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PRACTICE BASED COMMISSIONING

Dewsbury Doctor Consortium

COMMISSIONING PLAN 2010/2011

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Table of Contents 1. INTRODUCTION

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2. DECIDING THE PRIOIRITIES

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3. COMMISSIONING PRIORITIES AND TARGETS

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4. IMPLEMENTATION TIMETABLE

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5. PERFORMANCE MONITORING

21

6. PATIENT AND PUBLIC INVOLVEMENT

21

7. TRAINING & DEVELOPMENT

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8. RISK MANAGEMENT STRATEGY

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9. USE OF EFFICIENCY GAINS

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Introduction This document sets out the Practice Based Commissioning intentions for Dewsbury Doctors Commissioning Consortium for 20010/11 based on local health needs and an agreed strategic direction for service development through effective service user and public involvement. All the priorities built into this plan have been assessed through QIPP – Quality, Innovation, Productivity and Prevention to identify efficiencies and are all evidence based following work with the PBC Manager, Performance Analyst and Assistant Finance Manager. This plan also links to local and national priorities delivery principles of: • • • • • •

Reducing health inequalities across the population Care provision in the right setting Appropriate access and choice to services Improved clinical outcomes Staff supported and engaged Financial balance and robust management

Background The geographical area covered by Dewsbury Doctors Commissioning Consortium lies across three localities in the North of the Kirklees patch. Within the three localities, there is a varied picture of health profiles across the 4 practices.

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The Consortium consists of four GP Practices covering a total population of 15532 at 1st January 2010. Dr Sarathy has now retired and the practice has closed, leaving 4 member practices for 2010/2011. During 2010/2011, Dr Prasad will retire and we will welcome Dr D’Umbrugio and Dr Blackman to the group who have taken responsibility for the Greenside Practice. Achievements during 2009/2010 The consortia submitted a proposal document to the B&FP during 2009/10 that included a list of 8 areas that they wished to take forward. Peer review was approved and implemented in February 2010. The second meeting in April will also be attended by some of the Stand Alone GP’s as DDC has opened this out to other people to work together. Other areas approved to take forward to a full business case include: Dermatology, Ophthalmology and medicines management For the 3rd year running the consortia has achieved Freed Up Resources and await confirmation as to when these funds can be utilised.

Financial Statement The PCT 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 is 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 on delivering cost efficiencies than there has been in recent years.

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This Consortia Commissioning Plan will support the drive for improved efficiency and productivity whilst maintaining or improving the quality of patient care next year and onwards. Definitions for DDC There is an average list size of relatively young, predominately white and urban/town dwelling population with average percentages of patients belonging to each ethnic group, and average percentages of patients aged 0 – 14 years and 65 years and over. The consortium has average levels of income deprivation. A further breakdown is listed below for the three locality areas. Practice Population Graphs

Consortium (at Dec 09) % % Males Females males females 527 513 538 543 560 599 536 615 602 593 489 509 473 367 288 193 114 54 12 8125

6% 6% 7% 7% 7% 7% 7% 8% 7% 7% 6% 6% 6% 5% 4% 2% 1% 1% 0% 100%

464 517 536 544 509 492 479 506 505 464 400 423 407 317 289 220 161 116 58 7407

Consortium (at Dec 08) % % Males Females males females

6% 7% 7% 7% 7% 7% 6% 7% 7% 6% 5% 6% 5% 4% 4% 3% 2% 2% 1% 100%

502 456 483 457 468 540 473 519 549 490 405 416 395 292 251 154 100 48 7 7005

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6% 6% 6% 6% 6% 7% 6% 6% 7% 6% 5% 5% 5% 4% 3% 2% 1% 1% 0% 86%

