Transcript Primary Care - NHS outer north east London and City

Programme Board Commissioning Intentions 2017-19
Clinical Commissioning Forum November 2016
Table of Contents
2
Programme Board
Number
Primary Care Quality
1
Long Term Conditions
2
Planned Care
3
Early Years – Maternity & Children’s
4
Crisis Care – Integrated & Urgent Care
5
Mental Health
6
Prescribing
7
Primary Care Quality Board (PCQB)
1
Three areas to consult on:
1)
CCE Contract 2017-19:
•
All ready consulted on minor changes
Do we want to have a fresh look at referrals e.g. take a more longitudinal approach?
•
Do we want to have a fresh look at A&E
•
GP forward view – (see PCQB Appendix 1) summary of what CCGs have to do •
Plan to spend access money of £6 per head for London – need to offer 155
additional hours of care per week incorporating weekends and weekdays from 6.30-8.00
•
Practice transformation support – £3 per head – including high impact areas
2)
3)
4
Reconsider whether the CCG takes on level 2 or level 3 delegated commissioning of
primary care (see PCQB Appendix 2)
Delegated commissioning of primary care
Rationale as seen by NHS England:
•
Critical to STP planning
•
Supports the development of more coherent commissioning plans for healthcare systems
•
Gives CCGs greater ability to transform primary care
•
Gives CCHG greater insight into practice performance issues
•
Gives greater opportunities to develop a more sustainable primary care workforce
•
Helps strengthen the relationships between CCGs and practices
Additionally for C&H:
•
We have good primary care so why not take it on/we are practically already doing it so why not do it
officially
5
Benefits and risks of taking it on as seen by the CCG:
•
Deal breaker for Devolution
•
There still are unquantified financial risks about taking it on – e.g. need to make recurrent savings to
the budget through a QUIPP – NHSE has made savings to date through changes to business rates and
efficiencies in waste disposal
•
Is there any real freedom to use primary care budget without reference back to NHS England
•
NHSE support team is under-resourced - CCG would have to make an additional investments to plug
this
•
Change in fundamental relationship between the CCG and members if it takes on performance
management
•
Some flexibility open to the CCG re DESs and QOF
Long Term Conditions (LTC)
2
“Must Do’s” and the CCG IAF
Learning Disabilities: Work in the “Transforming
Care Partnership” to reduce specialist inpatient care
Personal Health Budgets: Increase
Prevention: National Diabetes Prevention Programme
“At risk” registers and annual reviews; LTC contract
Management: Focus on patients with diabetes not
achieving the “triple target” and attending structured
education
Improve self-care and reduce demand: see next
page
7
Supported self management and patient activation
•
•
•
•
•
8
Peer support; Time to talk; Social prescribing
National Diabetes Prevention Programme
Structured education for people with diabetes
What else should we be doing?
GP confederation’s demand management project will be piloting
e-consult; a patient app; group consultations and maximising the
pharmacy offer via healthy living pharmacies
Virtual clinics
•
•
9
How is the virtual CKD service working?
Any thoughts on the next service we should consider?
Planned Care
3
Planned Care Headline Commissioning Intentions 2017-19
Community services:
•
Implement a new model for gynaecology with HUH; including a tiered model of care with enhanced primary
care, community and secondary care pathways under one lead service provider
•
Develop a community-based DMARD monitoring pathway/service with HUH moving appropriate patients
from rheumatology to primary care possibly via the GP confederation.
•
Commission new audiology services for the community
•
Review the community dermatology service and build on the pilot Teledermatology service for roll out across
primary care
Cancer:
•
STP/NEL cancer commissioning board plans to reduce pathway delays and deliver the constitutional
standards. Aiming towards 50% of patients diagnosed within 28 days by 2020.
•
Plans to widen GP direct access to diagnostics such as CT and upper and lower GI, improve screening
uptake.
•
NEL cancer commissioning board plans to improve earlier diagnosis
Misc:
11
•
Implement a new model of community and primary care interpretation services replacing the current BiLingual Advocacy Service.
•
Continue to work with HUH to deliver a tier 3 weight management service
•
Clinical Leadership Programme and demand management
Community Services
Gynaecology - Redesign of services:
A four tier gynaecology service delivered in:
•
Tier 1: Primary Care
- Ensure pathways are followed – all practices
•
Tier 2: Enhanced Primary Care - Routine procedures and follow up – possibly hub model
•
Tier 3: Community Service
- Routine one stop diagnostic and treatment services
•
Tier 4: Secondary Care
- Complicated care services
To provide a service that delivers the right care in the right environment, whilst supporting the education of
clinicians and patients.
Community and secondary care services provided by HUH to manage the clinical pathway.
Tier 1 & 2 services provided by local GPs.
Dermatology
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•
Following the pilot teledermatology (clinical photography/consultant review) service commencing in Feb
2017, we aim to expand this service across primary care by September 2017.
•
Review community service and align with teledermatology and minor surgery services
•
Commission teledermatology service- review and maximise current community GPSI services to deliver
•
Improve access to allergy services including paediatrics
•
Provide directed education to GPs
Community Services (Cont)
Rheumatology
•
Undertake audit to understand the reasons behind HUH’s high follow up rate in rheumatology
•
Develop a rheumatology pathway that outlines future arrangements for: DMARD monitoring and the
prescribing of Subcutaneous Methotrexate
•
Evaluate options for providing support to primary care delivery as part of this new rheumatology
pathway
•
Commission primary care services and education to support this new way of working
Audiology
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•
Review current service provision including the availability of: direct access and community locations
•
Evaluate commissioning options to promote integration, including closer working with children’s
services, One Stop Services for patients
•
Implement new national framework model including the options of direct access and children's services
•
Align the future audiology services with ENT services based in the community and HUH
Cancer
Cancer:
Overall direction for cancer is set by the National Strategy.
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•
STP/NEL cancer commissioning board plans to reduce pathway delays and deliver the constitutional
standards. Aiming towards 50% of patients diagnosed within 28days by 2020.
•
NEL cancer commissioning board plans to improve earlier diagnosis
•
Improve screening uptake
•
Public awareness campaign messages via Public Health
•
Dissemination of best practice across STP footprint
•
City and Hackney Cancer contract with the GP confederation to continue
•
Bowel screening uptake
•
Safety netting 2ww refs
•
Plans to widen GP direct access to diagnostics such as CT chest and abdomen, upper GI and implement
straight to test model for lower GI endoscopy.
•
GP education (via clinical leads) using data from cancer practice profiles (including raising awareness of
rates of patients diagnosed via A&E etc), increase use of decision support tools, SEAs etc
•
Continue to support improvements to support survivorship and recovery and improve overall patient
experience
