘outputs’ (the number of patients seen).

Where a LES is largely process-focused, outcomes such as health improvement and patient satisfaction may be considered for inclusion.

The service specification will include the methodology for undertaking review and audit locally – outlined in stage four.

Price setting and payments

In determining the price ,commissioners may look at a number of considerations. These could include a calculation of the costs to the provider of

delivering the service, how that cost compares to any tariff price that it might substitute and benchmarking of prices paid elsewhere for the same or

broadly similar activity.

Professional Local Representative Committees (LRCs) must be consulted on the service specification, including the pricing.

Payments for enhanced services should be identifiable on practice budget statements where possible. Where this is not feasible, alternative

solutions should be considered such as an annual statement of enhanced service £sum totals.

By involving general practice IT system suppliers early-on, it is possible to develop a set of enhanced service read codes. This places a marker on all

enhanced service activity so that data searches can be conducted to provide audit/evidence that the service has been delivered according to the

specification.

Stage Two:

Agree an appropriate financial

model for the service

specification

88

Stage Three: Identify who should provide the enhanced service

Deciding on service providers

The commissioner may wish to offer their local enhanced services to all providers or practices for

“generalist” services or for more specialist services to a select group of providers with the

necessary skills, staff, equipment or premises.

Having due regard for professional and medical opinion, commissioners should decide if there are any minimum eligibility/quality criteria for the

provision of each local enhanced service and, if so, what they are and how they will be assessed.

The process through which providers are selected should be transparent, fair and equitable.

Commissioners could also consider opportunities to achieve economies of scale through a network of practices combining to employ particular

staff (such as an additional nurse to provide immunisations and vaccinations) or share a piece of equipment that can be used by a network of

neighbouring practices. Commissioners will also need to consider the number of providers required to deliver a LES in order to address the health

needs of the population.

All patients should be able to access the service

For reasons of equity, commissioners should have an alternative strategy in place to cover any gaps in service so that complete population

coverage is achieved.

Where a practice is not providing a LES, either through choice or accreditation, then whole population coverage for the service can be achieved by

commissioning a neighbouring provider to deliver the service to the non-participating provider’s patients.

Commissioners may want to consider identifying host sites for enhanced service delivery with inter-practice referrals so that provision is via a care

network.

Draft Work In Progress 10

Stage Three:

Deciding which providers should

provide the service

89

Draft Work In Progress 11

STAGE FOUR:

Review and evaluation

Stage 4: Review and Evaluation

Commissioners should undertake a regular review, evaluation and update of each of their enhanced

services.

LESs should be subject to periodic review and impact assessment. Clinical engagement in audit and outcomes should be a key part of this process. A

robust process would take into account a review of the evidence of impact of each LES, its value for money and strategic fit with local and national

priorities. The LRC must be consulted as part of this process.

To facilitate this task, commissioners may consider setting-up a group to review their LES portfolio, which includes stakeholders from finance, IT, public

health, pharmacy, primary care, contracts, LRCs, GPs and Practice managers. A LES review process may require significant time input from group

members and a commissioning resource to oversee the process and deliver any contract changes.

Following the review of a LES, the commissioner may decide to make modifications (for example, strengthening the service specification, payment

thresholds, adapting the outcome measures) or to decommission the service depending on the review outcome.

Modifications to LESs should be subject to consultation with the LRC and arrangements made for due process, in line with governance frameworks.

Undertaking a formal review and evaluation of enhanced services can help commissioners to identify opportunities for improving the administration of

these contracts. For example, this could include establishing read codes or having a single enhanced services contract to cover a number of related

existing enhanced services.

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Draft Work In Progress 12

Enhanced ServicesFuture Roles and Responsibilities

The precise commissioning

arrangements for enhanced services

are not yet known.

As we move towards transition CCGs

already have an important role to

play in deciding on the ability of

practices to provide enhanced

services and which services should

be commissioned and it is likely that

their role will broaden further.

Ensuring that the LES offer

effectiveness, value for money,

quality and impact as well as

processes for governance, audit and

patient involvement will be a key

challenge for the new architecture.

Context and Background

A national operating model for the development of enhanced services post-transition has not yet been designed however the known organisations

and their interactions are outlined below.

91

Local Enhanced Service Specification for XXXXXXX

Commencement date – End date

A local enhanced service between [commissioner] and [Provider(s) name(s)].