415 479 460 447 452 437 422 428 436 383 350 357 339 268 239 184 123 108 52 6379

7% 8% 7% 7% 7% 7% 7% 7% 7% 6% 5% 6% 5% 4% 4% 3% 2% 2% 1% 100%


90 and Over

% Males

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 10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Practice-Level Cluster for Yorkshire and Humber Yorkshire and Humber Public Health Observatory (YHPHO) has developed practice-level clusters for the Yorkshire and Humber region. Practice population characteristics have been used to define clusters of practices sharing similar characteristics to aid comparisons of data between practices – these allow for more relevant comparison of practices that are within the same cluster. The characteristics chosen to define the practice-level clusters were: practice list size; age; sex; ethnicity; deprivation and geography (urban/rural). For this Consortia, 3 of the practices fall into the same category of Lilac, therefore demonstrating very similar demographics however Greenside is Yellow. This means that when looking at data for all four practices and looking at implementing service, the consortia will take into account this difference when working with the Performance Analyst. Individual Practice Breakdowns

Practice

1

2

Albion Mount Medical Practice, Dewsbury – B85646 Slaithwaite Road Medical Centre, Dewsbury – B85606

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Cluster Colour (Y&H Observatory)

Population

Lilac

5778

Lilac

5255


Cherry Tree Surgery, Batley – B85655 Dr Prasad, Cleckheaton (Dr D’Ambrugio and Dr Blackman) Total

3 4

Lilac

Yellow

2404 2095 15532

Health Improvement Teams: Dewsbury Consortium has clinical leads working with the HIT teams: HIT Cardiology

Clinical Lead Dr Thimmegowda

Research / deciding on the priorities An exercise to identify the areas of most activity and spend has been undertaken, with the PBC team including both Performance Analyst and Assistant Finance Manager. Working together we have identified and agreed the areas of priority. The majority of over activity falls in the categories of Elective and Follow ups. VARIANCE - OVER/(UNDER) SPEND 200,000

150,000

100,000

50,000

0 Electives

Follow-up Standard Day Case

A & E High Cost A & E Standard Attendances Emerg/Non-Electives First Seen Planned Follow-up Planned A & E Minor First Seen Standard Attendances Attendances

(50,000)

(100,000)

(150,000)

(200,000) VARIANCE - OVER/(UNDER) SPEND

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On breaking down the elective activity, this report shows the category overspend: 60,000

MID YORKSHIRE HOSPITALS NHS TRUST 50,000

40,000

30,000

20,000

10,000

0

E - E - Cardiac Surgery and Primary Cardiac Conditions M - M - Female Reproductive System and Assisted Reproduction K - K - Endocrine and Metabolic System L - L - Urinary Tract and Male Reproductive System A - A - Nervous System B - B - Eyes and Periorbita N - N - Obstetrics

M - M - Female Reproductive System and Assisted Reproduction

F - F - Digestive System

C - C - Mouth Head Neck and Ears

D - D - Respiratory System

P - P - Diseases of Childhood and Neonates

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U - U - Undefined Groups D - D - Respiratory System

P - P - Diseases of Childhood and Neonates

Q - Q - Vascular System

W - W - Immunology, Infectious Diseases and other contacts with Health Services

S - S - Haematology, Chemotherapy, Radiotherapy and Specialist Palliative Care

VARIANCE - OVER/(UNDER) SPEND

G - G - Hepatobiliary and Pancreatic System J - J - Skin, Breast and Burns

MID YORKSHIRE HOSPITALS NHS TRUST 50,000

VARIANCE - OVER/(UNDER) SPEND

H - H - Musculoskeletal System

(10,000)

F - F - Digestive System C - C - Mouth Head Neck and Ears

(20,000)

H - H - Musculoskeletal System (10,000)

Outside of Mid Yorks, the activity is similar:

40,000

30,000

20,000

10,000

0


On review of the financial forecast and activity and the JSNA, the consortia has decided to concentrate its priorities on: • • • • •

MSK – due to it being the highest area of over activity Ophthalmology Dermatology Tackling and Reducing Obesity Reviewing the 4 highest areas of overtrade and activity both in activity and financial costs – as detailed above and in the performance analysis reports

The Joint Strategic Needs Assessment (JSNA) For the Dewsbury, Batley and Spen Localities – those in bold are significantly worse than Kirklees average: Children and Young People JSNA Infant Deaths - under 1 year – per 1000