Miscellaneous
Misc:
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•
Tier 3 Weight Management – Redesign dietetic services to provide T3 pathway
•
Bi-Lingual Advocacy Review – A total redesign aiming for an interpretation model that is more equitable
and includes criteria for telephone, face to face and perhaps skype services where appropriate. Advocacy
is focussed on a limited criteria for new patients and is time limited
•
Paediatric ENT – review pathways following audit and provide service in the community service if
appropriate
•
Clinical Leadership Programme (with Homerton) - Developing pathways, Continue general demand
management :
•
Agreed shared pathways for outpatients
•
Increasing e-Referral and email advice services
•
Making better use of electronic systems more widely such as tQuest
•
Introducing more technology such as virtual clinics, video appointments where appropriate.
Early Years - Maternity & Children’s
4
Commissioning safe & effective maternity care
There have been six maternal deaths at the Homerton between 2013 and 2016 and two CQC inspections requiring
improvements to the Homerton maternity service. Most actions have now been implemented and embedded into clinical
practice. Pregnant women continue to present with high levels of complexity (medical, obstetric, social and psychological) and
in 2015/16 approximately 52% of deliveries at the Homerton fell under the category ‘with comorbidities and complications’.
We will require the Homerton to deliver a number of actions and improvements to provide assurance that local maternity care
is safe, effective and responsive to women’s needs:
•
Audit of tariff coding to understand high levels of acuity in deliveries
•
Staffing review to ensure staffing levels and skill mix (medical & nursing) reflect reported increase in acuity
•
Increase the number of midwifery led births (home births and at the birth centre) and increase the proportion of women
booking for care by 10 weeks of pregnancy
•
Increase the numbers of women receiving continuity of care from their midwife and develop midwifery offer for women
receiving obstetric led care
•
We will continue to monitor progress against the joint CCG / HUH combined action plan to ensure all recommendations
from CQC inspections and maternal deaths reviews have been implemented and have produced positive change.
Ongoing items are centred on audit, training and staffing levels.
•
We will also review local services against “Better Births” national maternity review, and develop a shared local plan that
focuses on:
•
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•
Personalised care and care planning
•
Improved postnatal care and perinatal mental health support
•
Choice and continuity of carer
•
Community hubs and care close to home
We will continue to input into NEL maternity network demand and capacity work stream to ensure there is adequate
local maternity provision that is women centred and needs led.
Reducing infant mortality
The Infant mortality rate in C&H is 5.7, higher than national and London averages. In the period 2011-2013, 26 infants
died before their first birthday. In the same period there were 79 stillbirths in C&H, a stillbirth rate of 5.8 stillbirths per
1,000 births. The London rate was 5.5, the national rate 4.9.
We have committed in our STP to reducing the rate of infant deaths and stillbirths in line with national expectations
(20% by 2020). We will task the services we commission to deliver the following initiatives and recommendations:
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•
Implement recommendations from Public Health review of recent stillbirths and neonatal deaths, identifying
preventable deaths and areas for service development.
•
Improve the quality and safety of care in pregnancy and labour by strengthening the monitoring and escalation of
raised blood pressure & increasing prescription of aspirin to women identified at risk of pre-eclampsia
•
Ensure recommendations from the joint Homerton & CCG diabetes audit are locally implemented to ensure local
compliance with national standards and best practice management of diabetes in pregnancy.
•
Ensure recommendations from national “Savings Babies Lives” care bundle continue to be locally embedded
into clinical practice and are monitored for impact:
•
CO screening & swift referral to cessation services to reduce numbers of women smoking in pregnancy (aiming
to half numbers by 2021).
•
Implementation of risk assessment and surveillance for fetal growth restriction, via London RCT study of GAP
and GROW tools.
•
Raising awareness with women of reduced fetal movement, by providing Mama Academy wallets to encourage
women to take action when they experience reduced fetal movements.
•
Effective fetal monitoring during labour - ensuring Homerton is committed to the continuation of the
Cardiotocography (CTG) midwifery posts, who deliver training and on the spot support to staff to evaluate CTG
results effectively and escalate accordingly.
Reducing health inequalities – vulnerable women
It is estimated that of 5783 deliveries at Homerton Hospital in 2013, 19% were to women classed as socially
vulnerable. This equates to around 1096 women and babies. A 2016 CHIMAT toolkit estimated that in C&H, 1,435 to
2,335 women will have a mild, moderate or severe mental health need in the perinatal period each year. Local rates of
breastfeeding, while high at 92% a birth and 83% at 6-8 weeks, mask lower levels of exclusive breastfeeding for some
groups including some groups of Black and Asian women. We also know that maternal and infant mortality and
morbidity disproportionately affects women and babies from deprived backgrounds.
Locally we will ensure that a variety of local health and voluntary sector providers deliver services that address and
reduce health inequalities, by providing targeted and tailored support to vulnerable pregnant women:
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•
Define and strengthen the vulnerable women’s care pathway to ensure a clear service offer is in place and
agree a “failsafe” process to flag up women who DNA appointments with either their GP or Midwife.
•
Extend the provision of targeted and tailored support for women who may struggle to access mainstream
services, and evaluate impact of services, including:
•
Targeted antenatal classes
•
Bump buddies peer support in pregnancy service
•
Postnatal group support (bonding with baby)
•
Review impact of the locally developed perinatal mental health kite mark. Implement the London perinatal
mental health service specification with local acute, community and mental health providers. Monitor uptake of
and access to perinatal mental health services including 6 week IAPT waits for pregnant women and new
parents.
•
Jointly commission breastfeeding peer support services with the LA to ensure best use of pooled resources and
to target support to reach women with lowest rates of exclusive breastfeeding at 6-8 weeks. Develop a tariff for
the tongue tie service and review impact of service on breastfeeding continuation (and potentially failure to
thrive).
Reducing health inequalities – vulnerable children
40% of City and Hackney children live in poverty. 3.2% of 0-4 children are coded as vulnerable with 2.7% coded UPP.
659 children had a joint vulnerable child action plan in 15/16. 27% of 4-5 year olds are obese. The CCG is an outlier
for high numbers of 0-4 years admitted to hospital with unintended and deliberate injuries, and for children under 1
with emergency admissions for lower respiratory tract infections. We will continue to focus on early identification of
needs and joint management of risks through the Early Years contract, key components will continue to be:

