PRACTICE BASED COMMISSIONING PLAN 2010/11
Table of Contents Section
2. CHAIRMAN’S REVIEW
5. GEOGRAPHY & POPULATION
6. HEALTH NEEDS
7. COMMISSIONING PRIORITIES
7.1.1 Partnership Working 7.1.2 Health Improvement Teams 7.1.3 Sustainability of Locally Commissioned Services 7.1.4 Paediatric Primary Care Based Services 7.1.5 Review & Audit of MSK, Gastroenterology & Respiratory 7.1.6 Diagnostic Procedures 7.1.7 Review of Prescribing & Obtaining Appliances 7.1.8 Physical Activity Intervention 7.1.9 Increased participation in Local Enhanced Services 7.1.10 Improving Pathways of Care for People in Care Homes
12 13 14 16 17 18 19 20 20 21
8. MEDICINES MANAGEMENT
9. PATIENT & PUBLIC INVOLVEMENT
10. ORGANISATIONAL DEVELOPMENT
11. EDUCATIONAL, TRAINING & GOVERNANCE
12. ACTION PLAN
Appendix 1 – PBC WORLD CLASS COMMISSIONING COMPETENCIES
Appendix 2 a) – Day Case Activity by HRG Chapter 2009/10 b) – Elective Activity by HRG Chapter 2009/10
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This plan sets out the Practice Based Commissioning intentions for the Three Valleys Commissioning Consortium for 2010/11. It aims to present an overarching framework highlighting four main areas of focus:• • • •
Service Improvement and Redesign Medicines Management Organisational Development Education, Training and Governance
Ongoing work will establish specific project plans to underpin the identified work-streams, and ensure that a clear process is in place to optimise achievement of these priorities. The Commissioning Consortium Executive Team underwent re-election last year and have benefited from and built upon the strong foundations previously developed through working as a small, cohesive team, in partnership with the wider PBC team. Financial Statement NHS Kirklees is moving towards the end of the current 5 year comprehensive spending review, with the last being 2010-11. During this period the levels of growth it has received have been relatively high compared with historic levels and these continue in 2010-11. As we move into 2011-12 and onwards, the levels of growth are anticipated to be much lower than in recent years and therefore this Commissioning Plan is produced in the context of a more difficult financial climate and with greater uncertainty than in recent times. However, the financial position for 2009/10 has proved more challenging than at any time since the PCT was formed in 2006, mainly due to over spends on acute contracts. Consequently, there is a greater emphasis within the financial plan for 2010/11 on delivering cost efficiencies than there has been in recent years. The Practice Commissioning Plan will support the drive for improved efficiency and productivity whilst maintaining or improving the quality of patient care next year and onwards. Quality, Improvement, Productivity and Prevention The Executive Team supports the need to ensure efficient services are in place, and the drive for quality and has based this commissioning plan around these priorities and the need to drive efficiency.
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2. Chairman’s Review
The Three Valleys Commissioning Consortium is a consortium of 10 GP practices serving a population of over 60000 patients. The executive team of six elected members (three GPs, 2 practice managers and one nurse practitioner) is well supported by a management team from the PCT which includes input from performance and information, finance, public health and medicines management. Over the last year we have been pleased with the performance and success of our various initiatives; these include: •
The provision of a teenage advice service from Kirkburton Health Centre
The funding of a Nurse Practitioner at Shepley Health Centre to improve the management of patients with long term conditions-this has achieved year on year cost savings.
The Pain Self Management Programme delivered from Kirkburton Health Centre continues to provide a holistic, multidisciplinary team led approach to pain management and has demonstrated excellent patient satisfaction scores. Further evaluation in terms of its cost effectiveness is in progress.
The Primary Care Cardiology service continues to be delivered by Dr Beith from Meltham Road Surgery. This needs further publicity to increase referral rates.
The Practice Nurse Development programme has been a huge success and we continue to run monthly workshop sessions for our practice nurses, to up skill them for better and more care within primary care, and ensure they are integral to developing PBC.
In 2009/10 we embarked on a project based approach to commissioning. Our progress report is as follows: •
Primary care based paediatric services-our aim is to set up a community based paediatric service to be delivered from 4 sites within the consortium. The writing up of the business case was hampered by long term sickness absence of our management lead but this is now a priority for us. We believe that such a service is QUIP compliant and can deliver cost effective services closer to patient’s homes.
Diagnostic procedures closer to home-after close scrutiny and a cost/benefit analysis, we came to the conclusion that this was not a practical option to implement at present. We continue to support the development of such services at Holme Valley Hospital.
Develop participation in a local enhanced service for the care of patients with alcohol problems-this has been a success and we now have 3 practices in the consortium that run a shared care alcohol service from their practices.
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Improving the care of patients in care homes-implementation of this has been hampered as we await an evaluation of a current local enhanced service which is available to some practices in the PCT area. We feel that the position is inequitable both in terms of resource allocation and service delivery. We will work with the PCT in redesigning services to Care Homes to ensure an equitable and consistent high standard of care is provided to Care Home residents across Kirklees.
Enhance clinical engagement-this is an ongoing success story through our annual practice visits, monthly GP forum meetings and 3 monthly plenary events, not mentioning our website and newsletter. We were runners up in a national competition in this category. Successful clinical engagement has led to the Three Valleys constituent practices gaining the highest achievement across Kirklees for the first six months of the 2009/10 Financial Incentive Scheme (FIS). Details of each target are detailed below: Three Valleys FIS April to November 2009/10 102% 100% 98% 96% 94% 92% 90% 88% 86% 84% A&E
Improving medicines management - one success story is the setting up of a pilot dressing store at Meltham Group Practice from which community and practice nurses can access appropriate dressing formulary compliant dressings, reducing wastage and rationalising usage in line with best practice.
As to the future, we know and appreciate the scale of the financial challenge, and we will work closely with our fellow commissioners to ensure that scarce resources are put to best use and that we collectively embrace the QIPP agenda. We appreciate the importance of working closely with our colleagues in secondary and social care and we will engage fully to transform and future proof community based services. Our priorities for next year are set out in this document and we believe that all of them are achievable and will promote quality with cost savings. Dr Anil Aggarwal Chair Three Valleys Commissioning Consortium.
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To commission services effectively and efficiently for the population we serve in order to improve patient care.