1. Introduction and Background

The introduction should include:

• Overall scope of service including needs analysis and links to appropriate/relevant guidance/documentation

• Details of length of contract (eg. fixed term, rolling 2 or 3 years etc)

2. Aims

This section should be considered carefully as it will aid evaluation and review of the service as well as criteria decided for routine monitoring. How will you know if the LES has been successful? It should include:

• Projected outcomes/outputs

• Desired efficiencies

• Quality markers

3. Eligibility and exclusions

This should include details of the target population or any specific terms for eligibility of accessing services, e.g. age, gender, diagnosis, etc If there are any patients from defined criteria that need to be excluded for this service, e.g. long term condition diagnosis with a certain prescribed medication, etc they should be outlined here.

4. Service Specification

This section should be used to describe the service to be commissioned and the minimum contracted requirements. This may differ considerably in size depending on the complexity of the service to be commissioned, however, should still contain the following minimum requirements:

• Description of the service to be commissioned

• Valid and measurable outcomes, outputs and necessary processes

• What is included and what is not included; details on resources required eg staff/consumables – to be reimbursed or already factored into price for service.

• Patient feedback on quality of LES where appropriate This section should detail any arrangements for providing a service to a network or practices or a neighbouring practice where appropriate.

Set out any reasonable minimum standards of qualifications, equipment required, staff or premises necessaryThis section may also include evidencing continuing competency such as

inserting minimum number of IUCD per year or number of minor surgical procedures etc

Where a LES is largely processed focused, outcomes such as health improvement and patient satisfaction may be considered for inclusion eg patient feedback metrics

92

5. Payment Schedule

This section should give clear activity and pricing details and should include:

• Full details of the payment structure, i.e. per head, per intervention, percentage thresholds, per session etc

• The price paid for clearly defined, valid and measurable service outcomes, outputs and processes.

• Associated expenses – premises, staffing costs etc. to be reimbursed or included in price for service

6. Monitoring

This section should be used to outline any routine monitoring arrangements. The data requirements for LESs should be as relevant, simple and straightforward as possible. They should not be onerous to produce or analyse. However the commissioner should carry out suitable audit such as regular reviews of payments and activity. The section should include:

• Frequency of reporting

• Data required

• Reporting mechanism

• A requirement that all patient specific activity is recorded on the patient record

• Sample post payment verification (including details of frequency and method of selecting cohort for PPV)

7. Review of the Service

Commissioners should use this section to outline:

• The frequency for planned service effectiveness review during the course of the agreement

• The possible interventions that a review may trigger (for example continuation/extension of the service, suspended or terminated activity, alterations to payment thresholds etc)

8. Variation/Termination of Agreement

This section should give a clear minimum notice period for both the commissioner and provider to terminate an agreement (not less than three months) and outline the process for varying the LES and the minimum notice period that should be given to providers (not less than three months). It should also describe the process and governance arrangements for making the decision to vary/terminate the LES. This section should also state what steps would be taken if there was a failure on the part of the provider to deliver to the required standard (ie termination due to sub standard performance) and the process that would be followed.

9. Protecting Patient Confidentiality

93

This section should outline responsibilities for patient confidentiality with due regard to Caldicott Guardianship principles.

94

Contract

Acceptance of Terms: Service Specification for ... [Enter name and contract length] Local Enhanced Service (LES) Practice Code………………… Name of Practice: …………………………………………..

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 the ... [commissioner] and ... [provider] to provide Enhanced Services. 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 [provider] by.……………………………………………………….. Print name…………………………………………………… Date: ………………………..

Practice Stamp:

Signed on behalf of [Commissioner]……………………………………………… Print name………………………………………………… Date: ………………………..

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Appendix - definitions

This section may include:

• Any necessary full definitions of abbreviated terms

• Precise definitions of any phrases that are used throughout the document (for example duration of a “session”, definitions of target populations etc)

• Other details such as the date at which lists sizes may be taken if used to calculate payments

96

‘Once for London’

Pan-London Operating Principles for Primary Care

PMS Contract Review

97

Once for London

The Once for London Project

• The NHS Commissioning Board will have a direct role in the commissioning of primary care services including medical,

dental, pharmacy and optometry.