Vulnerable children’s register, joint action planning and review, with HVs

Offer and deliver new patient checks to 5-17 year olds

Maintain a register of CYP who have a ‘carer’ role and refer for support

Promote offer of a 16th Birthday health check
New developments for discussion:
•
Family organisation template (family tree)
developed following learning from a serious case review; provides a mechanism to record all of the members of the household; enables
assessment of available family support and assists in the identification of possible risk, therefore enhancing paediatric assessments

Care planning with school nurses
referral to / communication with school nurses not included on the EMIS template currently, consider consistency in communication with SN
team via the Early Years contract?

Social Care pathway
continue developing better communication between GPs and Social services by providing detailed information about the
cases and the outcomes. Involve GPs in decision making at the time of closure of the cases and finally create social care pathway
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Improving pregnancy outcomes
There are just over 8,000 women aged 20-45 years with one long-term condition (LTC), 1,200 with two or
more and around 350 pregnant women with one or more LTC. Rising levels of obesity are impacting on
maternal health and pregnancy outcomes: in 2014/15 17% of women delivering at HUH had a BMI >30 and
3% had a BMI >40. Local uptake of maternal flu and pertussis immunisations is low at 32.6% compared with
the national average of 39.8% and London average of 35.9%.
Locally we will commission enhanced services for pregnant women with additional medical or social needs
from primary care and acute services, and specifically we will:
•
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Review performance & learning from the GP Confederation early years preconception and pregnancy
contract, with a focus on evidencing:
•
Efficacy and uptake of preconception care for women with LTCs
•
Better management of pregnant women’s LTCs.
•
Earlier identification of women with social & psychological needs and risks, and increase the number of referrals to
local support services (perinatal mental health, bump buddies, targeted antenatal classes)
•
Increased local uptake of folic acid, aspirin and healthy start vitamins
•
Ensure a clear local pathway and services are available for women with a high BMI and implement
recommendations from Public Health review of maternal obesity
•
Review the success of the NHSE & Homerton immunisation in pregnancy SLA, ensuring there has
been a significant increase in the number of women who receive Pertussis and Flu jabs during their
pregnancy.
•
Ensure pregnant women, partners and parents have the opportunity to provide feedback on their
experience of using maternity services and are kept informed on what steps have been taken to
improve services.
Improving children’s outcomes (LTCs)
•
In 15/16 practices coded the following numbers of children: asthma -1895; epilepsy -166; diabetes -102
•
Focus of 17/18 LTC contract will be: asthma, diabetes, epilepsy and sickle cell . Purpose across all areas is:
-
oversight of management; regardless of where the CYP receives their care; proactive follow up as needed
-
check that there are no gaps in / poor experience of care
-
check that care is coordinated, and CYP have personalised care plans
Sickle Cell
-
Establish register, deliver annual review
-
Deliver transition discussion jointly with HUHT community specialist Nurse (supports transition to adult services
and promotes repatriation to HUHT service where clinically appropriate)
Asthma
-
A Single, personalised care plan, used across HUHT and primary care
-
Annual review, more often as required
-
Follow up post unplanned care attendance
-
Assessment of ‘at risk’ of asthma - what is GP feedback on how this is working this year?
Developments
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
Need agreed approach to sharing clinical information across care providers to support local oversight of care /
promote transfer of care to local providers where clinically appropriate
Special Educational Needs and Disabilities (SEND)
Education and Health Care Plans (EHCPs) have replaced statements for CYP 0 to 25 years.
Personalised, outcome based plans, that identify the needs an individual has that are impacting on their learning.
Education, health, and social care work together to identify and meet these needs.

What is the role of the GP in supporting CYP with disabilities?

How much do GPs understand about the change from statements to Education and Health Care Plans
(EHCPs?)

Are health pathways clear for GPs and for families?
Specific priorities:
-
LD health checks – what other input do GPs have/ what do families ask of you?
-
Supporting health input to EHCPs for 18 to 25 year olds; a pathway needs to be agreed so that health
information informs the plan
Community paediatrics /therapy teams / CAMHS lead on this for children only
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Spotlight on Community Paediatrics



Would further information / education session about community
paediatrics be helpful?
Is it clear when / how to refer?
Do you receive care plans ?
Developments
 Children with disabilities needs assessment being undertaken
in Q3 16/17
 We know it will highlight lack of local health data
 Consider roll out of consistent, simple coding of (disability)
conditions in 17/18, across HUHT and primary care
 If you had a practice based children with disabilities register
would this enable you to provide more support to families / help
identify training needs?
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Community Paediatrics- scope of service
Clinics based at Hackney Ark
Neuro developmental clinics
(1 per children’s centre area)
School age neuro
developmental
(complex)
Complex communication
clinic (linked to ASD
pathway)
Social Communication
Assessment Clinic (autism
diagnosis for 5-14yr olds)
Physical Assessment
Infant Neonatal
Development clinic
Health in Care Clinic (LAC)
Child Protection Medicals
Education and Health Care
Plan (EHCP)
School medical clinic
LEAP (MDT specialist
obesity clinic)
Audiology Tier 2
Based at Hackney Ark but provided by Moorfields: Children’s vision clinic
Clinics delivered from other sites
Special advisory clinics -3 clinics, covering the North, Central and South regions of Hackney
Paediatric Continence service – based in 2 health centres and toileting advisory clinic at the Ark
Child Health clinics - trainees support these clinics as part of their training
Provision at special schools in Hackney
Multidisciplinary assessment clinic at Ickburgh special school
Paediatric clinic at the Garden special school
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Medicals at Stormont special school
Joint prevention priorities with LbH and City
Immunisations
 Priority to achieve 95% herd immunity for Childhood Immunisations within 2 years
 Non-recurrent funding secured, contracting options being explored
 Significantly increase uptake by pregnant women of flu and pertussis immunisations
Healthy start vitamins
 Increase uptake of healthy start vitamins for all pregnant women and mothers up to 1 year post birth and
babies from 4 weeks to 4 years through enhanced promotion (including via GPs as part of Early Years
contract)
Obesity

Proposal to decommission the community paediatrics component of the LEAP MDT from April 2017;
currently this is a one off medical assessment without follow up

Consider whether a primary care pathway could replace this medical input

The CCG and LBH / City need to consider a joint strategy, recognising the CCG responsibility for Tier 3

Lack of evidence around Tier 3 services; CCG to consider an enhanced psychology based /MDT offer

Clarity on referral pathways for GPs (for women planning a baby, pregnant, postnatally and for children)
and opportunity to train primary care staff in motivational interviewing / brief interventions / how to raise
the issue.
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Smoking
 Midwifery, Health Visiting and Primary Care focus on identifying parents who smoke and referring them for
support to quit. Implementation of CO screening in Health visiting.
Activity in urgent care – children
Increasing Activity

Increase in paediatric A&E attendances of 658 in months 1-5 in 2015/16 compared with 2016/17

The increase in the 0-4 years cohort accounts for 457 of these additional attendances; the 5-9 year cohort
account for a further 191

Analysis of the data shows that 61% of cases are discharged and do not require any follow-up treatment

PUCC data indicates a 39% predicted reduction in activity in 2016/17 compared with 2015/16. This is
attributed to reduced staffing and increasing acuity
What can we do? Current A&E and frequent attenders audit work will inform the ideas below

Is there a new model for winter baby clinics in Primary care to cater specifically for infants under 1 with acute
breathing related illness? How we can we work with the community paeds trainees?

Targeted health promotion with OJ community around accident prevention and home safety

Develop pathway for management of minor head injuries in primary care

Promote use of duty doctor / alternatives to going to A&E
Are children prioritised?
Shall we consult with users ?