Spen

Batley

Dewsbury

8.5

8.5

9.3

Infants deaths – still births – per 1000 Average number of decayed teeth, under 5 yrs – per 1000 Physically Inactive – 14 year olds more than 60 mins a day

Fewer than 5

Fewer than 5

6.7

2.2

3.8

3

322

292

323

More than 30 mins a day Smoking Weekly – per 1000 14 year olds smoking weekly or more Using Drugs – per 1000 14 year olds taking drugs monthly Teenage Pregnancies – per 1000

289

325

340

162

150

154

55

34

49

45.6

42.4

51.3

236

405

331

557

491

470

Children in households claiming CTC or WTC per 1000 claiming benefits Achievement at early years foundation stage – per 1000 do not achieve

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5 GCSE A*-C inc English and Maths. Males achieve per 1000 Females achieve per 1000 Obesity 11 year Olds Adults JSNA Life Expectancy at Birth Males Life Expectancy at Birth Females Heart Disease aged under 65 – per 1000 Stroke – per 1000 under 65

377

381

356

434

430

462

189 Kirklees against 183 National per 1000 Batley 76.1

Spen 76.6

Dewsbury 75.6 years

79.4

80.2

79.9 female

33

31

38

10

5

13

Per 1000 over 65

39

28

Diabetes – per 1000 over 17

79

20 (better than Kirklees) 74

52

56

66

169

130

175

216

205

241

201

213

200

340 1.21

359 1.09

345 1.2

1.59

1.55

1.76

219

204

250

287

278

260

91

Under 65 Over 65 Depression, Anxiety and nervous illnesses – per 1000 aged over 17 Obesity – per 1000 BMI over 30 Per 1000 overweight Cancer deaths under 75 years – per 1000 Deaths all causes 15-64 years – per 1000 Smoking per 1000 – at least 1 day Enough Physical Activity – per 1000 undertake at least 30 minutes 5 times a week

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Commissioning Priorities and Targets Priority area No.1

Ophthalmology

Aims To implement a primary care service for DDC practices and other North Kirklees Practices to reduce secondary care activity and triage GOS18 to reduce referrals. To include: Removal surgically, small lumps and bumps from the eye e.g. chalazion and other cysts • Provided in one practice with an inter practice referral scheme – or any willing provider opportunity • Triage GS018 to see if referral needed and prevent unnecessary referral • •

Issues • •

Activity of DDC is not high enough to warrant its own service, therefore needs expanding to all North Kirklees Training costs would need to be included – refresher needed

Current position Three meetings have been undertaken with the data reviewed, this has identified that the possible primary care services for the 4 practices is not sufficient to warrant a half day session. The group has therefore met with NKCC chair Dr David Kelly and agreed to take forward a service together. Consultant Ophthalmic Surgeon is meeting with the group in April to discuss the next steps. The planned care lead has also offered support to bring this case to fruition. • •

Current secondary care services are overwhelmed and it is difficult to secure appointments in DDH In other providers the current wait time is more than 40 days

Proposal: • • • •

Identify activity and capacity, cost benefit and raise business case Implement inter practice referral at one practice for patients to be referred to To set up other services in Primary care headed by a consultant and supported by other clinicians It will be possible eventually to transform selective follow up cases from secondary care to primary care, initially for the consortia and eventually for the North area To provide 20 to 30 appointments per week

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Expected Outcomes/ Performance Indicators: • • • • •

Reduced ophthalmology referrals to secondary care Reduced referrals due to triage of GOS18 Service to be provided locally in the community Service to be provided efficiently and professionally reducing wait times Cost effective service resulting in savings for future expansion of the service