• London’s Primary Care Professional Leadership Group (PLG) are developing unified operating models for the commissioning

of primary care services to:

– Support continuing improvement in the quality and productivity of primary care services as part of QIPP

– Ensure fairness, equity and transparency in the way general practice services are being commissioned across London

– Embed best practice approaches across all commissioning organizations

• The output of this work will be a suite of operating principles that can be consistently applied to improve the way we

commission key primary care services. Initially this work programme will focus upon:

– For general practice - List Maintenance, Enhanced Services and PMS Reviews

– For dentistry - End of Year Process, Performance Approach and Contract Changes

• The expectation is that this programme of work will synchronise with transition towards a single operating model for

primary care commissioning nationally. It may therefore extend to looking at all aspects of primary care commissioning and

other contractor groups within London both implementing national operating models and influencing the shape of these by

sharing local operating principles.

Developing the Operating Principles

• A set of task and finish groups have been established to ensure that there is wide collaboration from across London.

• Approximately 70 primary care leaders have participated in this work to date with representatives from clusters, contractors,

LMC, LDC, FHS organisations, clinicians, practice managers, public health, finance and contracting.

• These task and finish groups have provided a forum through which primary care leaders have shared experiences, skills and

knowledge to develop a unified approach to a basket of key QIPP challenges.

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98

Summary

• In 2006 the Secretary of State for Health requested that all PCT’s undertake to review PMS contracts to establish value for money and to improve access to services.

• There are clear benefits that flow from renegotiating and updating PMS contracts across London to reflect the changing primary care agenda, ensure value for money, consistent quality and better reflect national and local priorities.

• Many PMS contracts no longer effectively incentivise high quality primary care services and do not contain incentives or provide funding support which will facilitate a reduction in the use of hospital services and deliver more services closer to home in a primary care/community setting.

• In many cases PMS contracts have been superseded by the development of QuOF and enhanced services and as a result there is sometimes little difference between the services provided by PMS and GMS practices

• In 2007/8 an analysis of GP earnings and expenses suggested that the cost paid per patient under PMS agreements was on average 13% higher than the average under the GMS contract

• PMS contracts do not always offer value for money and PMS practices usually (but not always) receive higher payments per capita than GMS practices which creates a perceived inequity in PMS contracts.

• In the case of many PMS contracts the original objectives and allocated growth funds have not been reviewed and there is significant variation in their per capita payments

• This paper sets out an approach to review the above issues and realign the PMS contracts to address the needs of the local population in a cost effective manner.

Background

• Personal Medical Services (PMS) Pilots were first introduced in 1998. The current PMS Contracts have been in place since 2004 and are locally determined contracts with specific objectives that should link to local and national targets.

• The contract was an opportunity to develop more flexible and locally responsive services.

• PMS practices were awarded growth monies attached to the delivery of additional capacity and or locally negotiated services to improve access, encourage the take up of screening programmes, increase the level of childhood immunizations, and improve the management of long-term chronic conditions.

• All PMS practices were expected to have an open list and received additional funding for a planned increase in list size or to attract GPs to the practice in locality areas where GP recruitment was difficult.

• This approach brought a wide range of benefits, being used to develop new services for specific populations, to attract doctors and nurses and to improve services for patients.

3

99

4

Key Principles

This paper aims to establish a set of pan London principles which provide an operating framework within which commissioners across London

reviewing PMS contracts will operate . The aim is to negotiate equitable PMS contracts which incentivise and reward outcomes which align with

local and national priorities and which meet the needs of the community they serve in line with a set of agreed principles.

A summary of the key principles is as follows:

Process

•The negotiation process, roles, formal processes and representation should be defined and agreed at the start of the process and clearly

communicated to all stakeholders

•LLMC should provide advice and support; local LMCs should lead on negotiations and represent local PMS Practices as mandated by

individual practices and the resulting contract should be offered to all PMS practices

•PMS contract review should be applied to all PMS Practices

•There should be extensive engagement with practices and consultation with LMCs on the renegotiation of PMS contracts and the process,

timeframe and reasons for PMS review should be clearly articulated at the outset

•The commissioner should take all possible measures to reach agreement on PMS contract reviews through timely, well communicated

meaningful and open engagement. Termination should not be part of the negotiation process and where possible all PMS practices should

transfer to the new arrangements. PMS practices should be made aware of their option to return to GMS contracts.