Develop promotional materials with PH and Children’s centres regarding appropriate access to health
services

Develop and define pathways for children with long-term conditions

Develop and define pathways and support for vulnerable families

Investigate capacity / access issues in Primary care.
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Appendix 1 NEL 5 year STP: Maternity (draft)
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Early Years: Key Questions
1.
2.
3.
4.
5.
6.
7.
8.
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How is the universal and targeted preconception work going? What is
appetite for support from women?
How confident do GPs feel referring women to services such as perinatal
mental health, voluntary sector services, support around breastfeeding
etc?
How can we best promote choice in maternity care to women? (e.g. what
hospital women book with and where they have their baby)
Would a school nursing pathway support better communication around
transition to school and school health plans?
Do GPs receive sufficient clinical information about their children managed
at Trusts other than HUHT? What are the gaps / pathways we should
prioritise?
What do GPs see their role to be in supporting children with SEND
(special education needs and disabilities)?
How can GPs support women and children to achieve a healthy weight?
Are GPs interested in delivering medical reviews for obese children?
Can we better use the various primary care contracts to help children
avoid hospital use (CHUHSE, Duty Doc, Extended Hours, PUCC)?
Crisis Care - Urgent and Integrated Care
5
Overview
In 2017/18 the CCG is intending to adopt an integrated approach to commissioning crisis
services across local service providers. There are three component parts to our approach:
•
Introduction of a local single point of coordination to co-ordinate crisis services 24/7
across health and social care
•
Develop and strengthen the quadrant model for provision of integrated community
services
•
Improving discharge and delayed transfers of care
Alongside this work, we are part of the North East London Urgent and Emergency Care
Network. We are commissioning a new 111 service in collaboration with 7 CCGs across
North East London, due to go live in February 2018.
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To support patients in crisis and ensure that care is co-ordinated around patient needs,
Coordinate My Care (CMC) will be used for urgent care planning across as many care
settings as possible to improve patient care. As well as frail elderly and end of life care
patients, in 2017/18 CMC will be used for care planning with the top 2% of patients at risk
of admission (AUA DES register). This will support decision-making across the system for
high-risk and frail elderly groups.
Single Point of Co-ordination (SPOC)
•
Implement a single point of coordination for all crises calls, taking referrals from the health
and care professionals and interfacing with the local integrated urgent care service (111) for
patient-facing referrals.
•
Delivered via an alliance of providers who will have collective responsibility for delivering
outcomes.
•
key Features
•
•
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-
24 hours 7 days a week
-
Centralised call centre for triage and initial assessments
-
Range of clinicians/services, including integrated pathway with social care and mental health crisis
-
Arrangements in place to ensure access to care plans (CMC) in the call centre and community
Key Benefits
-
Provide better response for urgent care needs
-
Be easier to navigate
-
Give confidence to service users
-
Prevent people not falling between services
Timescales
The local Single Point of Co-ordination will be developed through a series of gateways over the course of November to
March 2017, with fully operational capabilities established by April 2017 to receive referrals from the London Ambulance
Service and health and social care professionals.
Quadrant Working
•
Our intention is to develop quadrant working and integrated community services that will ensure highrisk patients receive integrated health and social care, with proactive care plans electronically shared
via co-ordinate my care.
•
This will be achieved through a range of multidisciplinary services integrating with each other, with GP
practices and with the single point of coordination/crisis services, working to common goals. Key
features are:
- Strong assessment and care planning with care planning discussions at practice level
- A range of services from keeping well to more intense support and specialist teams, including voluntary sector
services
- One named professional to take lead for patients
- GPs kept informed about actions and progress
•
•
Services will be geared to strong community working alongside primary care in a way that will reduce
hospital admissions and enable patients to stay at home, concentrating on patients most at risk of
admission/those on the FHV list, and minimise hospital stays.
We will apply lessons learnt from One Hackney and City to shape the operational model, including:
- Clearer quadrant leadership and quadrant team structure
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- Clear objectives, metrics and accountability
- Consistent documentation and information sharing processes across professionals
Discharge/DTOC
We are working jointly with the London Borough of Hackney and the Trust to improve
discharge processes and address Delayed Transfers of Care (DToCs).
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•
Discharge planning will be supported by inpatient teams viewing care plans agreed with
patients prior to admission, with long-term plans and wishes clearly identified. Earlier
discharge will be enabled across 7 days through quadrant teams with enhanced
capabilities, undertaking assessments previously confined to a hospital setting.
•
A plan to develop a local discharge to assess model will be established as part of a
wider programme of quadrant development.
•
Comprehensively embed the trusted assessor model across the acute and community.
•
Support patients’ choices to avoid long hospital stays and ensure that families
are fully involved in planning.
Demand Management
Managing Demand in Primary Care
Urgent care demand will continue to be managed in primary care 24/7, with patients accessing
consistent and responsive GP telephone triage in and out of hours. The sickest patients will be
visited at home or referred to secondary care, with onward referral to multi-disciplinary teams
supporting patients at home where possible.
•
The Frail Home Visiting, Duty Doctor and Paradoc service will be commissioned from
recurrent funding from 2017/18
•
The current contract for Enhanced Access will expire on the 31st March 2017
•
CHUHSE are contracted to deliver the Out of Hours contract until 1st December 2017
Acute-based Demand Management
Acute-based ambulatory care will ensure that patients with ambulatory-case sensitive conditions
receive outpatient-based care rather than acute admissions.
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Ring Fenced Budget
A ‘ring fence’ financial framework for crisis care for 2017/18 within an integrated care alliance:
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•
In 2017/18 the contractual arrangements would remain largely as they are now - i.e. PBR
and other current payment arrangements unless new national guidance emerges or the
providers want to propose a different mechanism.
•
The total budget for the services will be ring fenced and the providers will be wrapped
together by an agreement which will establish a collective responsibility for the achievement
of financial balance within the ring fenced budget and the achievement of KPIs.
•
The CCG will enter a 2 year service contracts on 1 April 2017 on this basis linked to delivery
of the shared/collective metrics. This will be renewable after 2 years to a total 4 year
arrangement in the light of satisfactory performance.
•
The wrapper contract will be signed by every provider which has a contract for services
which are deemed to be funded from the ring fenced budget.
•
The performance and activity of the services within the ring fenced budget will be overseen
by a Crisis Service Management Board and which will be chaired by a provider who will be
responsible for service integration.
Mental Health
6
Summary of Mental Health Programme Board’s Commissioning Intentions 2017/18