The Three Valleys Commissioning Consortium is made up collectively of 10 practices catering for a population of approximately 62,000. The table below details the constituent practices. 1 2 3 4 5 6 7 8 9 10
Dr Aggarwal and Partners Dr Benson and Partners Dr Lord and Partners Dr Mitchell and Partners Dr Orme and Partners Dr Pacynko Dr Priestman and Partners Dr Seeley and Partners Dr Welch and Partners Dr Hindle and Partners
Meltham Road Surgery Marsden Health Centre The Surgery, Honley Meltham Group Practice Shepley Health Centre Meltham Village Surgery Kirkburton Health Centre Dearne Valley Health Centre Skelmanthorpe Family Doctors Croft House Surgery
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5. Geography & Population
The Consortium practices fall into three locality areas, Denby Dale and Kirkburton (DDK), The Valleys and South Huddersfield. The Consortium area is therefore is not coterminous with a distinct locality, and as such there are some differences in the health needs from one locality to another. Where this maybe not be significant, it is important to acknowledge this in identifying priorities across the Consortium. The area is characterised by three main valleys, the Dearne Valley, Holme Valley and the Colne Valley. The geography of the area often means that accessing healthcare services across and within the valleys can be challenging, as can hospital based services located out with the immediate local area. This difficulty is further compounded by the local transport infrastructure. Access to public transport is particularly relevant for those people who live some distance from their local community and who have no access to their own transport. Recognition of these particular characteristics and their impact on the population is pivotal to the need to develop a range of services closer to home. The provision of services in one valley may not necessarily mean they are easy to access from another for example the locally commissioned pain self management service based at Kirkburton Health Centre.
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The following table demonstrates the population breakdown per age band. The proportion of working age people within the Valleys and DDK, is higher than the Kirklees average. In addition these two localities have the highest proportion of people about to move into retirement (JSNA, 2009) Maintaining health and well being, and encouraging behaviours which contribute to healthy ageing are pivotal to ensuring people not only live longer but also have a good quality of life in those extra years.
90 and Over 85 to 89
80 to 85 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 05 to 09 00 to 04 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 % % % % % % % % % % % % % % % % % % % % %
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Age Ba nd 90 and Over 85 to 89 80 to 85 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 05 to 09 00 to 04 Gra nd T ota l
Ma le s % Ma le s Fe ma le s % Fe ma le s 99 0.2% 299 0.5% 294 0.5% 617 1.0% 580 0.9% 822 1.3% 855 1.4% 1,001 1.6% 1,267 2.0% 1,344 2.1% 1,620 2.6% 1,580 2.5% 2,313 3.7% 2,306 3.7% 2,145 3.4% 2,107 3.4% 2,140 3.4% 2,182 3.5% 2,551 4.1% 2,397 3.8% 2,532 4.0% 2,461 3.9% 2,311 3.7% 2,342 3.7% 1,705 2.7% 1,769 2.8% 1,702 2.7% 1,652 2.6% 1,718 2.7% 1,591 2.5% 1,917 3.1% 1,727 2.7% 1,877 3.0% 1,810 2.9% 1,847 2.9% 1,720 2.7% 1,874 3.0% 1,738 2.8% 31,347 49.9% 31,465 50.1%
T ota l % T ota l 398 0.6% 911 1.5% 1,402 2.2% 1,856 3.0% 2,611 4.2% 3,200 5.1% 4,619 7.4% 4,252 6.8% 4,322 6.9% 4,948 7.9% 4,993 7.9% 4,653 7.4% 3,474 5.5% 3,354 5.3% 3,309 5.3% 3,644 5.8% 3,687 5.9% 3,567 5.7% 3,612 5.8% 62,812 100%
6. Health Needs
The Health Inequalities Strategy for England has identified the need to ensure action is taken proportionately across the entire population (Marmot 2010*). This means not simply focussing on the health of the poorest people in society, but targeting action to improve health according to need. Marmot (2010) suggests urgent action is required to reduce not only avoidable premature deaths but also increase the amount of disability free years. The three key public areas for action that the health inequalities strategy for England has identified are Smoking; Obesity; Physical Inactivity. The Joint Strategic Needs Assessment (JSNA 2009) for Kirklees sets out the health challenges for the population of Kirklees. Within the 3 Valleys Commissioning Consortium area the JSNA has identified specific issues that can and should be addressed by local action. On the surface the population within the Three Valleys area experiences better health outcomes and greater relative affluence than Kirklees overall. That said there are issues impacting on specific groups within the population that if not challenged could increase the health inequalities gap within the 3 valleys population. Health inequalities can be overlooked in an area that believed to be affluent. Whilst there maybe fewer young people (compared to Kirklees) living in households claiming income related benefit, these young people (described later in this section) appear to be suffering proportionately higher emotional health and well being problems than young people living in other areas of Kirklees. In contrast, to the financial circumstances of young people in the Valleys, nearly 1 in 6 (16%) of older people are living in poverty. * Marmot M, Allen, J, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I. (2010) Fair Society, Healthy Lives, The Marmot Review. Page 9 of 46 Three Valleys Consortium, PBC Plan 2010/11
There were significant numbers of people in the Valleys (1 in 4) who thought their house was inadequate for their needs. In the Colne Valley area 1 in 3 pensioner households felt their house was inadequate. People may therefore be “asset rich but cash poor”. Poor housing can have a detrimental impact on health. Not being able to heat ones home in winter can lead to a range of cold related illnesses including respiratory problems, excessive falling and also premature death in older people. The 2009 JSNA refresh of the health status of the population of the 3 Valleys found: • • • • • • •
An increase in the prevalence of diabetes in persons aged under and over 65. High blood pressure in persons aged under 65. Back pain in the working age population in the Colne valley (28%) the highest reported rate in Kirklees. Lack of physical activity in line with recommended limits. Excessive alcohol binge drinking in females (1 in 3 reporting bingeing). Men in the Holme Valley exceeding the recommended weekly units of Alcohol ( 2 in 5). The physical functioning and emotional health (depression) of adults is worse than 2008.
It is important to focus on the things that can be changed when reviewing commissioning intentions. The emotional health of children and young people is one such important factor, due to the clear links between emotional wellbeing and health outcomes in this population. The JSNA (2009) indicated that Young People (14 year olds) within the Three Valleys reported significant levels of low emotional well-being and excessive consumption of alcohol (higher than the Kirklees average). In relation to emotional well-being the young people reported: • •
feeling angry and miserable. feeling unhappy with self and lacking someone to talk to.