Outcomes

•To provide a consistent framework for PMS contracting

•Funding and pricing should reflect and reward work carried out and represent value for money

•That PMS practices agree and sign up to changes on an individual practice basis

Financial

•Agree an equitable basis for core and enhanced funding, based on services carried out and quality achieved

•Rebasing and funding comparisons and modelling should reflect appropriate, accurate and relevant financial models and assumptions

•Any released savings should be directed into borough Commissioning Strategy Plan (CSP) priorities

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5

Managing the change

That the impact of change will receive facilitation and support from the LMC and the PCT in recognising that practices have a varied

start point in capability.

Commissioners should ensure that the pace of change allows a move to the new arrangements with a minimum of disruption to

practices and patients

Performance Management

Performance management arrangements should be

• Specific, measurable, achievable, relevant, time bound.

• Evidence-based

• Not duplicate other schemes such as QOF

• Not be onerous on data collection

• Minimise KPIs

• KPIs should reflect outcomes, processes, or be hybrid.

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6

Where are we now? What are we trying to achieve?

There are a number of shortcomings with many current PMS

contracts which include:

•Many PMS contracts have not been subject to regular

systematic review by commissioners and have not been

reviewed or amended since their inception.

•Many contracts have objectives which no longer align with

cluster/CCG objectives or reflect their current priorities.

•The introductions of both Quality and Outcome Framework

(QOF) and Enhanced Services (ES) have superseded some of

the original objectives of PMS contracts (although this has

been offset to an extent by the PMS quality points offset)

•There is potential for practices to be double funded for their

activity under their PMS contract as well as attracting payment

through QuOF.

•There is significant variation in the range, quality and type

of services providedunder PMS contracts and the payments

which they generate.

•There are often significant disparities in the payments per

capita between practices (both PMS and GMS) with little

correlation between the value of the contract and the

performance outcomes which the practice achieves or the

services they are providing.

•In many cases list sizes have not increased in line with

growth projections and commissioners may be funding

patient lists which are significantly less than the contract

allows for.

•A set of pan London principles which provide an operating framework within which

commissioners across London reviewing PMS contracts will operate

•Contracts which maximize the capability and capacity of primary care to support a

shift of services out of hospital and deliver extended services as part of an

integrated care pathway.

•Contracts which incentivise and reward outcomes which align with local and

national priorities and which meet the needs of the community they serve.

•A set of contracts which provides value for public money where greater

investment yields measurably better outcomes and range of services

•A set of broadly equitable PMS contracts which establish a basket of locally

relevant high quality services that patients can expect to receive as a minimum

level of service

•Contracts which support and provide for flexible locally agreed extra service

provisionover and above the basket of services where they offer value for money

and strategic fit.

•Contracts which support the implementation of health care priorities both

national and those identified in local JSNAs and Public Health reports

•A set of KPIs, linked to funding, which are simple to measure, achievable and a

structure for future monitoring arrangements

•An established mechanism for adjusting payment to quarterly changes in the

normalised weighted list population

•Consultation with individual contract holders and a range of stakeholders

including LMC and borough/cluster commissioners as appropriate, bearing in mind

CCGs as their roles and responsibilities are defined.

What are we trying to achieve?

102

How will we achieve it?

7

Action Summary

Commissioner

carries out an

audit of the

current PMS

landscape.

A first step will be to confirm that current PMS contracts comply with statutory regulations , that they are up to date and in the same

format across all PMS contracts within the health community. Commissioners should complete a comprehensive structured practice by

practice audit of what PMS is currently being delivered over and above GMS and the current levels of per capita funding for each

practice.

This will include:

•An in depth financial review of each practice to establish the range of per capita payments (using the definitions of what to include in the

diagram overleaf). The assessment will also report on the services the practice provides and the outcomes it produces.

•A focus on local health needs outlined public health intelligence in the borough JSNA

•Comparative data on quality outcomes and value for money across different contracts (GMS and PMS).

•Care that comparisons between per capita payments are made on a like for like basis and Clusters should use the Carr-Hill normalised

weighted list (which is used to determine GMS Global Sum Payments) for the denominator in the calculation.

•An audit of additional payments and existing incentive schemes and where there are LIS’s in existence an alternative LES should be

considered to ensure there is a proper contractual mechanism in place.