•
Mental Health Alliances will be closely aligned to the Integrated Commissioning chapters with each alliance
contributing to the planning work of workstream area.
•
CAMHS: new funding will improve eating disorders, perinatal and autism pathways, provide 24/7 crisis support
and transform services to improve links with schools, children’s social care, youth justice and continue to
address early intervention and family support
Primary care mental health: monitor MH screening, reviews/physical health checks, referrals and targets
using the Primary Care MH Dashboard. Improve medication reviews with physical health checks for SMI
patients focusing on those where diagnosis appear not to match medication. Increase engagement of HCAs to
take time pressure off GP.
IAPT services: we will continue to hit our access target by working with voluntary sector providers, improve
access for BME groups through co-locating therapists in community organisations and will continue work on
improving recovery.
•
•
38
•
Dementia: continue to achieve the diagnosis targets and improve support for people with dementia and their
carers. The dementia alliance will work towards more integrated care planning and care navigation pathways,
identify ways to reduce excess bed days for people with dementia in acute hospital settings, acute psychiatric
wards and rehabilitation/continuing care wards. Review crisis pathways and crisis line access and improve
carers assessment and support.
•
Crisis and urgent care: we will make more efficient use of combined inpatient beds across all three boroughs
(CH, NH, TH), invest in a fully funded CORE psychiatric liaison service and compliant EIP service (aim to
expand EIP), build on our innovative pre crisis initiatives: SUN Project, Crisis Café and pilot virtual street
triage as part of the Crisis Line. We will review the case for bringing mental health urgent care under the
umbrella of a new urgent care alliance, improve access to substance misuse services for inpatient wards and
pilot ‘Open Dialogue’
Mental Health Strategic Priorities 2017- 2019
•
•
•
•
•
•
•
39
Reduce inequalities
Improve the health of children and young people - in particular tackling childhood
obesity and working with pregnant mothers and children under 5 to improve outcomes
in early years
Minimise the use of tobacco to reduce premature mortality
Promote mental health, focusing on relieving depression and anxiety
Caring for people with dementia and their carers
Address social isolation
Delivery the 5 Year Forward View Priorities in line with STP planning
Dementia Alliance
Aligned to the Urgent Care and Prevention Integrated Commissioning Chapters
• Improving carer’s assessments
• Better integrated pathways, care planning and care navigation
• Reducing excess bed days
• Improved crisis pathways and crisis line access
40
CAMHS Alliance and CAMHS Transformation Programme
Aligned to the Children and Early Years Integrated Commissioning Chapter
41
•
Review the current crisis pathway and aim to provide 24/7 crisis resolution and liaison mental
health services, which are appropriate for children and young people of City and Hackney.
•
Increased integrated pathway to schools
•
Better support for parenting
•
Child to adult transition
•
Improving the interface with Youth Justice
•
Increased collaboration with wider CAMHS Alliance partners, namely City and Hackney schools,
primary care, the youth justice system, maternity services and both local authorities.
•
Ensure all current and future access and waiting time standards including the overarching 35%
access rate are met including any sequential yearly targets.
Psychological Therapies Alliance
Aligned to the Planned Care Integrated Commissioning Chapter
42
•
Increasing access rates for psychological treatments
•
Improving equity of access for BME groups
•
Reducing waiting times and waiting lists for psychotherapy
•
Improving return to work rates
•
Improving information – creation of a clinical dashboard to better monitor waiting lists, waiting
times, engagement and recovery across the alliance
•
The application of a stepped care model with a greater use of Well Being intervention and guided
self help through online therapy
•
Improving outcomes and recovery
Primary Care
43
•
Primary Care MH Dashboard to monitor MH: screening, reviews/physical health checks, referrals and targets
•
Funding for primary care mental health reviews, physical health checks and screenings over and above QoF
•
Improved medication reviews with physical health checks for SMI patients focusing on those where diagnosis
appear not to match medication
•
Primary Care Alliance (GP Confed, CEG, CCG, Family Action) co-ordinates and supports this programme
•
Increasing engagement of HCAs to take time pressure off GP
•
EPC - bi-monthly review and planning meetings with the GP Confederation, the CEG, ELFT and the CCG
•
Closer working between ELFT Primary Care Liaison workers and GPs.
Urgent Care
Aligned to the Unplanned Care Integrated Commissioning Chapter
• Support efficient inpatient bed availability across all three boroughs
•
•
•
•
•
•
•
44
(CH, NH, TH)
Fully funded CORE psychiatric liaison service and compliant EIP
service (aim to expand EIP)
Build on innovative pre crisis initiatives: SUN Project, Crisis Café
Pilot virtual street triage as part of the Crisis Line
Improve access to substance misuse services for inpatient wards
Pilot ‘Open Dialogue’
Review case for bringing mental health urgent care under the umbrella
of new urgent care alliance
Ability to deliver 24/7 urgent home assessment
Prescribing
7
Prescribing Workstreams and the Five Year Forward Plan
Framework
46
Five Year Forward Plan
Framework
Workstream 17/18
PREVENTION
•
•
•
•
•
•
•
•
•
•
•
•
•
Acute Kidney Injury Project
Heart Failure
Respiratory Reviews
PINCER
Medicines Safety Tools
Scriptswitch
CCE Contract
NEL STP Medicines Optimisation Group
Medication Error Reporting
Corticosteroid Use
Reduction of Medicines Waste / Improve Prescribing Systems
Biosimilars
Drugs of Limited Clinical Evidence
EARLY YEARS
•
Future adaptation of the successful respiratory project to focus on children
CRISIS CARE
•
•
Antibiotics
Antidiabetic Drugs and agents
PLANNED CARE
•
•
•
•
•
•
•
Management of High Cost Drugs
Formulary
Interface
Domiciliary Medication Reviews
Anticoagulation
DMARDS
Continence Care
Prescribing Incentive Scheme / CCE Contract 2017/18 –
Prescribing elements
Why?
47
• Although benchmarking information for available prescribing indicators shows City &
Hackney to perform well across a many prescribing indicators, there is still considerable
scope for improvement. Also prescribing and utilisation of medicines is an evolving
area requiring ongoing work including patient level reviews & audits to ensure standards
remain high and the medicines that are made available in City and Hackney are cost
efficient and the best for our patients
• There is a longstanding use of Prescribing Incentive Schemes across the country, as a
tool to incentivise practices to remain within their prescribing budget allocation as well
as improve quality of prescribing
• Recent NHS Policy documents such as NHS Five Year Forward View have highlighted
that there is a greater need for medicines optimisation
• Over the last few years, there have been a number of tools introduced / expanded in
C&H to support with the optimisation of medicines that our patients take and also to
reduce medicines wastage.
• Submission of stipulated work is incentivised (for 2016/17, practices receive £0.60 per
registered patient once all required work is submitted within required timelines).
• Practice feedback over the last 2 years led to PSPs taking on majority of work for CCE
for 2016/17, though this has raised the standard of work submitted allowing for better
CCG wide collation of results, there is possibility that for some practices, this has
reduced potential practice learning.
Prescribing Incentive Scheme / CCE Contract 2017/18 – Prescribing
elements
Proposed
Service Change
• Practices are asked to:• A. To have a discussion as to whether to continue with practice prescribing work plans within an
incentive scheme for practices OR whether the incentivised scheme is retired, with PSPs continuing to
lead on prescribing work plans
• B. To agree role of PSP within a Practice Prescribing Incentive Scheme (if the Scheme continues)
• C. To agree the outline of proposed 2017/18 Prescribing Scheme
Proposed 2017/18 Prescribing Incentive Scheme