The issue of alcohol consumption and specifically binge drinking in adults as well as young people is of great concern locally. 1 in 3 people binge drink and consequently run the risk of the becoming susceptible to the health problems associated with excessive alcohol consumption. Binge drinking in potential mothers is identified as the worst in Kirklees, with major implications not only for individual’s health but also for future health of the next generation. Heavy or frequent drinking by women during pregnancy can affect the prenatal and postnatal development of their baby and lead in particular to foetal alcohol syndrome (FAS) or its less severe form, foetal alcohol spectrum disorders (FASD). In industrialised countries an estimated 0.4-2.0 live births per 1000 are affected by FASD. Children born with foetal alcohol effects can experience a range of developmental problems and some consequences may be apparent throughout their lifetimes. Alcohol is second in importance, after smoking, as a proved cause of cancer and is responsible for 3.5 percent of deaths from cancer in the UK, or nearly 5000 deaths a year. Whereas premature deaths from Cancer and Heart disease across the Consortium population are lower than the national average, there are other significant implications associated with excessive alcohol consumption.
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Chronic heavy drinking increases the risk of stroke. Hypertension accounts for about 3000 deaths a per annum in the UK, and about 300 of these may be specifically related to alcohol consumption. In 11 percent of men with hypertension, alcohol consumption is the main cause. There is a high proportion of overweight or obese women (aged 18-44), who additionally smoke daily, and drink excessively. In summary the ongoing challenges facing the Three Valleys are: • • • • • • • •
Depression in adults. Asthma/Respiratory problems. Smoking. Excessive Alcohol consumption in men and binge drinking in females. Management of Long Term Conditions in particular respiratory disease, diabetes and hypertension. Pain Management. Physical Functioning- particularly in older people. Emotional Health and Wellbeing of Children and Young People.
7. Commissioning Priorities The plan for 2010/11 sets a number of key priorities which will enable resources to be targeted appropriately and effectively in line with QIPP. There is a specific focus on:•
evaluation of existing commissioned services to ensure that they remain as effective as possible in meeting the needs of the local population, the outcomes identified and provide both high quality and value for money. consolidation of projects progressed last year. progressing new priority areas identified.
In setting out this yearly plan, as in previous years the Executive Team has proposed a number of key areas which will need further exploration to determine feasibility and ensure that the priorities remain focused on those areas most capable of creating positive change. This will also include the ongoing development of project plans to underpin the priority work areas, with identified time scales and outcome measures. Commissioning Priorities • • • • • •
Partnership working. Review the sustainability of locally commissioned services. Development of Paediatric Primary Care Based Services. Review and audit the management of musculo-skeletal referrals. Review and audit the management of identified respiratory conditions. Review and audit of Gastroenterology referrals. Page 11 of 46 Three Valleys Consortium, PBC Plan 2010/11
• • • •
Actively contributing to “Kirklees Way”, reviewing hospital admissions/re-admissions for elderly people. Review of current processes for prescribing appliances e.g. stoma, catheters Working in partnership with the Medicines Management Team to review current prescribing practice. Health Improvement programmes linked to Marmot review (Smoking, Alcohol, Physical Activity, Obesity).
7.1.1 Partnership Working Aim: To continue to develop and enhance partnership working, building on the firm foundations established over the preceding months and years, ensuring that resources are most effectively directed to those areas which will have the biggest impact for the local population. To focus on key priorities for the consortium, whilst continuing to actively engage in the wider strategic commissioning plans. To work in a whole system approach to commissioning, which will rely on other commissioning groups leading areas which are relevant, but “non priority” areas for the Three Valleys Commissioning Consortium. Issues: Requirement to focus on the priorities of the Commissioning Consortium versus a need to balance wider demands for engagement placed on the Consortium. Maturity within the commissioning arena to accept that the Consortium will define priority areas to focus on, whilst other priorities are developed as part of the whole system of commissioning. This may mean that the Executive Team are not actively involved in some areas of development. Focusing on quality and productivity in relation to QIPP, this underpins the review of current and future priorities, thus reducing risk associated with spreading skills too thinly. Current Position: The Executive Team is keen to ensure that their time is wisely spent focusing on those areas which create the biggest impact for the local population. Working closely with the constituent practices they are keen to embrace processes which actively support the practices to not only better understand the commissioning priorities, but also to be as effective as possible in working towards achieving these. Communication with constituent practices is well supported through the range of approaches in place to underpin this e.g. plenary sessions, practice master classes, and also as a result of 6 out of the 10 practices having a representative on the Executive Team.
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Proposal: • Jointly agree those areas where the Executive Team can effectively contribute on a wider basis. • Agree those areas where the Executive team are confident that other commissioning groups will lead on their behalf. • Continuing to actively participate and engage in the Commissioning College. • •
Identify key health Improvement Teams (HITs) to participate in which will support the priority areas of the commissioning consortium. At constituent practice level establishing and embedding practice master classes on a quarterly basis, continuing to develop and review the quarterly plenary sessions and undertaking annual practice based visits.
Expected Outcomes: • Clearly defined priority areas with demonstrable achievement of identified outcomes against plan. • Evidence of continued engagement and active contribution to the Commissioning College • Active participation in priority HITs. • Positive feedback from practices following the plenary and master classes.
7.1.2 Health Improvement Teams
Aim: To continue to actively participate in HITs relevant to priority areas of the Consortium. Risks/Issues: Work undertaken is not aligned to the overall strategic priorities of the individual HITs Executive Team members may not be the most appropriate clinicians/managers to actively engage in individual HITs; however there are potential issues in freeing up practice based time for other individuals to participate. In identifying specific priorities the Executive Team aim to ensure that they can optimise the outcomes possible through PBC, thus ensuring that they do not dilute their focus by over commitment to a range of areas. Typically PBC groups are called upon to be involved in a wide range of areas, and there is potential to become distracted from the areas that will make the greatest impact locally. Current Situation: • Key areas have been identified that link in with Three Valleys priorities such as working with the Children & Young Person’s Partnership Board. • Work with other consortia and stand alone PBC practices to ensure that PBC representation on the HITs reflects collective opinion, supports two way communication and best utilises human resources. Page 13 of 46 Three Valleys Consortium, PBC Plan 2010/11
Proposals: To identify the key HIT teams which will underpin the priority areas for the Consortium
Expected Outcomes: The Executive Team identifies the main HITs which will make the biggest impact for their population and actively participate to influence these agendas.
7.1.3 Sustainability Of Locally Commissioned Services
Aim: To evaluate the impact of existing services commissioned through PBC for the local population to ensure that they are sustainable (where appropriate), high quality and effective.