Priority area No.2 – Tackling and preventing Obesity Aims To work with an identified group of patients to tackle obesity and help reduce BMI and increase activity to improve overall general health of these patients. This should also promote prevention of obesity in patients. A minimum of 1 of the 4 practices will joint the pilot scheme with Kirklees council for 1 year. Issues : The motivation of some patients to take the action needed to tackle this area and the secondary effects on health due to weight issues. Current position: The Consortia has a high prevalence of obesity with 2088 patients with a BMI over 30. Cherry Tree = 307 Greenside = 373 Slaithwaite Road = 794 Albion Mount = 615 The JSNA identifies the following areas as having inequalities in these areas: • • •

females between 18-44, all males and females between 45-74 black obese

It also identifies the following groups as having particular issues in these areas: • • • •

Those with a physical disability CVD and Stroke patients Patients with pain Diabetic and Asthma patients

This is also to identify patients who may fit into the ‘Let’s get moving’ commissioned service during 2010/2011

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Proposal • •

A named nurse will take the lead for the service. Working with Kirklees Council and the Public Health Team, we will implement a weight management clinic for patients with a BMI over 30, those with Long Term Conditions that affect or are affected by obesity and also target other overweight patients who may be identified as needing this service. Healthy lifestyle interventions will be identified as part of this service. Consideration will also be given to identifying if this is a service that can be undertaken in a community pharmacy setting.

Expected Outcomes/ Performance Indicators: • • •

To reduce the rate per thousand of patients registered with a BMI of over 30 by 1% To reduce the incidences of secondary care activity through improved health and weight management with this cohort of identified patients Increase the activity levels of the identified patients by 30 minutes per week

Priority area No. 3 - Dermatology Aims To manage patients with common skin problems who presently attend secondary care: 1. atopic eczema treatment and management working with dermatology nurse service; 2. psoriasis including patients receiving methotrexate or cyclosporin; 3. acne including initiating and managing roaccutane treatment 4. triaging other skin conditions which may reduce secondary care referral Issues • • • • •

Equipment: dermatoscope ( price range £400 to over £1000) and other equipment (usual items e.g. curettes, sutures, local anaesthetic etc) liquid nitrogen availability and safe storage for cryotherapy for certain skin conditions e.g. solar keratosis operating room for excision etc additional nursing time additional doctor time and doctor to train for the position: o need to do an accredited course in dermatology eg Diploma in Practical Dermatology (DPD) which is a 12 month on line course with few days attendances at Cardiff University; o half day locum per week to allow the doctor to study and attend local dermatology clinic o full day locum to allow doctor to go to Cardiff when needed

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o course fee of £3495

Current position Data from secondary dermatology care not available. Information from Claire Birkby (email dated 25th Feb ) includes procedures done at hospital and we do not have data for e.g. follow-ups for psoriasis and eczema and other first attendances for the same or possible cases that could have been treated in surgery, patients on roaccutane therapy or methotrexate treatment for psoriasis.

Proposal • • • •

Review patient data to identify what services could be undertaken in primary care Identify the activity and capacity requirements Identify cost benefit analysis and method of implementation Raise business case

Expected Outcomes/ Performance Indicators If 150 patients were dealt with in the first year without secondary care referral, which is 3 patients per week, this would produce a saving against secondary care. This service would be opened up to other surgeries. In addition the service would need to see a further 3 patients to cover costs of doctor time and hence any further consultations which do not need secondary care would benefit • • • • • •

Reduced referrals to secondary care Implemented efficient service providing patient choice and closer to home service Financial efficiencies Reduced wait times Reduce secondary care follow ups Commission to provide internally

Priority area No.4 – MSK – including Orthopaedics Aims One of our main priorities in 2010 is ensuring that our management and more specifically indications for secondary care referral of Musculoskeletal conditions are in line with national evidence-based guidelines. Our focus on MSK conditions has been prompted by 09/10 financial data

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Issues • •

Availability of clinicians to join a district wide group to review MSK Views and suggestions being heard in a wider group

Current position The consortia currently has an increase in activity from 2008/9 to 2009/10 from 11.56 procedures per 1000 patients rising to 14.80 procedures, a 28% increase in activity and a 12% increase in cost, spending over £521k between April and September 2009. These are mixed across the practices and therefore activity will include reviewing how each practice works differently in this area and sharing best practice. This is broken down as follows: Practice Greenside Albion Mount Cherry Tree Slaithwaite Road

