Transcript Dr Patricia Moultrie Sessional GP Presentation June 2013

Contract meeting for Sessional
GPs
June 2013
Dr Patricia Moultrie
Glasgow LMC Sessional GP Representative
Glasgow LMC
What is a Local Medical
Committee?
 elected committee of local GPs
 represents GPs in Glasgow and Clyde
 provides support and advice to GPs and
practices
Glasgow LMC
Funding
• voluntary levy paid by all GPs, cost
dependent upon list size
• levy also finances the LMC’s
contribution to the GP Defence Fund for
national GP representation
Glasgow LMC
Helping individual GPs
• The LMC provides help and advice to assist GPs
steer through the NHS. Such help is available on all
matters relevant to general practice including:
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Workload issues
Coping with change
GPs’ remuneration
GPs’ terms and conditions of service
Complaints
Premises/Partnership affairs
Any disputes which may occur
Sick doctors and those with performance problems
Glasgow LMC
National debate and policy
setting
 Scottish and National Conferences of LMCs.
Proposals from individual LMCs across the
country are debated alongside those from the
GPC.
 The outcome of the debate determines the
framework for the profession’s negotiations at
both national and local levels.
Glasgow LMC
Glasgow LMC and Sessional
GPs
 relationship
 communication
 representation
 information
 common interest
Glasgow LMC
Contact Glasgow LMC
 Dr Patricia Moultrie, Sessional GP
Representative on
[email protected]
 Mrs Mary Fingland, Office Secretary on
[email protected]
Glasgow LMC
Components of the Current
GMS Contract
Alastair Taylor
Vice Chair
Glasgow LMC
Glasgow LMC
Funding Streams
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Global Sum & MPIG
Quality and Outcomes Framework
Enhanced Services
Health Board - administered funds,
including seniority
• Premises
• IM&T
• Dispensing/personal administration of
drugs
Glasgow LMC
Global Sum
• Calculated (Scottish Allocation Formula) to
reflect:
• The age and sex structure of the practice
population (demography)
• The additional need of the practice
population (morbidity and deprivation)
• The rurality and remoteness of the
practice population
• Creates a “Weighted List” to allocate the
Global Sum
Glasgow LMC
Global Sum Covers:
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Essential Services
Additional Services
Staff Costs
Locum Reimbursements (for appraisal,
career development and protected time)
• The cost of GPs “employers
superannuation” contributions for those
funding allocations mapped across from
the old red book contract.
Global Sum Deductions
• For opting out e.g
– Out of Hours 6.0%
– Cervical Screening 1.1%
Glasgow LMC
MPIG
• Minimum Practice Income Guarantee
• MPIG = Global Sum via formula+
Correction Factor
• Correction factor = How much greater
Global Sum Equivalent was than
Calculated Global Sum
Glasgow LMC
Quality Outcomes
Framework QOF
• Clinical Areas:
• Atrial fibrillation, CHD, Heart failure, Hypertension,
Peripheral arterial disease, Stroke and TIA,
Diabetes mellitus, Hypothyroidism, Asthma, COPD,
Dementia, Depression, Mental health, Cancer,
Chronic kidney disease, Epilepsy, Learning
disabilities, Osteoporosis, Rheumatoid arthritis,
Palliative care, Cardiovascular disease - primary
prevention, Obesity, Smoking, Cervical screening,
Child health surveillance, Maternity, Sexual health
Glasgow LMC
QOF (2)
• Quality and productivity (QP) e.g.
Referrals/ACP
• Patient experience (PE) – 10 min
appointments
• Quality improvement (QI) – Trigger
Tools/Patient Safety Questionnaire
• Medicines management (MM)
• Public health (PH) “Blood pressure” in
over 40s
Glasgow LMC
Enhanced Services
• Directed (DES)
– e.g. Childhood Immunisation, Flu jabs,
Extended Hours
• Local (LES)
– E.g. CDM
Glasgow LMC
Other Streams
• Seniority:
– starts after 2 years in post (6 yrs
reckonable)
• Premises
– Cost Rent/Notional Rent
• IM&T
– Hardware and Software supplied – to
specification
• Dispensing
– Won’t discuss here
Any Questions for the Panel at the End?