Current position: Pain Self Management Service This is a pilot programme commissioned for the 3Vs population, to test out a model of provision for patients with chronic pain. An interim evaluation has been conducted (see report January 2010) which provides baseline data on the characteristics of patients and their priorities and needs on entry to the service. The results indicate that patients accessing the service have benefited from the multi-disciplinary support. The success of this model will inform the development of a Kirklees wide long term pain pathway, which is currently being planned. Perceived issues such as transport need further exploration, if the model is to remain sustainable and accessible. Primary Care Long Term Conditions Service This model of provision aims to improve the approach to the management of Long Term Conditions, reduction in admission to hospital, the implementation of schemes aimed at primary prevention of the development of long-term conditions e.g. primary prevention, domiciliary home visits and osteoporosis prevention. The proposal is based on short, medium and long term outcomes which will realise the benefits over differing periods of time. Primary Care Based Cardiology service This service focuses on patients with atrial fibrillation and palpitations. Work is underway to evaluate the current model, in line with the Cardiology Health Improvement Team, with an aim to enhance and maximise the service. Teenage Health Clinic The service continues to provide local access for young people. It is currently in the process of being evaluated to demonstrate its continuing impact for the local population.
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Risks: There is an imperative to commission services on a shorter term invest to save basis, which releases savings for re-investment into service provision. This however prohibits the ability to focus on longer term outcomes, which require a more extensive time scale to demonstrate the benefit, and may also arguably be attributable to more than one intervention. Ongoing monitoring and evaluation of commissioned services may identify that the outcomes are not those anticipated. Where services are in pilot form, there is a need to ensure the model for provision is sustainable in the longer term, and that the evaluation proves a mechanism for establishing decision making regarding the ongoing commissioning or otherwise of these services.
Proposal: To continue to monitor and evaluate and improve existing commissioned services, building on the learning gained. To remain outward facing in promoting the developments and outcomes achieved for the benefit of the wider commissioning system. To develop a framework for ensuring that services continue to meet patient/carers needs, and that there are options to underpin ongoing development through active patient/public engagement.
Expected Outcomes: • Clear framework for patient/carer engagement identified, with structure for feedback and response. • Demonstrable outcomes against planned measures. • Communication plan for feedback to Consortium members, Executive Team and wider commissioning community. • Services commissioned meet the health needs set out in the JSNA and the requirements of QIPP.
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7.1.4 Paediatric Primary Care Based Services Aim: To explore the feasibility of commissioning paediatric primary care based services that enable children and young people to access effective care closer to home.
Issues: Delivering Healthy Ambitions sets out a number of recommendations and levels of delivery for the improvement of children’s health. In developing local services there is an inevitable need to marry the work being developed at PCT level and wider, with the drive and timescales anticipated in delivering change in year. The paediatric services at Calderdale and Huddersfield Foundation NHS Trust, are now based predominantly in Calderdale, with access potentially perceived as an issue for some families. The JSNA identifies that emotional well being is of high concern to young people locally, with reported problems regarding feeling miserable and angry, and low self esteem as specific issues.
Proposal: To consolidate the work undertaken over the last year, which will continue to focus on:•
Reviewing current access to primary care, including assessment, diagnosis and referral pathways across the Consortium population. This will form part of the Quarterly Practice Master class agenda, and be incorporated as part of a Plenary agenda. Exploring the feasibility of commissioning primary care based services to support a number of care pathways which will improve care for children/young people, particularly those with Long Term Conditions (LTCs).
This might for example include:reviewing paediatric outreach provision to support the care and management of children in their own home, where feasible. • Primary care based consultant led reviews, which would enable joint learning within primary care teams, provide care closer to home. • Focusing on improvements of outcomes, such as reducing asthma related admissions to hospital, and work in conjunction with the PCT to define an appropriate pathways to improve care (in line with proposals set out in Healthy Ambitions). See Table 1 for current admission data.
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Expected Outcome: • Baseline measures and data across Consortium practices in relation to access, diagnostic procedures, referral rates, admission patterns • Option appraisal of specific models of provision against which to commission improved pathways to underpin primary care based services set out and submitted for approval • Active involvement with the Children’s and Young People’s Partnership Board. • Baseline measures against which to demonstrate improvement in relation to asthma related admissions. • Agreed Individual care plans in place for each child (and family as appropriate) for identified conditions e.g. asthma. • Action plan to identify improvements at practice level across all Consortium practices. • Evidence of feedback regarding overall patient experience identified and an appropriate format for engaging with service users to shape service change identified. • Development and submission of a business case proposal to support the commissioning of service models in primary care
7.1.5 Review and audit of the management/referral of musculo-skeletal (MSK), gastroenterology and defined respiratory conditions Aim: To review/audit current referrals patterns in relation to the management of musculoskeletal and gastroenterology conditions. Issues: Following review of existing referral data the Three Valleys Commissioning Consortium have a demonstrably high number of referrals to secondary care for these two areas (see appendix 2).
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Previous work has focused on updating clinical staff in relation to current pathways and audit of referrals and this has achieved some change in referral. Proposal: To undertake an audit across all practices for each condition specific area. To develop and agree an action plan via the newly established practice based master classes Establish clinical workshops, as part of the ongoing plenary sessions to underpin learning and up skilling clinicians. Working in partnership to review pathways if required. Expected Outcome: • Increased understanding of current referral patterns to secondary and primary care providers. • Plenary based clinical workshops which will underpin learning and development. • Reduced number of referrals to secondary care. • Appropriate referrals to primary care based services. • Improved quality and effectiveness in relation to referral and management and ensure consistency and adoption of best practice and NICE Guidelines.
7.1.6 Diagnostic Procedures Aim: To improve cost awareness of identified diagnostic procedures and reduce unnecessary tests and/or duplication of diagnostic tests. Risks/issues: It may not be possible to demonstrate savings or ensure treatments are cost effective given that many of the diagnostic procedures are either included in the block contract or part of tariff. Current Position: There is the potential for duplication in some diagnostic procedures or the requirement for onward referral in order to obtain or exclude a diagnosis. Improved access to specific diagnostic procedures would improve the overall patient pathway, reduce the impact on identified pressurised pathways, reduce any potential duplication and support care closer to home, and improve access. Proposal: Ensure costs of commonly used diagnostic tests are circulated to all practices both electronically and print format.
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Utilise the practice master classes to inform and educate the constituent practices on appropriate use of diagnostics to add value to patient care. Work in partnership to support the development of work at HVMH to develop diagnostic services closer to home, which add value to the patient pathway. Expected Outcomes: • Identify baseline data against which to measure cost impact. • Increased awareness across constituent practices measured through feedback and cost analysis.
7.1.7 Review of the current processes for prescribing and obtaining appliances e.g. stoma appliances, catheters
Aim: To review and re-design the current processes for prescribing defined appliances.