Activity 14.17 per 1000 (1% increase) 18.05 per 1000 (72% increase) 19.50 per 1000 (19% increase) 9.32 per 1000 (2% decrease)

Cost 6% reduction in cost 49% cost increase 43% increase in cost -33% reduction in cost

Proposal • • • •

To participate in the district wide review of MSK, working with Sue Richardson, the appointed lead for MSK To review our own data and identify any ideas for changes especially in the area where there is a gap between activity across practices Share best practice Input clinically to the process and provide clinical advice in these areas

Expected Outcomes/ Performance indicators • •

Recommended new service Participation to advise and implement the service

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Priority area No.5 – Review of highest activity and cost areas Aims: To use the financial information available to review the following areas of increased activity and these will be undertaken within the verification exercises: • • • •

Nervous System – chapter A Skin, Breast and Bones – Chapter J Vascular System – Chapter Q Immunology, Infectious Diseases and Other Contract Areas – Chapter W

Issues: Insufficient time available to review the information A possibility of no meaningful outcome to the findings Current Position: There are currently high levels of activity in relation to Mid Yorkshire Trust Particularly around day cases. • • •

Chapter A – Nervous System – There has been a 43% increase in activity and but an 18% decrease in cost Chapter J – Skin, Breast and Bones – there is a 110% increase in day cases, a 125% increase in elective and an 88% increase in cost Chapter Q – Vascular System – a 1002% increase in day cases has resulted in a 886% increase in cost. A 80% increase in elective activity has resulted in a 163% increase in cost and a 201% increase in first seen standard has resulted in an increased cost of 142% W Chapter – Immunology and other contract areas – A 99% increase in follow ups and a 92% increase in non electives has resulted in a 100% and 96% increase in costs respectively.

Proposal: • To take a verification approach to this data, undertaking 1 per quarter • To work with the performance analysts to identify the information to review • To review, report and discuss our findings with the PBC Manager and the team • To identify any changes in how these are handled, or identify any coding issues • To recommend any district wide initiatives that may be needed and identify any pathway changes that could be made to create efficiencies. Expected Outcomes/ Performance indicators • • •

Review of one per quarter and all 4 in the year 10/11 Findings to be completed onto dedicated and approved templates Activity to be undertaken by all 4 practices within the consortia

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Brief outline of rationale for choosing target

Ophthalmolo gy

Tackling and preventing Obesity

To tackle obesity and help reduce BMI and increase activity to improve overall general health of these patients. The practice has a high prevalence of obesity with 2088 patients with a BMI over 30

Detailed actions required to achieve target

Complet ion Date

Target 1

Description

Identify activity and capacity, cost benefit and raise business case

1 June 2010

Implement inter practice referral at one practice for patients to be referred to

1 September 2010

• •

1/6/10 A named nurse will take the lead for the service Working with Kirklees Council 1/6/10 and the Public Health Team, we will implement a weight management clinic for patients with a BMI over 30, those with Long Term Conditions that affect or are affected by obesity and also target other overweight patients who may be identified as needing this service A minimum of 1 practice will join the pilot

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Nominated lead

Key links

Dr Sood

Consultant

Dr Gowda Alison Moorby – Kirklees Council


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4

Dermatology

MSK

Healthy lifestyle interventions will be identified as part of this service. Consideration will also be given to identifying if this is a service that can be undertaken in a community pharmacy setting Review patient data to identify what services could be undertaken in primary care

30/4/10

Dr Patel

Consultant

Identify the activity and capacity requirements

30/4/10

Performance Analyst

Identify cost benefit analysis and method of implementation

30/5/10

Finance and PBC Manager

Identify cost benefit analysis and method of implementation

30/5/10

PBC Manager and Facilitator

To participate in the district wide review of MSK, working with Sue Richardson, the appointed lead for MSK

To be Dr D’Ambrugio confirmed by and Dr planned care Blackman lead

Planned Care Lead

To review our own data and identify any ideas for changes especially in the area where there is a gap between activity across practices