Prescribing Advisor Visits
•Annual prescribing visit + 4 follow up meetings with PSP(s) to discuss and agree prescribing work streams
Audit to support:•Review of bi-annual prescribing data on dressings, hospital only/non-formulary drugs, specials
•Medication Error reporting and risk management eg opportunistic audits in response to Drug Safety Alerts
•Appropriate prescribing and medicines optimisation in patients with heart failure
•Preventing acute AKI and supporting patients with AKI
Proposed Implementation
48
Training – practices will be asked to participate in the following
•Specified e-learning related to AKI
Prescribing Indicators –the practice will review their prescribing against the following indicators:
• Prescribing for UTI: ratio of the number of trimethoprim prescriptions vs. nitrofurantoin prescriptions [↓]
• Number of prescription items for trimethoprim for patients >70 years [↓]
• Antibacterial items per STAR PU [↓]
• Cephalosporins, Co-amoxiclav & Quinolones as % of all antibacterial items [↓]
• Least costly low/moderate dose ICS/LABA inhaler as a % of all low/moderate dose ICS/LABA
inhalers[↑]
• Low and moderate dose ICS/LABA items as a % of all ICS/LABA [↑]
• Analogue insulins prescribed as a % of all long acting insulins [↓]
• Pregabalin Cost per ASTRO-PU[↓]
• Tramadol – Defined Daily Doses (DDDs) per 1000 patients [↓]
• Emollients Cost per 1,000 patients [↓]
Prescribing elements of 2017/18 CCE contract
2017/18 Medicines work stream of
Clinical Commissioning and Engagement Contract
Evidence to be submitted
Payment
Section A: Entry Level for CCE - Prescribing
1a. Practice to meet the prescribing advisor at least once during the Copy of Post-Visit Letter from Practice
year, by 30th June 2017, to discuss Medicines Management:
Pharmacist including agreed action
o
Performance during previous 12 months
points
o
Action planning for 2017/18 and in particular to understand the
basis of the required work including audits and QIPP
1b. Practice will in addition to 1a, be asked to have three (3)
subsequent meetings with Practice Pharmacist / Specialist
Pharmacist during 2017/18 to include progress & feedback on:
• Prescribing Performance during previous 12 months
• Medication Review
• QIPP programme
• Audits
• ScriptSwitch
Any Specialist Reviews e.g. Respiratory
1c. Practice to send to the MMT, at least bi-annually, a register
outlining current prescribers / leavers & joiners to the medical and
non-medical prescribers in the practice
49
Practice’s submission of action points
agreed at these 3 meetings
Part of the core CCE contract
Prescribing elements of 2017/18 CCE contract
Section B: Audit Levels for CCE - Prescribing
2017/18 Medicines work stream of
Clinical Commissioning and Engagement
Contract
2. Bi-annual submission of Reviews of
Prescribing data on ‘Restricted Prescribing
List’
Review data on:• Dressings
• Hospital only
• Non-Formulary
• Specials
50
Evidence to be submitted
Each Practice to submit data outcomes forms, no
later than
28 July 2017
(review of latest 3 month data)
31 January 2018
(review of latest 3 month data)
Plus Dressings:Q4 2017/18 ePACT data to show 95% reduction
from baseline (Jan-Mar 2016) on costs of FP10
dressings (that are available via dressings store)
Payment
Practice support pharmacist time
provided by the CCG
&
incentive of
2p per registered patient for
prompt submission of Practice’s
Data Outcomes Forms
and
Prescribing achievement for
dressings
Prescribing elements of 2015/16 CCE contract
Section B: Audit Levels for CCE - Prescribing
3. Error reporting and risk management
•
•
Responding to MHRA Drug Safety
Alerts
Medication Error Reporting
4. Clinical Audit 1 –
Heart Failure – ensuring appropriate
prescribing and medicines
optimisation in
patients with heart failure.
5. Clinical Audit 2 –
Clinical Audit & Training –
preventing acute kidney injury
(AKI) and supporting patients with
AKI.
Practice will be asked to:• utilise the PINCER audit tool which facilitates
practice identification of pts potentially at risk
of harm through prescribing errors/inadequate
drug monitoring
• report medication related errors via the
National Reporting and Learning Systems
(NRLS). A summary of learning and action
plan from the error should be submitted to
MMT
• Action Drug Safety Alerts -record and submit
reviews conducted in response to at least 75%
of MHRA Drug Safety Alerts (those relevant to
general practice) during 2017-18
•
Proposed that each Practice submits, a
Summary report which outlines what the
Learning from the Audit have been & the
Practice’s Action Plan.
•
Proposed that each Practice submits, a
Summary report which outlines what the
Learning from the Audit and AKI e-learning
modules have been & the Practice’s Action
Plan.
E-learning needs to be completed by a
specified deadline.
AKI posters are to be displayed
Provision of leaflets – confirmed by PSP
•
51
•
•
Practice support pharmacist time
provided by the CCG
&
incentive for prompt submission of
Practice’s Learning & Action Points
of
2p per registered patient per review
Practice support pharmacist time
provided by the CCG
&
incentive for prompt submission of
Practice’s Learning & Action Points
of
2p per registered patient per audit
Practice support pharmacist time
provided by the CCG
&
incentive for prompt submission of
Practice’s Learning &
Action Points of
2p per registered patient per audit
Prescribing elements of 2015/16 CCE contract
Practices that submit the Summary of Learning Points and Action Plan, by the due dates for the 2 audits will be incentivised
with a payment of 10p per registered patient
52
6. Proposed that each Practice will actively engage in the
Medicines QiPP Agenda & reach stipulated thresholds
[threshold figures will be made available to practices shortly]
MMT will: provide quarterly QIPP dashboard at least quarterly
Practice will review prescribing against QIPP indicators,
demonstrate improvements and reach the soon to be published
thresholds for the 10 indicators below:
Dashboard Quarter4 2017/18
•Analogue insulins prescribed as a % of all long acting insulins [↓]
•Antibacterial items per STAR PU [↓]
•Cephalosporins, Co-amoxiclav & Quinolones as % of all
antibacterial items [↓]
•Emollients Cost per 1,000 patients [↓]
•Least costly low/moderate dose ICS/LABA inhaler as a % of all
low/moderate dose ICS/LABA inhalers[↑]
•Low and moderate dose ICS/LABA items as a % of all ICS/LABA [↑]
•Number of prescription items for trimethoprim for patients >70 years
[↓]
•Pregabalin Cost per ASTRO-PU[↓]
•Tramadol – Defined Daily Doses (DDDs) per 1000 patients [↓]
•Volume of prescribing for UTI: ratio of the number of trimethoprim
prescriptions vs. nitrofurantoin prescriptions [↓]
Practices are encouraged to review,
monthly, their current QIPP status on the
secure site of the Prescribing site (as per
monthly email to practices)
Epact data Q4 2017/18 data will be
available June 2018
Payment
5p per registered
patient for achieving
each of the 10
prioritised indicators
on Action No5 , so
max total 50p per
registered patient for
achieving all 10
indicators
Safer Care Culture – NRLS and Medication Safety Tools (Scriptswitch,
PINCER)
•
It is anticipated that there are 1.8 million serious prescribing errors in primary care each year evidence predicts 5% of general practice prescriptions are erroneous, of which 0.18% are serious
Developing an open, learning and safer culture locally is a high priority in delivering the Forward
View: NHS Planning guidance 2016/17 – 2020/21
NHS England published a Patient Safety Alert: Improving medication error incident reporting and
learning in 2014 directing small healthcare providers including general practices, dental practices,
community pharmacies and those in the independent sector to report medication error incidents to
the National Reporting and Learning System (NRLS)
Medication errors are the most commonly reported safety incidence from GP practices, which have
a very low reporting rate. The NRLS GP eform has been designed to simplify GP reporting.
ScriptSwitch is a tool that provides GPs with detailed, locally authored patient safety information
messages, drug switch recommendations and dosage optimisation information right at the point of
prescribing.
PINCER describes an evidence based approach to patient safety in which it has been demonstrated
that the intervention of a pharmacists in general practice using a GP computer systems to identify
patients at risk, can substantially reduce medication errors. Not only will it be possible to target