Issues: Initial review demonstrates that prescribing of appliances is a high cost area and at the current time there appears to be variation in how a number of appliances are prescribed and obtained. Increased understanding of the current processes will potentially lead to a more systematic approach and the development of a formulary to underpin prescribing. Proposal: To develop and agree a project plan to support the process. To undertake a more in depth review to better understand current processes. To establish a formulary for defined appliances which support decision making.
Expected Outcomes: • Increased understanding of current prescribing and procurement of stoma care and catheter appliances. • Development of a formulary for the prescribing of appliances. • Systematic approach to prescribing demonstrated against use of formulary. • Plenary based clinical workshops which will underpin learning and development. • Streamed pathways for patients to request and obtain appropriate appliances.
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7.1.8 Improving Outcomes for people referred to physical activity intervention
Aim: To improve the outcomes for people referred to physical activity intervention from primary care.
Risks/Issues: Further work is required to plan out the approach working collaboratively with a range of partners. There is a potential risk regarding the reluctance of GPs and/or patients to adopt new physical activity referral practices.
Current Position: Currently there are a range of exercise referral options and interventions available to primary care practitioners within Kirklees. The challenge is to make use of the most effective intervention to support patients and improve health outcomes.
Proposal: Work in partnership with NHS Kirklees, the Local Authority and other partners to pilot the â€œLets Get Movingâ€? Physical Activity referral protocols within Kirklees. Develop a Project Plan. Work collaboratively with constituent practices to ensure appropriate usage of these services.
7.1.9 Increased Participation In Local Enhanced Services
Aim: For all constituent practices to optimise participation in the Local Enhanced Services for obesity, smoking and alcohol and develop practice based plans to support this approach.
Risks/current situation: Improved understanding of the impact of Practices participating in local enhanced services. There are reported problems with early alcohol drinking among 14 year old, with some of the highest rates in Kirklees. Binge drinking in adults is an issue across all the areas, although more pronounced in Denby Dale and Kirkburton. Other associated reported unhealthy behaviours are identified for all areas. Tackling these issues will require a partnership approach, underpinned by the Rainbow Model of Well being and Health.
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The JSNA defines the terms in the following way:“Health as maximising the individuals experience of mental and physical ability and functionality” “Well being defined as the personal experience of feeling empowered and having the opportunity to enact the maximum possible amount of choice and control over their lives”. Improve understanding of the perceived gaps in reported versus expected prevalence. • • • •
7 out of the 10 practices report lower than expected CHD prevalence. 6 out of 10 practices reporting lower than expected prevalence of diabetes. All but 1 practice reporting heart failure prevalence as expected. All but 1 practice reporting CKD prevalence as expected.
Action: Improve identification of people at risk of cardio vascular disease. Ensure practice staff is trained in cardiovascular risk assessment and treatment attend PCT CVD training. Review the use of care planning for people with diabetes initially and for other LTCs. Use of predictive risk tool to support identification of gaps in prevalence.
Expected Outcomes: • Increased uptake in Local Enhanced Schemes against the baseline. • Increased numbers of practitioners completing Brief Intervention Training. • Numbers of people with reduced BMI recorded. • Numbers of people with smoking status recorded. • Numbers of people participating in Brief Interventions programmes, with outcome recorded. • Numbers of people with agreed managed care plan. • Numbers of people accessing weight management regimes.
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7.1.10 Improving Pathways Of Care for people in Care Homes
Aim: To work in partnership with care homes, to improve pathways of care for patients with LTCs.
Risks/current situation: Previous work over the last year has started to focus on specific areas in relation to wound management, use of nutritional supplements and medicines management as examples whereby pathways of care can be improved across the Consortium population. There is further work to progress in developing robust pathways, supported by action plans to achieve improvements, with a planned focus to work alongside care homes to facilitate the roll out of this. The Long Term Conditions strategy sets out the generic pathway for improving the overall management of patients, and working in partnership with the key leads, the Executive Team aim to focus on embedding commissioned services to improve overall care. This may for example maximise the resource available through the community matron’s team, to work proactively within the practice units and practice teams. There is already a Nurse Practitioner role, working across two GP practices, and a number of care homes to support the overall management of patients in a proactive way. Learning from this approach will be key to this area of work.
Proposals: To build on and progress work focusing on improving pathways of care in relation to:• • • • • •
Nutritional assessments and the prescribing of supplements. Wound assessment and management. Medication reviews. Case management for identified patients with complex needs. The underpinning of a person centred approach. Improved access to specialist assessment for example through primary care based consultant sessions and/or domiciliary visits to support care closer to home, and reduce admission to hospital where possible. Continue to work in partnership, to drive forward the LTC strategy. Review opportunities to participate in the Local Enhanced Scheme (LES) for Care Homes.
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Expected Outcomes: • Increased numbers of people having nutritional assessment. • Numbers of people with ongoing medication review against the baseline. • Increased percentage of people with managed care plan, and identified case manager (where appropriate). • Option appraisal for primary care based consultant sessions/domiciliary access set out for approval. • Review of wound management assessment/prescribing against the wound care formulary. Feedback disseminated regarding the dressing pilot currently in place. • Participation in Care Homes (LES) pending outcome of the evaluation of the current scheme.
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8. MEDICINES MANAGEMENT
Aim: To promote good prescribing practice amongst consortium practices. To effectively manage prescribing resources within allocated budgets without affecting the quality of prescribing. To minimise the risks to patients associated with medicine taking. To deliver national and local priorities on prescribing.
Issues: A prescription is the most common intervention made to treat patients in the NHS. There continues to be an increased demand for medicines due to changes in population demographics and the development of effective treatments for conditions where previously there was no treatment. Using the principles of evidence based prescribing, practices and consortia will be able to treat patients with effective medicines in the most cost effective manner. The increasing complexity of prescribing in primary care means that the importance of ensuring that safe prescribing systems are in place becomes ever more important. The consortium will continue to monitor prescribing systems and take note of national safety guidance and information (e.g. NPSA and MHRA Patient Safety Alerts) to continually improve the safety of prescribing in the area.
Proposals: Practices within the Consortium working collaboratively with NHS Kirklees’ Medicines Management Team & the Three Valleys Executive Team will focus on a range of prescribing issues as outlined in the 2010-11 Medicines Management Action Plan. This plan includes elements of quality, safety and cost effectiveness. •
Quality and Safety: • ensuring NPSA methotrexate alert is fully implemented in all practices • reviewing prescribing of prescription of antispychotics to patients with dementia • reviewing patients prescribed unlicensed liquid specials. • Practices will work in partnership with the PCT Medicines Management team to improve prescribing in care homes in line with the recommendations from the CHUMS study (Care Homes Use of Medicines Study).