30/6/10

PBC Manager, Performance Analyst and Facilitator

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5 Review of Highest Activity Areas

To use the financial information available to review the following areas of increased activity and these will be undertaken within the verification exercises: •

Nervous System – chapter A Skin, Breast and Bones –

Share best practice

30/9/10

Input clinically to the process and provide clinical advice in these areas

30/9/10

To take a verification approach to this data, undertaking 1 per quarter

30/6/10

All GP Leads in the Consortia

PBC Team

To work with the performance analysts to identify the information to review

30/8/10

Practice Managers

PBC Team

To review, report and discuss our findings with the PBC Manager and the team

30/10/10

Practice Manager and Lead GP

PBC Team

To identify any changes in how these are handled, or identify any coding issues

30/12/10

Practice Manager working with Performance Analyst and Facilitator

PBC Team

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Planned Care Lead DDC clinical leads


Chapter J Vascular System – Chapter Q Immunolo gy, Infectious Diseases and Other Contract Areas – Chapter W

30/12/10 To recommend any district wide initiatives that may be needed and identify any pathway changes that could be made to create efficiencies.

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Consortia working with PBC Team

PBC Team


PERFORMANCE MONITORING The Consortia will monitor, audit and prioritise each target as identified monthly. Working with the PBC Manager, Performance Analyst and Assistant Finance Manager we will hold a monthly meeting with both Clinical Leads and the Practice Manager to review our present performance and identify where improvements are required. Both a finance pack and performance pack will be reviewed.

PATIENT AND PUBLIC INVOLVEMENT Patient and Public involvement in decision making around services and service redesign has been recognised by the Consortia as a high priority. We are working with the PCT and other recognised agencies to ensure that we are working in partnership to support the development of this process. Two levels of involvement will take place: • •

Consulting with Patients and Public prior to and part of putting together a new service Undertaking quality and experience surveys with patients for ongoing services e.g. for 24 hour BP and Phlebotomy

TRAINING AND DEVELOPMENT We will identify any training and development requirements needed to implement the priorities identified. We will also use the Peer Review events to improve our knowledge and best practice. We will seek any sponsorship to assist the consortia to undertake development sessions during 2010 / 2011.

RISK STRATEGY The practice will endeavour to regularly examine service re design systems in order to identify factors that could potentially cause any detriment to it patients by using risk assessment methodologies to focus on patient safety during the process of service planning, design and implementation.

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RISK 1 Overspend on Indicative PBC budget The Consortia for 2009/10 have spent more on actuals during 2009/10 than previous years and we need to ensure that this trend does not continue and an overspend is prevented: • •

A monthly meeting will take place with the Performance Analyst and PBC Manager and the information will be reviewed Actions will be identified and implemented

RISK 2 Resource to cover PBC and to achieve the Plan The Consortia has limited resource and a risk exists in relation to unexpected absence, we aim to counteract these with: • •

Ensuring all areas of the plan are diarised and actions taken and reviewed in line with this plan For all Practice Managers to participate in the monthly exec meetings and take actions where needed

USE OF FREED UP RESOURCES The present position of the practice indicates that there will be Freed Up Resources achieved in 2010/2011 in addition to the FUR for 2008/9 and 2009/10. Once confirmation is given for the availability of use of these resources, the Consortia plan to resurrect and update thie proposal document issued to the PCT in September 2009 with many ideas for efficiencies and enhancements for patient services. All the priorities identified aim to make this achievable both in activity and financial performance. I confirm that this plan is an accurate representation of the practice’s intentions for PBC for 2010/2011. Signed:

Dr Thimmegowda

- Albion Mount

Dr Patel – Slaithwaite Road

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____________________________ Dr Sood – Cherry Tree

_______________________________ Dr D’Umbrugio / Dr Blackman - Greenside

Date:

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http://www.kirklees.nhs.uk/fileadmin/documents/publications/PBC_Plans/2010_PBC_Plans/DDC_Commissioni