medicines management resource more effectively by improving the quality of care, but it will also
make cost savings by reducing health-care use resulting from adverse drug events
•
•
Why?
•
Why?
•
•
•
•
Proposed
Service Change
•
•
•
53
Utilisation of PINCER audit tool by all practices
A local reporting and learning culture to be established by practices reporting medication
related errors via the National Reporting and Learning Systems (NRLS). A summary of learning
and action plan from the error should be submitted to MMT as advised.
Practices are to review and act on Drug Safety Alerts and document action taken using
templates provided by MMT. (Practice must record and submit reviews conducted in response
to at least 75% of MHRA Drug Safety Alerts during 2017-18)
Practices to continue to prescribe safely and effectively taking into account safety
recommendations provided by Scriptswitch
PINCER approach to patient safety to be practiced by Practice Support Pharmacists when
conducting medication reviews
Acute Kidney Injury
Why?
Why?
In August 2016, a patient safety alert from NHS Improvement (NHSI) relating to resources to
support the care of patients with acute kidney injury (AKI). The alert is further to one issued in
June 2014 on standardising the early identification of AKI. Key facts regarding AKI include:
• One in five emergency admissions to hospital will have AKI.
• 60% of AKI starts in the community
• AKI is 100 times more deadly than MRSA infection
• Around 20 per cent of AKI cases are preventable
• Costs of AKI to the NHS are £434-620m per year
Think Kidneys is an NHS campaign designed to improve the care of people at risk or with acute
kidney injury. The objectives of the campaign are to:
• Develop and implement tools and interventions for prevention, detection, treatment and
enhanced recovery
• Promote effective management of AKI
• Provide evidence-based education and training programmes
• Highlight importance of AKI to commissioners, health care professionals and managers
The following activities are proposed:
Proposed
Service Change
54
• Each Practice will be asked to submit, a summary report which outlines what the Learning
from the Audit and AKI e-learning modules have been & the Practice’s Action Plan
• E-learning would need to be completed by a specified deadline.
• AKI posters to be displayed in the practice
• Provision of leaflets – confirmed by PSP
Antibiotics
Quality Premiums (QP)
•
•
•
•
Why?
•
•
•
•
•
•
•
•
•
•
•
Proposed
Service change
55
Antibiotics are the cornerstone of modern medicine and need to be preserved.
In recent decades antibiotic resistance has become a reality globally.
Inappropriate and overuse of antibiotics are known drivers of resistance; reducing the amount of antibiotics consumed slows
bacteria developing resistance to these vital drugs, and therefore helps prevent antibiotic resistant infections.
Over the last few years antibiotic consumption has been included in the CCG’s Quality Premiums. The two measures were:
• Reduction in the number of antibiotics prescribed in primary care.
• Reduction in the proportion of broad spectrum antibiotics prescribed in primary care.
In 2015/16 City and Hackney CCG did very well in both these indicators. Achieving greater reductions than the London average.
Current prescribing data (June16) suggests that the CCG will also maintain this prescribing reduction for 16/17.
From 2018 NHS England will be running a new 2-year Quality Premium scheme.
Bloodstream infections will be a new mandated QP.
This QP has three elements:
• Part A: Reducing gram negative blood stream infections (BSI) across the whole health economy.
• Part B: Reduction of inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care.
• Part C: Sustained reduction of inappropriate antibiotic prescribing in primary care.
This QP will require joint working across the entire health economy.
The CCG will also retain the previous QP (reduction in volume and broad spectrum antibiotics).
To help coordinate AMR workstream, the CCG has become a member of the North East London Antimicrobial Resistance Group.
A GP antimicrobial lead has been appointed to help coordinate these efforts.
Primary care antimicrobial guidelines have been drafted in conjunction with HUHFT.
Urology guidelines that clearly outline the need to prescribe nitrofurantoin over trimethoprim.
Part A: Reducing gram negative BSI
• a ≥10% reduction in all E coli BSI based on 2015/16 performance- collection & reporting of a core primary care data set for all E coli
• collection and reporting of a core primary care data set for all E coli BSI.
Part B: Reduction of inappropriate antibiotic prescribing for UTI in primary care.
• a ≥10% reduction in the Trimethoprim: Nitrofurantoin prescribing ratio based on CCG baseline data.
• a ≥10% reduction in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data.
Part C: sustained reduction of inappropriate antibiotic prescribing in primary care
• Items per Specific Therapeutic group Age-sex Related Prescribing Unit(STAR-PU) must be equal to or below England 2013/14 mean
performance value of 1.161 items per STAR-PU
Similar tests will apply for 2018/19.
Medication Reviews
•
•
Why?
•
•
Proposed
Service Change
GP Consortia meetings have highlighted some problems with medication use and hoarding of medicines.
Feedback from practices currently providing domiciliary medication reviews via domiciliary medication
review pharmacists and Practice Support Pharmacists (PSPs) has been positive
Previous Patient Public Involvement (PPI) Committee meetings have highlighted that patients/public
want more time to discuss their medicines and that this would also help to reduce medicines wastage.
A recent medicines review survey found that 83% of patients said that there was a need for more support
to help manage their medicines better.
• To provide a CCG wide domiciliary medication review (DMR) service by clinical pharmacists, ensuring
there is a clinical review using patient records, evidence based guidelines and assessments of how
patients take their medicines.
• To provide medication review service by clinical pharmacists in care homes (including providing drug
administration, prescribing & medicines management advice to patients, care home staff and GPs
• To extend this to practice based clinics for patients who are able to come to Practices
• To work with Practice Support Pharmacists in increasing the number of medication reviews
Medication reviews involving DMR pharmacists, care home pharmacist & PSPs who will work closely with
GPs to identify and provide support to the following high risk vulnerable patients:
•
•
•
Proposed
Implementation
56
Patients who have frequent hospital admissions
Patients on complicated medication regimens
Patients on ‘high risk’ medicines (e.g. warfarin, digoxin, antipsychotics, opioids, antihypertensives,
injectable or enteral medicines, medicines requiring TDM)
Any recommendations made will be discussed with the patient and their GP. To ensure integrated care is
received, other healthcare professionals will be contacted if needed (e.g. social care, specialist nurses,
community pharmacists) with the patients consent.
The Interim report for the DMR service pilot (Jan 16- April 16) showed that 500 interventions were made for
112 patients visited. The acceptance rate by practices for advice provided by the service was 84%. Positive
feedback has been received from patients, practices and other health care professionals on the medication
reviews undertaken by DMR pharmacist and nursing home pharmacist. Also improvements in the CQC
report of one the care homes with regards to medicines management.
Practice Leavers & Joiners (Prescribers)
•
NHS Business Services Authority (NHSBSA) sends various reports to the Medicines
Management Team (MMT); these reports sometimes includes instances where prescribers in
a City and Hackney GP practices have used codes of practices not within City & Hackney.
These incidents arise from practices not notifying the appropriate NHS agencies of
•
o prescribers that have not ‘joined’ to the City and Hackney practice
o prescribers have left the City and Hackney practice
Why?
These leads to significant work by the MMTs of C&H and prescribers new/ previous CCGs in an
attempt to redress financial responsibility associated with this ‘miscoding’ and also puts C&H CCG
at financial
Proposed
Service Change