Quality and cost-effectiveness • Reviewing prescribing practice in the three therapeutic areas outlined in the national Better Care, Better Value indicators – renin-angiotensin drugs, lipid lowering agents and proton pump inhibitors. • Reviewing prescribing of glucosamine, bisphosphonates and clopidogrel in line with NICE guidance. • Reviewing the prescribing of sip feeds, ‘Grey Drugs’ and other therapeutic areas included in local prescribing indicators. • Reviewing the prescribing of appliances with a view to optimising prescribing processes.
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Expected Outcomes • Safer prescribing systems resulting in improved patient safety. This has the potential to reduce admissions to hospital due to avoidable medicines related safety incidents. • Improved patient outcomes through use of evidence based medicines. • Improved utilisation of prescribing resources to ensure that increased demand for medicines can be met within the allocated budget.
9. Patient and Public Involvement
Aim: To ensure that there is demonstrable involvement in shaping service re-design and developing local services.
Risks/Issues: There are a number of ways that both patients and the wider public can be involved in driving forward service re-design, and in many cases there is the potential to over engage with the same groups of people whilst not always finding out the views of those which are harder to reach. Engagement fails to take place as it is deemed to be too complex, or too challenging. This is deemed an area which the Executive Team are least well developed in relation to achieving world class commissioning competencies (see appendix 1 – for self assessment).
Current Situation: There is an acknowledgement of the need to ensure that actively seeking wider public and patient support in developing and shaping services, is something that becomes a fundamental part of service re-design. There are a number of groups, methods and processes which would support this and provide a comprehensive and inclusive approach. There are a number of ways that patients/carers and the public can be actively involved, and often one type of approach is used as opposed to the most suitable to support the end outcome.
Proposals: Work in partnership to maximise the opportunities for ensuring that services are shaped and developed through accessing a range of appropriate methods to underpin this. Explore fully the most effective ways to underpin wider involvement in shaping and re-designing services e.g. Broader engagement with children & young people locally. Link into the locality based events where these can be an opportunity to develop locally based services which address some of the broader determinants of health. Page 25 of 46 Three Valleys Consortium, PBC Plan 2010/11
Expected Outcomes: • Demonstrable evidence of involvement of the wider public and patient groups in shaping and developing services. • Measurement of impact of changes to services demonstrated. • Agreed action plan setting out key ways of working with partner organisations and groups to achieve this. • Active participation in locality events, where appropriate.
10. Organisational Development Aim: To devise an overarching framework to support the development and training needs of the Executive team, the wider consortium practice teams and PBC/PCT aligned staff to support and sustain progression towards a whole systems approach to commissioning, underpinned by World Class competencies.
Risks: In driving forward the commissioning agenda, to affect the level of change required for example in many aspects of LTC management there will be a need to address cultures and expectations, not only of patients, carers and the public but also within and across professional groups. This is particularly relevant for example in moving towards a culture of person centred, self managed care underpinned by health needs assessment, and a drive towards focusing on longer term health outcomes as opposed to short term invest to save principles. Practices are constantly facing new challenges and embracing change occurs on an ongoing basis, however in terms of embracing the level of transformational change required to facilitate a shift towards the above approach there is a need for re-design of existing pathways and an overall shift in cultures and behaviours. Production of an overarching framework setting out the development and training plans for the Executive Team, Consortium practice teams and the PBC team.
Current Situation: The Executive Team has pioneered an apprenticeship approach to recruiting and supporting potential Executive Team members. The benefits of this are that apprentices have the opportunity to make an more informed choice over a period of weeks, as to whether this is an areas in which they want to participate in. There is also opportunity to review past learning and utilise this to move forward in an effective and efficient way to focus on key priorities which will make the biggest impact.
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Proposals: To continue to run twice yearly “away day” sessions for the Executive Team to develop and enhance the skills within the team, plan ongoing priorities for the wider team to ensure a sustainable approach to commissioning. To continue to learn from and develop the Plenary sessions to incorporate identified clinical and commissioning priorities as areas to focus on and share learning amongst practice teams. To actively engage with the Commissioning College, and the wider system of commissioning to be able to underpin the ongoing development for the Consortium. Continue Practice Nurse Development sessions to support on going clinical development and increased understanding of the impact of PBC. Member of the Executive Team continues to participate in Kirklees Way. Performance management of Commissioning Consortium against the relevant World Class Commissioning Competencies.
Expected Outcomes: • Production of an overarching framework setting out the development and training plans for the Executive Team, consortium practice teams and the PBC team. • Ongoing active clinical leadership demonstrable. • Away days planned for Executive Team, with clear outcomes. • Demonstrable continued engagement of the wider practice teams in the PBC agenda.
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11. Education, Training & Governance
Aim: To develop a framework which underpins the training and education of the wider practice teams to support the PBC agenda and improvements/re-design in clinical pathways.