Glasgow LMC
Contributing to practices’
contract work
2013/14
Dr John Ip
Glasgow LMC
Importance of QOF
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Significant funding for practices
Increased levels of work
More indicators
Higher thresholds
Glasgow LMC
2013 QOF Changes- RA
• New Rheumatoid Arthritis domain
• 4 indicators total of 18 points
Glasgow LMC
2013 QOF Changes- RA
• Register (1 point)
• Annual face to face Review (5 points)
• Assess CVD Risk 30-85 years using
ASSIGN (7 points)
• Assess Fracture Risk 50-91 years
using FRAX (5 points)
Glasgow LMC
2013 QOF Changes
• Diabetes
–Annual dietician review (3)
–New patients- referral to Structure
Learning Programme (11)
–ED screening, advice (4) &
treatment (6)
• COPD
–O2 Sat for Grade 3 and above (5)
Glasgow LMC
2013 QOF Changes
• Depression
–Biopsychosocial assessment at
time of new diagnosis
–10-35 day review after diagnosis
• Primary Prevention CVD
–SCOT-PASQ for patients with HT
diagnose after 1 April 2009
Glasgow LMC
Glasgow LMC
2013 QOF Changes
• All 15 month targets are now 12 months
• Some thresholds for full achievement
increased ( 5-10% increase)
Glasgow LMC
Other Contract Work
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Medicines Management
ScriptSwitch
Anticipatory Care Pathways & eKIS
Polypharmacy Reviews
Glasgow LMC
Tips for EMIS
Glasgow LMC
Correct Coding
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Using Templates
Values e.g. BP, BMI
Medication Reviews
Smoking Status & advice
Glasgow LMC
Reviews of Patient
• LARC advice for Contraceptives
• Dementia review
Glasgow LMC
Population Manager
• The Pop up boxes
• What do they mean?
Glasgow LMC
Other Tips
• Searching in consultations
• Audit trail for medicines
Glasgow LMC
Questions?
Glasgow LMC
Anticipatory Care Planning,
Poly-pharmacy and KIS
24th June
John Nugent
Clinical Director
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Anticipatory Care Planning, Polypharmacy
• Improving Care for Patients at High Risk of
Emergency Admission
• ‘…appropriate ACP can improve the quality of
care, reduce the risk of medication harm and
either (or both) the number of future
admissions and lengths of stay…’
• ‘As poly-pharmacy can significantly increase
the risks (of admission/harm)…it has been
agreed as appropriate to include’
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What is/the point of an ACP?
• Improving the quality of care;
• ‘Anticipatory care planning encourages people
to adopt a ‘thinking ahead’ approach and to
have greater control and choice by planning
for what their preferred support and care
interventions would be in the event of a
future flare-up or deterioration in their
condition, or a carer crisis.’
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QOF QP
• Identifying patients for ACP and Poly-pharmacy
Reviews
• Using a SPARRA risk threshold of between 40% (20%)
and 60% will generate a cohort of around 5% of
patients in the practice to fulfil the QP006 indicator
• Working down from an ‘upper ceiling’ of those with a
60% risk score will enable the practice to improve
outcomes for people most likely to benefit from an
Anticipatory Care Plan and a poly-pharmacy review.
• This will complement other local ACP initiatives that
target cohorts with greater than 60% SPARRA risk
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Rationale
• Patients < 60% SPARRA risk more likely to be
engaged with the practice team than active on
the community nursing caseload i.e. mobile
• Interventions < 60% represent earlier
intervention likely to reduce escalation of
dependency and to optimise adherence to
medicines.
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Guidance
• Scope to apply clinical judgement to what constitutes
'at risk of emergency admission' ; may be patients who
would benefit from an ACP but do not have a risk score
within the risk thresholds specified
• The Key Information Summary (KIS); tool by which
practices create and share (with consent) ACPs
• Summary of medical history/patient wishes, replaces
paper based faxing between GPs and OOH
• More generic version of the electronic Palliative Care
Summary (ePCS).
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Guidance
• Current ePCS patient information will transfer
automatically to KIS but needs checked once KIS is
switched on (ePCS patients that transfer
automatically to KIS will not count as part of the
cohort required for QP006 and QP007)
• NHS24, SAS, A&E, OOH and Acute Admission Areas
already have access to KIS
• Access in other acute areas/departments depends
on Board PMS systems and clinical portal
developments
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Poly-pharmacy
• 50% drugs not taken as prescribed
• 5-17% admissions due to adverse reactions
• If on multiple medications more side effects
• Potential harm of drug may outweigh benefit
QOF QP; QP004(S), 7 points
• QP004(S). The contractor meets internally to
review data on emergency admissions, for
patients on the contractor's registered list,
provided by the NHS Board and the learning
from at least 25 per cent of the Anticipatory
Care Plans (ACPs) completed for QP007(S)
• Template for reporting will be agreed
nationally
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QOF QP; QP005(S), 17 points
• QP005(S). The contractor participates in an
external peer review with either a group of
local practices, or practices from within the
board area, to compare its data on emergency
admissions and to share the learning from at
least 25 per cent of the Anticipatory Care
Plans (ACPs) completed for QP007(S), and
proposes areas for internal practice
improvement and service design
improvements for the NHS Board.