Financial

modelling

Establishing a robust per capita funding analysis is a crucial part of the process. As part of their financial modelling commissioners should

ensure that:

•Comparative per capita payments are calculated without additional funds such as premises, QuOF and seniority payments (see

diagram on page 6 and appendix 2 for an example of a GMS funding per capita equivalent calculation)

•Determine their commissioning intentions and determine a financial envelope to deliver these intentions which is affordable to the PCT

- delivered through a basket of services over and above the core services

•PMS per capita payments should demonstrate value for money in delivering effective services over and above what an average GMS

practice provides. The commissioner should ensure that the services and standards attached to the additional investment in PMS over

and above GMS delivers measureable cost effective quality outcomes.

•Costing should be calculated for each of services in the basket separately. Once clusters build their basket to reflect local needs , CSP

priorities and financial constraints they can set a per capita value can be set against the services , setting aside a sum for stretch target

payments.

•PMS practices are provided with financial support to manage the transition to the new arrangements within a 12 month period

•Deducted QOF points are noted if they are incorporated into the per capita funding analysis, Out of Hours payments are noted as

included in the per capita funding

• There is a clear process for quarterly list size changes

• Scope of annual reviews is clearly stated 103

This model provides a

diagrammatic

representation of GMS

and PMS contracts and

the payments made for

the same and different

work that they

undertake.

The basket of PMS

services correlates to the

£s per patient over

Global Sum that all PMS

practices receive for

providing those services.

GMS practices should be

given the option to

provide the PMS basket

of services as individually

priced LES.

Enhanced Services over

and above the basket of

PMS services are offered

to both PMS and GMS

practices

Where PMS practices opt

to provide them they

become part of the PMS

contract

Option for GMS

practices to

provide the PMS

basket of services

as individually

costed/priced LES

Locally agreed

additions to

reflect the

community

need

Essential and

Additional

Services

QOF

Seniority

Premises

Payments

Premises

Payments

Seniority

QOF

GMS PMS

Enhanced Services provided over and

above the basket of services by

practices wishing to provided these

extended services

Essential and

Additional

Services

Variable

practice

income.

Outside scope

of review.

New PMS fixed

practice

income.

Subject to

PMS review.

£

Dependent on actual QOF performance

Dependent on District Valuer’s valuation and actual cost of rates

Essential and additional services as defined in the national contract

regulations.

Includes Out of Hours income unless a

practice has opted out of its providing it

Proposed Pricing Model

PM

S C

on

tra

ctu

al R

eq

uir

em

en

t

Basket of services over which all PMS

practices are expected to deliver. These will

include KPIs and clear rules for

incentives/penalties as a result of

performance against them.

Enhanced services over and above the

basket are offered to all practices (GMS

and PMS) and are agreed with individual

practices .

PPA Payments PPA Payments

Personal, based on length of service

Ad hoc pay e.g.

locums for

sickness,

maternity etc

Ad hoc pay e.g.

locums for

sickness,

maternity etc

Dependent on prescribing activity

Variable from practice to practice and year to year in both GMS and PMS

pracitces

GM

S C

on

tra

ctu

al

Re

qu

ire

me

nt

Fixed

GMS

per

capita

Income

£

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9

Action Summary

Establishing

effective

collaboration

There should be extensive engagement with practices and consultation with LMCs on the renegotiation of PMS contracts and the

process, timeframe and reasons for PMS review should be clearly articulated at the outset.

Negotiating a basket of services with the local PMS GP community avoids duplication as broadly one contract is being negotiated

across a group of practices and also provides the opportunity for greater discussion and peer involvement in the negotiation and

agreement process.

The reasons and scope of the PMS renegotiation should be communicated clearly to contractors and their representatives and a

time line established for the renegotiated contracts to go live. Clusters should therefore :

• Clearly set out their plans to renegotiate PMS contracts in line with a set of common principles. Put in place governance

structures in consultation with the LMC and provide opportunities for regular input to the process that reflects the level of

stakeholder collaboration required.