Proposals: To continue to build on the existing programmes in place which have created a platform on which to enhance the knowledge and skills across the workforce. This will support integrated working across teams and maximise the specific skills and expertise. Practice Based Courses for Practice Nurses – this is a pilot programme which aims to ensure that practice nurses are integral to the PBC agenda, and enable them to participate in monthly sessions out of practice to develop professionally, update on key clinical areas and share learning. Plenary sessions –supporting the ongoing development of PBC and also setting out a programme of clinical based table top discussions to underpin shared leaning and support priority areas. Practice Masterclass - this will support all practices coming together on a quarterly basis and will provide some opportunity to move forward on joint areas in relation to PBC and the Financial Incentive Scheme for example. To explore the feasibility of providing Brief Interventions training in an accessible format across the 10 constituent practices. This will ensure that at least one practitioner from every practice has undergone this training, and will also enhance learning through peer support and shared learning. To ensure that there are clear frameworks in place to underpin all commissioned activity. Issues: Ability to free up clinical time to participate in ongoing training and education. Plenary sessions need to continue to meet the needs of practice teams and support the PBC agenda. Options to commission training that is accessible, provided in a timely way may inhibit ability to optimise “buy in” from constituent practices/individuals. Expected Outcomes: • Delivery of planned programme for practice nurses, with evaluation and options to continue this on an ongoing basis. • Identified number of clinicians accessing Brief Interventions training. • Evaluation of plenary sessions demonstrating ongoing participation and perceived benefit from this participation. Page 28 of 46 Three Valleys Consortium, PBC Plan 2010/11
ACTION PLAN â€“ COMMISSIONING PRIORITIES
Identify priority areas where the Executive Team can actively contribute on a wider basis Agree nominated representatives to attend the Commissioning College Agree specific HITs, which support the priority areas for the Commissioning Consortium
Sustainability of locally commissioned services
Identify priority order and timescales for evaluation April in line with QIPP priorities 2010
Identify and agree a clear framework for patient/carer engagement â€“ identify structured approach for feedback
Identify communication plan for feedback to Consortium members and wider commissioning community
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ACTION PLAN â€“ COMMISSIONING PRIORITIES
Complete project plan and identify timescales
Undertake audit across practices
June 10 July 10
Review and audit the management of identified respiratory conditions
Review current data/audit information Aug 10 Agree action plan Nov 10 Clinical workshop based sessions Feb 10 Evaluation of effectiveness 4
Review the current processes for prescribing appliances e.g. stoma, catheters
Complete project plan and identify timescales Undertake audit across practices Review current data/audit information Agree action plan Clinical workshop based sessions Evaluation of effectiveness
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May 10 June 10 July 10 Aug 10 Nov 10 Feb 10
ACTION PLAN â€“ COMMISSIONING PRIORITIES
Participation in Kirklees Way â€“ reviewing hospital admission/re-admission processes for elderly people
Continue to participate in the Kirklees Way project based approach to review hospital admissions/readmissions Identify communication plan for feedback to the Executive Team and wider engagement with constituent practices
Agree action plan with practices, timescales and proposals for on going work.
Patient and Public Involvement
To identify timescale for PCT led PPI workshops Work with practices to increase understanding and commitment to improve level of engagement/involvement Develop an action plan to identify most effective ways of ensuring ongoing service improvements are underpinned by appropriate engagement.
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ACTION PLAN – COMMISSIONING PRIORITIES
Participation in pilot of “Lets Get Moving” Physical Activity programmes prior to roll out across Kirklees
Complete project plan and identify timescales Complete communication plan Identify key stakeholders Agree action plan Evaluation
May 10 May 10 May 10 June 10
Review and audit of the referral and management patterns for musculo-skeletal gastroenterological conditions
Complete project plan and identify timescales Undertake audit across practices Review current data/audit information Agree action plan Clinical workshop based sessions Evaluation of effectiveness
May 10 June 10 July 10 Aug 10 Nov 10 Feb 10
Paediatric Primary Care Based Services
Review project plan and timescales
Completion and submission of business case,
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ACTION PLAN – COMMISSIONING PRIORITIES
working in partnership with PCT colleagues
Continue to work with Children and Young People’s Partnership Board
Working in partnership to support the development of agreed pathways e.g. asthma
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PBC World Class Commissioning Competencies Three Valleys Self Assessment rd 23 March 2010 Page 34 of 46 Three Valleys Consortium, PBC Plan 2010/11
Executive members of the consortium or stand alone practice have identified their training and development needs in commissioning
Executive members of the consortium or stand alone practice are actively participating in training and development about commissioning.
Methods for succession planning and attracting new executive members have been identified and implemented
(WCC 1c Position as an employer of choice)
Competency 2 (WCC 2a Creation of LAA based on joint needs)
The consortium or stand alone practice demonstrate awareness of JSNA/ Local area agreement priorities
The consortium or stand alone practice work with partners to agree and reconfirm JSNA/Local area agreement priorities
Constituent practices are participating in training and development programmes for PBC
Practices attend Plenary meetings, some have attended PBC training, some have attended NAPC event. To continue at this level we need to run the apprenticeship scheme.
The consortium or stand alone practice demonstrate clear joint leadership and engagement in creating, reconfirming and delivering JSNA/LAA
2009/10 Commissioning Plan contained parts of the JSNA.
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ACTION: Advertise apprentice scheme within next 3 months and add to May Plenary Agenda.
(WCC 2c â€“ Ability to conduct constructive partnerships)
The consortium or stand alone practice have worked with partners to produce a JSNA which assesses the health needs of the population
The consortium or stand alone practice have worked constructively and effectively with partners to produce a high quality JSNA which identifies the health needs of the population
The consortium or stand alone practice have worked with partners to assess impact on health outcomes
Actively work with Public Health to work on the outcomes of the JSNA.
The consortium or stand alone practice have developed partnerships across a range of settings to support and deliver the health and well being agenda. Competency 3 (WCC 3b Public and patient engagement)
The consortium or stand alone practice have a plan in place to actively engage patients and the public in commissioning of services
The consortium or stand alone practice formally and regularly involve patients and the public in review of services
The consortium or stand alone practice systematically collects, collates and uses individual patient and carer insights (e.g. individual feedback)
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Identify areas of redesign and then consult with PPI in how to involve the public.
Competency 4 (WCC 4a Clinical Engagement)
The consortium or stand alone practice contribute to the development of PCT strategic plan
Information from patients and the public is: Actively investigated Actively used in provider performance management discussions Has a direct impact on improving quality and health outcomes
The consortium or stand alone practice can demonstrate how proactive engagement with the local community is embedded in all commissioning processes and drives decision making
The consortium or stand alone practice can demonstrate how they work with patient forums and voluntary groups to capture patient/public views which have affected commissioning plans The consortium or stand alone practice are actively engaged in the development of PCT Strategic plan
The consortium or stand alone practice jointly lead development of PCT Strategic plan.
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Happy to stay on level 3. The consortium will continue to participate at Commissioning College and Kirklees Way.
(WCC 4b Dissemination of information to support clinical decision making)
The consortium or stand alone practice review information on health outcomes, activity, finance, quality and patient experience
The consortium or stand alone practice are actively engaged in agreeing priorities with the PCT for local quality and efficiency improvements The consortium or stand alone practice are actively and regularly engaged with secondary care clinicians to support commissioning The consortium or stand alone practice regularly and systematically review information on health outcomes, activity, finance, quality and patient experience
The consortium or stand alone practice participate in agreeing the local incentive scheme
The consortium or stand alone practice identify and jointly shape quality and efficiency improvement priorities with the PCT.
The consortium or stand alone practice take appropriate action based upon review of information on health outcomes, activity, finance, quality and patient experience.
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The consortium or stand alone practice identify health budgets which would be appropriate for devolution.
The consortium or stand alone practice jointly agree and sign the PCT:PBC agreement (compact) Constituent practices of the consortium or stand alone practice are aware that: There is a local incentive scheme in place They have an indicative budget Their consortium has agreed a commissioning plan with the PCT (WCC 4c Reputation as a leader of Clinical Engagement)
The consortium or stand alone practice demonstrate engagement in service redesign.