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QOF QP; QP006(S), 5 points
• QP006(S). The contractor produces a list of 5
per cent of patients in the practice, who are
predicted to be at significant risk of
emergency admission or unscheduled care.
This list can be produced using a risk profiling
tool accessible to practices e.g. SPARRA, or
where this is not available/required (by local
agreement), alternative arrangements can be
agreed between the NHS Board and LMC.
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QOF QP; QP007(S), 30 points
• QP007(S). The contractor identifies a minimum of 15
per cent (in 2014/15, 30 per cent) of those patients
from the list produced in indicator QP006(S) who
would most benefit from an Anticipatory Care Plan (the
ACP must include a poly-pharmacy review), be shared
with the local out of hours service and has an
appropriate review date. The frequency of each
patient’s review should be determined in the light of
their clinical and care needs. The contractor will be
responsible for ensuring that an appropriate system is
in place for monitoring and reviewing the patients
identified in this cohort.
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QOF QP; QP008(S), 10 points
• QP008(S). The contractor holds at least 4
meetings during the year to review the needs
of the relevant patients in the practice ACP
cohort, to agree any required changes in the
patient management and to share learning/
identify learning needs. These meetings
should be open to multi-disciplinary
professionals who support the practice’s
patients
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QOF QP; QP009(S), 10 points
• QP009(S). The contractor produces and submits a
report to the Board before 15 March 2014 on internal
practice and wider NHS Board system changes that
may benefit patients with Anticipatory Care Plans
(ACPs). The report should include Significant Events
Reviews (SERs) on 1/1000, to a maximum of 3 patients
per practice, of patients with ACPs from the cohort in
QP007(S), who were admitted during the QOF year,
after their ACP had been created. If less than the
required number of patients with ACPs were admitted
during the QOF year then the practice should write
SERs of the care of an equivalent number of these
patients who remained in the community.
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Summary
• Patient centred care; closer to home, reduced
harm
• Carers; communication, support
• Practices; supports review, professionally
satisfying, reduces ‘chaos’ (use)
• Boards; reduced admissions/lengths of stay
• Improves interface working
• Not about keeping anyone out of hospital who
needs hospital
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Issues - now
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SPARRA; ‘push not pull’
Review and decide who would most benefit
See in surgery/home
KIS; EMIS now, VISION 2 weeks
MDTs; membership, review
Poly-pharmacy review; overlap with LES
‘Face-to-face’
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Poly-pharmacy; overlap with LES
• Practices should generally only make one claim for payment
for a poly-pharmacy medication review, per patient, during
2013/14
• Exceptional cases may arise when an ACP/PP should be
developed after a Poly-pharmacy LES review has occurred or
vice versa
• Payment can only be claimed on behalf of the same patient
for a Poly-pharmacy LES and a ACP poly-pharmacy medication
review during 2013/14 if;
a. there are 2 distinct reviews recorded in the patient’s record
b. there is clear clinical justification to demonstrate the need for
a repeat review for the same patient during the lifetime of the
2013/14 Poly-pharmacy LES
Clinical Justification
• The clinical justification would include a change in a patient`s
clinical status due to one or more of the following occurring;
1. Hospital admission at least 1 month after the first polypharmacy review (ACP/PP or PP LES) had taken place
2. New clinical diagnosis
3. Deterioration in existing clinical condition requiring 3 or more
either changes to drug or drug dose (oral or parenteral
medication only)
4. Patient needing to go onto the palliative care register
Issues - later
• Role of DN/PN/Pharmacy support?
• Learning?
• Board support?
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Information held on KIS
• Significant Diagnoses and PMH
• Prognosis
• Medication and allergies
• Current Care Needs
• Help at home (e.g. Social Services / Care Packages)
• Legal Issues (e.g. AWIA, Power of Attorney)
• Preferred Place Care
• End of Life Care wishes
• DNA-CPR information
• Free-text Anticipatory Care Plan
Example of a KIS which has been
developed over a period of time?