•Should be clear about the reasons for the renegotiation setting out the potential benefits to patients, commissioners and providers

• Establish a clear timeline for renegotiation and the mechanisms for engagement in the process (meeting schedules, participants,

groupings of practices and so on)

•Transitional management planning should take into account the degree to which practices are changing services, contract value

changes and infrastructure requirements and ensure that the pace of change allows a move to the new arrangements with a

minimum of disruption

Governance

Arrangements

•Existing PCTs and their successor body for primary care contracting (planned to be NCB post April 2013) should ensure that there is

Board Level support and accountability through robust and transparent governance arrangements

•The plans for local PMS contract review should be ratified and approved at board level

•A sub-committee of the board should be established to design, steer and deliver the agenda with director level representation and

ownership

•Renegotiation of the contracts will require significant PMS contract expertise, performance data analysis and project management

resources. PCTs should ensure they have a project team in place to deliver from the outset with the capacity and skills to

implement the changes within the time frame they decide on. The project group should be responsible to the PMS Review sub-

committee.

•There should be a clear appeals and local resolution procedure.

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10

Action Summary

Establish a

basket of

services

PCTs should:

•Negotiate with their PMS practices to agree a basket of services which their practices should provide and the standards to which they

should be provided. These services/ standards should demonstrate value for money where practices are receiving payments in in

excess of Global Sum / Average GMS payments.

•A percentage of payments should be set aside for stretch target outcomes.

•Agree the basket as far as possible with all their PMS contractors in the borough

•The basket should be reviewed annually and should reflect local and national priorities

•The review should link to the annual Commissioning Intentions process

What might

a basket of

services

look like?

The basket of services is for local determination but in order to achieve a more uniform PMS service provision across London

commissioners may wish to include some of the baskets of services already adopted across London.

For examples of baskets of services commissioned across London see http://www.pathfinders.london.nhs.uk/wider-health-system-

information/

Commissioners should negotiate a per capita payment that reflects individual borough level negotiations and the results in a single

sum payment. Ensuring a clear and simple approach is taken by both the management and calculation of the contract value and

payment due.

Stretch

targets

•Commissioners should attach KPIs to the basket of services which are measurable, challenging and outcome focussed. Where services

are similar to elsewhere in London similar RAG rating and thresholds should be benchmarked as far as possible.

•Commissioners should negotiate a percentage of the payment to be dependent on the contractor being able to demonstrate

compliance with the KPIs/stretch targets

•The capitation payment negotiated for the basket of services should be subject to performance outcomes. The percentage of

payments for performance is for local determination but should be sufficiently high to reward excellence , drive gold standard

performance.

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11

Action Summary

Implementation Subject to the overall cost to commissioners being cost neutral;

•Where a practice was being paid less than the negotiated capitation payment their payment should be adjusted upwards

•Where a practice capitation payment was in excess of the newly negotiated capitation payment then the commissioner

will reduce the capitation payment.

•Transitional non recurrent support should take into account the degree to which practices are changing services, contract

value changes and infrastructure requirements and ensure that the pace of change allows a move to the new

arrangements with a minimum of disruption to practices

Enhanced services

and the out of

hospital agenda

PMS contracts allow for significant flexibility and commissioners and providers may decide to negotiate creative and

innovative services which integrate with their local priorities depending on the financial envelope available and the

strategic priorities of the cluster.

The Commissioner will present the opportunities for additional practice income that may be linked to the out of hospital

agenda, or enhanced services that sit outside those identified in the basket of services.

Action where

agreement is not

possible

•The commissioner should take all possible measures to reach agreement on PMS contract review through timely, well

communicated meaningful and open engagement. However where it is not possible to reach a mutually satisfactory

agreement it may be that the provider returns to a GMS contract.

•The contractor has the right to return to a GMS contract through regulation 19.

•There is no legal right for a GMS practice to move to PMS

107

The Commissioner will

present the opportunities

for additional practice

income that may be linked

to the out of hospital

agenda, or enhanced

services that sit outside

those identified in the

basket of services and core

services.

12

Commissioner engages

with PMS GP community

and outlines their desire

to renegotiate PMS

contracts in line with

QIPP objectives.

Commissioner proposes a

governance structure and

terms of reference

Committee Structure:

-Expert Advisory

Committee

- Project Board

-Set out mandate from

practices

-Representation

includes Public Health

and Business Support

Unit, GP’s, LMC, Primary

Care Management

(Commissioning)

Commissioner carries out

an audit of the current

PMS landscape. This will

include understanding the

investment per patient,

and will assume premises,

seniority and enhanced

services and QOF are

excluded. Information will

present the correlation

between performance

and investment

Commissioner sets out

commissioning

intentions and proposes

a core basket of services

that reflects national

and local priorities.