The consortium or stand alone practice actively inform and drive strategic planning, service redesign, quality improvement and innovation and efficient and effective use of
The consortium or stand alone practice jointly lead strategic planning, service redesign, quality improvement and innovation and efficient and effective use of resources
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The consortium or stand alone practice produce an annual commissioning plan.
The consortium or stand alone practice have a declaration of interest register identifying potential conflicts of interest. Competency 5 (WCC 5a Analytical skills and insights)
The consortium or stand alone practice are aware of the health needs and health inequalities affecting local population
The consortium or stand alone practice actively involved in identifying health needs and health inequalities affecting local population
The consortium or stand alone practice analyse effectiveness of past interventions e.g. services redesigned through business cases
Continue to analyse our business cases.
The consortium or stand alone practice engage with population risk stratification (WCC 5c Use of Health Needs benchmarks)
The consortium or stand alone practice and constituent practices benchmark against local practices
The consortium or stand alone practice and constituent practices benchmark against local practices on secondary
The consortium or stand alone practice have developed and implemented plans to address areas where
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The Consortium will endeavour to find data.
on secondary care activity and prescribing
care activity and prescribing
targets are not achieved.
The consortium or stand alone practice benchmark against national targets Competency 6 (WCC 6b Prioritisation of investment and disinvestment to improve populationâ€™s health)
Competency 7 (WCC 7c Creation of effective choices for patients)
The consortium or stand alone practice are aware of the criteria for prioritising invest and disinvestment and make proposals in line with this.
The consortium or stand alone practice work with the PCT to agree criteria for prioritising invest and disinvestment
The Consortium or stand alone practice regularly review the choice patients have.
The consortium or stand alone practice works with the PCT to increase uptake of choice at practice level
The consortium or stand alone practice participate in evaluating strategic initiatives
Bring format to exec.
The consortium or stand alone practice jointly lead decision making for development, implementation and evaluation of investment and disinvestment proposals
The consortium or stand alone practice explicitly and regularly tests with practices the acceptability of choice available.
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Regularly review via Choose & Book, this is a PCT wide issue. Consortium would like to become a level 2.
The constituent practices or the stand alone practice make information available for patients to exercise choice Competency 8 (WCC 8a Identification of improvement opportunities)
The consortium or stand alone practice participates in clinical pathway redesign
The consortium or stand alone practice proactively and regularly reviews and agrees clinical pathways
The consortium or stand alone practice proactively and regularly identifies opportunities for improvement and innovation based on best practice
(WCC 8c Collection of quality and outcome information)
The consortium or stand alone practice is aware of quality standards and performance monitoring arrangements with providers
The consortium or stand alone practice alerts the PCT to performance issues to enable challenges with providers
The consortium or stand alone practice jointly agrees quality standards and target setting based upon clinical evidence.
The consortium or stand alone practice actively participates in contract performance monitoring and negotiations.
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Competency 9 (WCC 9b Negotiation of contracts around defined variables) and (WCC 9c Creation of robust contracts based on outcomes) Competency 10 (WCC 10b Implementation of regular provider discussions)
The consortium or stand alone practice understands contracting and procurement processes
The consortium or stand alone practice is engaged in developing outcome based service specifications and in review of finalisation of contracts
The consortium or stand alone practice jointly develops clearly specified measureable and practical outcomes and quality metrics for contracts.
The consortium or stand alone practice understands the need to review performance against contracts at speciality and practice level
The consortium or stand alone practice contributes to PCT systems and processes to review performance of key providers
The consortium or stand alone practice jointly agrees systems and processes to review performance of key providers.
. The consortium or stand alone practice identifies areas and practices for further investigation and action
The consortium or stand alone practice jointly leads performance discussions with both secondary care and primary care providers leading to positive demonstrable change.
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Competency 11 (WCC 11b Identifying opportunities to maximise efficiency and effectiveness of spend)
The consortium or stand alone practice contributes to identifying opportunities for improving efficiency and effectiveness of spend
The consortium or stand alone practice contributes to identifying opportunities for improving efficiency and effectiveness of spend
The consortium or stand alone practice contributes to identifying duplicate and non added value interventions
The consortium or stand alone practice jointly and proactively identifies opportunities improving efficiency and effectiveness of spend . The consortium or stand alone practice jointly and proactively identifies duplicate and non added value interventions
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3VCC All Providers - 2009/10 YTD Day Case by HRG Chapter Spe cialty/Cha pter H - H - Musculoskeletal System F - F - Digestive System B - B - Eyes and Periorbita J - J - Skin, Breast and Burns L - L - Urinary Tract and Male Reproductive System E - E - Cardiac Surgery and Primary Cardiac Conditions P - P - Diseases of Childhood and Neonates A - A - Nervous System W - W - Immunology, Infectious Diseases and other contacts with Health Services Q - Q - Vascular System S - S - Haematology, Chemotherapy, Radiotherapy and Specialist Palliative Care Other Grand Tota l
Budge t £ 479,656 571,961 249,048 153,654 208,042 87,913 12,501 157,868 56,340 29,994 59,801 439,898 2,506,677
Actual £ 660,851 736,827 339,222 219,594 260,837 130,180 44,226 187,516 83,599 56,398 83,246 435,042 3,237,538
VARIANCE - OVER/(UNDER) SPEND 200,000
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VARIANCE OVER/(UNDER) SPEND £ 181,195 164,866 90,175 65,939 52,795 42,267 31,725 29,648 27,259 26,404 23,445 (4,856) 730,861
3VCC All Providers - 2009/10 YTD Electives by HRG Chapter Specialty/Chapter
Budget £ 1,085,318 157,118 374,887 163,141 151,003 22,862 54,656 603,469 323,727
H - H - Musculoskeletal System J - J - Skin, Breast and Burns F - F - Digestive System C - C - Mouth Head Neck and Ears E - E - Cardiac Surgery and Primary Cardiac Conditions D - D - Respiratory System A - A - Nervous System Other Variance <£20k L - L - Urinary Tract and Male Reproductive System Grand Total
Actual £ 1,370,732 272,271 483,208 267,994 221,260 56,355 86,516 575,990 280,254 3,614,580
VARIANCE - OVER/(UNDER) SPEND 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 (50,000) (100,000)
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VARIANCE OVER/(UNDER) SPEND £ 285,413 115,153 108,321 104,853 70,257 33,493 31,860 (27,478) (43,473) 678,400