• As part of the 17/18 CCE, practices will be asked to provide – at least bi-annually, an up to date
list of all prescribers that work in their practices to the MMT
•
Proposed Implementation
57
Practices will be asked to submit bi-annually to the medicines management team, listing
showing:
o Current up to date names of prescribers ( medical & non-medical) that work in the practice
o Names of medical & non- medical prescribers who have left practice within that quarter
o Names of medical & non-medical prescribers who have joined practice within that quarter
Local Formulary Agreements & Issues at the Interface
Why?
Issues at the interface
• NICE guidance on Medicines Optimisation highlights the imports of good communication at the interface.
• Concerns regarding poor communication relating to changes to medication when crossing healthcare settings has been raised by both patients
and GPs nationally.
• Interface issues that are highlighted to the Joint Prescribing Group, can be escalated to senior management at HUHFT.
• Recently the JPG requested that the HUHFT electronic discharging system is placed on the Trust risk register due to the risk posed by sending
out multiple discharge summaries.
Local Formulary
• In order to ensure City and Hackney patients receive equitable treatment across the borough we aim that practices prescribe in line with the
formulary.
• The proposal would be to continue to review the use of high cost none formulary items; In order to reduce the use of these medications.
• This will help GP practices to prescribe in a clinically appropriate and cost effective manner.
• Continuation of this programme will ensure GP practices receive support from PSPs who can facilitate the adoption of formulary choices with
support from the CCG medicines management team.
Issues at the interface
• The medicines management team will continue to monitor and record any primary care interface concerns.
• information will be collected by regular feedback with the PSPs Practices, GP leads and Programme Boards.
• The MMT continue to run a busy medicines information services, a large number of requests for this service are regarding prescribing
issues at the interface.
Proposed
Service
change
58
Local Formulary
• Review 2015/16 prescribing data to highlight high cost spending on none formulary items.
• high cost non-formulary drugs will then be reviewed with PSPs at a practice level to determine reasons for use
• This information gathering highlights the need for guidelines to be produced around formulary choices to aid prescribing. An example of
this is the recently developed eczema guidelines. This document will help GPs when choosing preparations.
• A further work steam will be the North East London STP medicines optimisation group: reviewing medication across the footprint. The
group have highlighted drugs of low clinical value. C&H MMT have taken a lead on this project.
• PSPs will provide targeted support to each of their allocated practices in the event of any specific issues related to none formulary
prescribing.
• Information will then be shared in the monthly prescribing newsletters to support best practice and improve use of the formulary
Interface work - Biosimilars
Why?
Proposed
Service change
59
Biosimilars
• A biosimilar medicine is a biological medicine which is highly similar to another biological medicine already licensed for use.
• Biological medicines are those that are made by or derived from a biological source such as a bacterium / yeast.
• The continuing development of biological medicines, including biosimilar medicines, creates increased choice for patients and clinicians.
• Biologics are often expensive and used to treat long term conditions.
• Biosimilar medicines are cheaper then the originator therefore these medicines have the potential to offer the NHS considerable cost savings
and widen the access to innovative medicines.
• Biosimilars also increase commercial competition & enhance value propositions.
• Potential savings of £347K to the local health economy have been identified if all infliximab & etanercept (charged from HUHFT & Barts Health
only, to C&H CCG) during 2015/16 had been prescribed & supplied as an equivalent biosimilar.
• NICE has written guidance on the introduction of biosimilars into the health economy.
• NHSE monitors uptake of biosimilars – currently monitoring the % uptake of biosimilar infliximab by Acute Trust .
• Implementation and increased uptake of biosimilar medicines in acute trusts has been identified as a priority area by the Medicines Optimisation
STP group.
• HUHFT previously agreed to work on an infliximab CQUIN to increase use. The trust has informed the CCG that they will not be agreeing to
another biosimilar CQUIN as the trust did not reach threshold for CQUIN payment.
• London Procurement Partnership (LPP) have proposed a 50:50 gain share agreement to increase the uptake of etanercept across London.
• C&H CCG is reviewing alternative options to implementing biosimilar introduction as the CCG is not supportive of Gain Share agreements
Barriers to implementation
• Introduction of biosimilars is more complex then generic switches for pharmaceutical drugs.
• Patients established on a brand will require additional support during switching.
• Clinicians will also require education and training on new products.
Overcoming Barriers
• The CCG and HUHFT have agreed to develop a working group to establish a work plan for the managed introduction of biosimilar medication.
• This work plan will involve an 18-24 month agreement between the CCG and the Trust.
• The trust will be provided with financial resource to help implement the safe up take of biosimilars into the health economy.
Anticoagulation
Why?
Why?
Proposed
Service Change
60
Many patients taking warfarin in City & Hackney continue to receive routine care in secondary care and do not
have equitable access to the community based warfarin services
The current mechanism for warfarin service provision could be more cost effective
No tenders were received following 2 open procurement tendering exercises for a new consultant led community
warfarin service
Alternative options for a local warfarin service will need to be assessed; the primary focus will remain the safe
transfer from secondary care into primary care – of initiation of warfarin and routine follow up of patients on
warfarin
Scoping feasibility of increasing / expanding current primary care provision
Review paper – outlining alternative options is being prepared for submission of Nov2016 contracts committee
Disease - Modifying Anti-Rheumatic Drugs (DMARDs)
•
•
Why?
Why?
•
•
•
•
•
Proposed
•
Service Change
•
DMARDs are a group of medicines that are used to treat primarily rheumatoid arthritis but also
used to treat other conditions such as chronic inflammatory skin or bowel disease.
DMARDs require regular monitoring due to their side-effect profile patients are required to have
regular tests
There are increasing numbers of patients prescribed DMARDs and currently many patients
continue to receive routine monitoring in the hospital.
Regular monitoring of DMARDs should be in line with the shared care agreements for individual
DMARDs. However, feedback from GPs has highlighted the following:
• Shared care agreements which provide information to manage patients safely are not
always provided by the initiating hospital specialists to GPs
• Where monitoring is carried out by the Hospital, often blood test results are not received by
GP practices in a seamless robust manner
• In addition, data on HUHFT follow up rates suggest very high rheumatology follow up rates,
possibly driven by frequent hospital attendance for DMARD monitoring
Planned Care Board have agreement with HUHFT for audit in 2017 to establish drivers for high
follow up rates
Working group is currently being set up to involve key stakeholders across interface
development of a a commissioning pathway which will identify which activities can be undertaken
by different providers ensuring that pathology data is fully shared
To review the options & feasibility for a community based DMARD monitoring service for clinically
appropriate patients prescribed a DMARD who have been stabilised in secondary care
The review will aim to look at the following:
• improved patient access offering a more convenient service, with care offered closer to
home and with reduced waiting times
• strengthened integrated pathway of care
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