Commissioner

negotiates RAG rated

KPIs that will be used to

evaluate performance

Commissioner establishes

new per capita payment

for all PMS practices and

sets stretch targets with

performance payments

using the KPIs negotiated

in stage 4.

1 2 4

5

3

Commissioner negotiates time

frame for normalising PMS

capitation payments across

PMS practices.

It is recognised that the

contracts will be signed

by the individual

practices and that

partners will retain the

option of either

agreeing the revised

PMS contract or

reverting to GMS

6 7

PMS Process Summary

108

Acknowledgements

13

Thank you to all those who contributed to the creation of these operating principles including:

Name Role Organisation

David Sturgeon Task and Finish Group Chair, Director of Primary and Community Services Transformation SEL

Greg Cairns LMC

Dr Paddy Glakin LMC

Claire Hornick Primary Care PMS Contract Manager SEL

Rachel Hawksworth Senior Contracts and Performance Manager (GPs) NCL

William Cunningham-Davis AD Primary Care (GP and OOH) SWL

Edward Ward Head of Primary Care ONEL

Julie Taylor AD Primary Care Contracting NWL

Lee Dolan PMS Practice Manager, Queen’s Medical Centre SWL

Annette Pautz PMS Practice Manager, Holmwood Corner Surgey SWL

Andrew Watson PMS Practice Manger, Fullwell Cross Health Centre ONEL

Mick Lucas AD Primary Care Finance SWL

Rael Gamsu Assistant Director of Finance ONEL

Tony Thomas Associate Director of Finance NWL

Jemma Gilbert AD Primary Care NHS London NHSL

Sean Fenelan PCC

Documents Referenced

Greenwich PCT approach to PMS Review

Harringey PCT Approach to PMS Review

Primary Care Quality and Productivity Challenge: Good Housekeeping Guide – NHS Primary Care Commissioning April 2010

109

14

Data £/patient

GMS Benchmark £ 64.59

London Weighting £ 2.62

QOF payment £ 2.66

Total £ 69.87

GMS Baseline Payment Calculation

As recommended by the DoH letter

Gateway Ref: 14380

para 6

http://www.dh.gov.uk/

Statement of fees and entitlements

Section 2 para 2.3

(as this payment is based on actual list

size the amount of £2.18 has been

multiplied by the relative list size

adjustment As per QMAS 1.1.11

Payments for chronic disease

management allowance , sustained

quality allowance and cervical cytology

payments included in PMS baselines

but received by GMS in their QOF

payments .

£13,050/5,891 (PMS points deduction

divided by national average list size)

multiplied by relative list size

adjustment factor as per QOF 1.1.11

Appendix 2

110

Learning Education and Development (LEAD)

CURRENT EVENTS FOR 2011/2012

http://www.lmc.org.uk/uploads/files/member%20community/events/2011/leadannualpro

gramme201112v2.pdf

Medical Records in Primary Care

(the importance of good record keeping)

• Tuesday, 21 February 2012

• 1.00-4.30pm • Medical Protection Society, 33 Cavendish Square, London W1G 0PS • Delegate fee £90.00 for Londonwide delegates and £108.00 for other areas • Maximum capacity 25 per workshop

General Practice Nurse and Healthcare Assistant Events

Family Planning: Contraception

• Tuesday, 20 March 2012 (1.00-5.00pm) • Hamilton House Meeting & Conference Centre, Mabledon Place, London WC1H 9BD

• Delegate fee £50.00 for Londonwide delegates and £60.00 for other areas

• Maximum capacity 40

Practice Manager Events

Risk Management

• Tuesday, 24 January 2012 (1.00-4.30pm) • Woburn House Conference Centre, 20 Tavistock Square, London WC1H 9HQ

• Delegate fee £79.00 for Londonwide delegates and £108.00 for other areas • Maximum capacity 40

Employment Law ‘Hot topics’

• Tuesday, 23 February 2012 (1.00-4.30pm) • General Chiropractic Council, 44 Wicklow Street, London WC1X 9HL • Delegate fee £49.00 for Londonwide delegates and £60.00 for other areas • Maximum capacity 70

111

If you, or a member of your practice team, are interested in any of these events please contact the

LMC office (mvassallo@lmc.org.uk) to register or request more information.

The New LEAD programme for 2012/13 will be available shortly so please look out for it!

Booking Form

112