Summary of main
issues
Summary of main
issues
Plan of action in event
of a deterioration
Summary of main
issues
Plan of action in event
of a deterioration
Medication that can be
used as PRN
Summary of main
issues
Plan of action in event
of a deterioration
Medication that can be
used as PRN
Details of other
professionals involved
in care
Summary of main
issues
Plan of action in event
of a deterioration
Medication that can be
used as PRN
Details of other
professionals involved
in care
Contact details of
family member
Information available on KIS
Patient Safety Indicators
Sessional GPs
Dr Paul Ryan, Clinical Director, NE Sector
SPSP in PC
• Aim is to reduce the number of events which could cause
avoidable harm from healthcare delivered in any primary care
setting
• “All NHS territorial boards and 95% of primary care clinical
teams will be developing their safety culture and achieving
reliability in 3 high-risk areas by 2016”
Three key workstreams
• Leadership and culture improving patient safety through the use of
trigger tools (structured case note reviews) and safety climate surveys
• Safer medicines: including the prescribing and monitoring of high risk
medications, such as warfarin and disease-modifying anti-rheumatic
drugs (DMARDs) and developing reliable systems for medication
reconciliation in the community
• Safe and effective patient care across the interface by focusing on
developing reliable systems for handling written and electronic
communication and implementing measures to ensure reliable care for
patients
GG&C plans for SPSP in PC implementation
• Leadership and Culture: covered by QOF. 11 points to
undertake safety climate survey and trigger tool review
• High risk area we are concentrating on is
“Safer medicines: developing reliable systems for
medication reconciliation in the community”
Guidance Patient Safety Indicators
Indicator
PS 1
PS 2
The practice conducts two case note reviews, using a validated
tool, to detect patient safety incidents, meets to discuss the
results, and shares a reflective report on actions and themes
that arise from this with the Health Board
The practice conducts a safety climate survey with all staff,
clinical and non-clinical, using a validated tool, meets to discuss
the results, and shares a reflective report on actions that arise
from this with the Health Board
Points
6
5
Adverse Event Causation
Technical
Factors
(30-20%)
Accident
Causation
(70-80%)
Human
Factors
=
Safety
Culture
+
Operator
Behaviour
Positive Safety Culture
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Safety a Priority
Eliminate “shame and blame”
Accept staff will make errors
Build systems to make care safer
Foster a culture where people can speak up
Team training
Organizational learning from errors and near-misses
Why is a strong Safety Culture Important?
A strong safety culture essential to safe reliable care
in any workplace
Francis Report and Culture
• There was an atmosphere of fear of adverse repercussions
• There was a lack of openness
• It did not listen sufficiently to its patients and staff or correct
deficiencies highlighted
• Above all it failed to tackle an insidious negative culture
involving tolerance of poor standards
Francis Report Recommendations
• Openness – enabling concerns to be raised and disclosed freely without
fear
• Transparency – allowing information about performance and outcomes
to be shared
• Candour – ensuring that patients harmed by healthcare are informed
• Replace culture of fear with culture of openness honesty and
transparency
• Real involvement of patients in all that is done.
Safety Climate Survey
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On line
Practice centred
Measurement
Diagnosis
Catalyst for change
How does the SafeQuest Safety Climate Survey
work in practice?
Trigger Review
• Reviewing your clinical records is the oldest form of audit!
• Looking for evidence of (undetected) safety incidents/latent risks
• Help you direct safety-related learning and improvement
• Quick and Structured versus Slow and Open
• Clinical triggers help you to navigate your records quickly
• Links with SEA and Quality Improvement
• Evidence for QOF, Appraisal and GPST etc.
• Random sample of 25 patients – high risk groups (e.g. >75 years,
multiple morbidity/poly pharmacy)
• Review the last 12-week period only (x2 3mths apart for QOF)
• Takes between 90 minutes to 3-hours
• Tested with large groups of GPs, Practice Nurses and GP Trainees
“Triggers” in Clinical Records
‘‘Triggers’’ are defined as easily identifiable flags,
occurrences or prompts in patient records that alert
reviewers to actual or potential safety incidents
(undetected)
Sections in GP Records
Triggers
Clinical encounters
(documented consultations)
≥3 consultations in 7 consecutive days
Medication-related
(acute and chronic prescribing)
Repeat medication item stopped
Clinical read codes
High, medium, low, allergies
New ‘high’ priority or allergy read code
Correspondence Section
Secondary care, other providers
OOH / A&E attendance / Hospital admission
Investigations
Requests and results
eGFR reduce <5, Hb < 10.0, INR > 5.0
Medicines Reconciliation
Care Bundles
A bundle is a structured way of improving the processes of care and patient
outcomes: a small, straightforward set of practices — generally three to
five — that, when performed collectively and reliably, have been proven to
improve patient outcomes.”
• The steps must all be completed to succeed
• The “all or none” feature is the source of the bundle’s power
• Pass/fail
Medicines Reconciliation – care bundle measures
•
Has the Immediate Discharge Document (IDD) been workflowed on the day of
receipt?
•
Has medicines reconciliation occurred within 2 working days of the IDD being
workflowed to the GP?
•
Is it documented that any changes to the medication have been acted on?
•
Is it documented that any changes to the medication have been discussed with
the patient or their representative within 7 days of receipt?
•
Have all the above measures been met?
Knowledge Page
hhtp://www.knowlegde.scot.nhs.uk/spsp-ps.aspx