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PRACTICE BASED COMMISSIONING PLAN

LIVERSEDGE HEALTH CENTRE

2010/2011

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Table of Contents

1. INTRODUCTION

3

2. DECIDING THE PRIORITIES

5

3. COMMISSIONING PRIORITIES AND TARGETS

10

4. IMPLEMENTATION TIMETABLE

14

5. TRAINING AND DEVELOPMENT

20

6. RISK MANAGEMENT STRATEGY

20

7. PERFORMANCE MANAGEMENT

21

8. PATIENT AND PUBLIC INVOLVEMENT

22

9. BEST PRACTICE

22

10. USE OF EFFICIENCY GAINS

23

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Introduction

Liversedge Health Centre comprises of a clinical complement of the following four General Practitioners and serves a population of approximately 3435 patients, as at 1 January 2010: GPs Dr Ghafoor Dr Khan Dr Khaliq Dr Nabi The partnership has continued to develop and deliver on core services whilst at the same time recognising the specific needs of its patient population we have designed and tailored new additional services to meet such needs. The practice remains a high achiever of national and local targets and will continue to strive to attain the highest levels possible. In 2010 the practice grew significantly with the movement of over 1100 patients from Dr Sarathy’s practice when he retired. This brought with it a great deal of unmet need and during 2009/10 we have seen a large financial impact on both the prescribing and the hospital indicative budget despite best endeavours to continue our normal practice. In previous years the practice delivered on three additional services for the benefit of its patient population and the subsequent success of this implementation as reflected by favourable clinical outcome data and equally significantly patient feedback information has led to the continued delivery of these services. • • •

Dermatology Cognitive Behavioural Therapy Advanced Minor Surgery

Our biggest success however has been the implementation of a “Long Term Conditions Service” which was formally approved in 2008/09 by the PCT business case committee and is now delivering personalised, responsive, holistic care for people with complex chronic conditions. The impact of this service in terms of both measurable clinical outcome and financial viability has proved significant. We are pleased to announce that following further formal approval by the PCT business case committee we envisage the continuation of this hugely successful service in 2010/11 and aim to continue to drive improvements in this area to secure further Freed Up Resources funding for 2011/2012.

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Vision / Mission Statement Despite the active management of ill patients the practice demographic is such that there are very high levels of morbidity. The graph and table below show the clinical incidence levels. The national norms have then been applied against our practice population to indicate the number of patients more or less we are managing than a practice with the same number of patients in a different geographical area. This makes particularly interesting reading for Coronary Heart Disease, Hypertension, COPD and Obesity. All of which are invariably linked. This is why we have been attempting to treat these conditions holistically. 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. 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 Practice supports the needs for efficient services and the drive for quality and has based this commissioning plan around these priorities and the need to drive efficiency.

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Health Improvement Teams: The Practice has decided on the following HIT team after being invited by the group to participate HIT Dermatology

Clinical Lead Dr Ghafoor

Deciding 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. Many areas of information have been used including deprivation, socio economic status, population and financial and activity data and the JSNA. Practice Population Graphs Practice (at Dec 09) Males

% males

Female s

106 106 106 113 118 127 89 130 165 109 114 93 113 70 77 45 24 17 9 1731

6% 6% 6% 7% 7% 7% 5% 8% 10% 6% 7% 5% 7% 4% 4% 3% 1% 1% 1% 100%

115 100 109 123 110 111 110 115 121 108 90 87 109 73 70 58 47 29 19 1704

Practice (at Dec 08) % female s 7% 6% 6% 7% 6% 7% 6% 7% 7% 6% 5% 5% 6% 4% 4% 3% 3% 2% 1% 100%

5

Males

% males

Female s

% females

81 74 70 76 80 80 64 96 109 66 82 67 62 46 40 32 20 13 4 1162

7% 6% 6% 7% 7% 7% 6% 8% 9% 6% 7% 6% 5% 4% 3% 3% 2% 1% 0% 100%

82 66 84 80 81 77 80 75 75 62 60 67 64 44 44 45 34 15 17 1152

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


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 10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Population has increased by 1121 patients from 08/09 to 09/10, a 32.6% increase. The population in the area presents many diverse needs, including a high proportion of single parent families and very high numbers of elderly patients; Household Type Single parent dependent children

% 23.20

Single parent non-dependent children

0.00

Single person under 60

14.10

Single person aged 60 and above

29.30

Couple with dependent children

13.10

Couple with non-dependent children

3.00

Couple with no children

14.10

Other

3.00

Total

100.00 Source: Kirklees MC Housing Assessment 2006

The average household is made up of 2.19 residents. Unemployment in the area is significantly higher than the national and local levels, as is the proportion of patients who are identified as long term sick or unable to work.

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Cleckheato n and Liversedge

Employment Status

Kirklees

Employed/self-employed full-time

25.70

34.10

Employed/self-employed part-time

8.40

10.90

Unemployed

6.70

4.80

35.80

34.20

Student 16 or over or trainee

0.60

1.00

Looking after family or home

14.50

9.60

Long-term sick/unable to work

6.10

4.00

Other

2.20

1.50

Total

100.00

100.00

Retired

Source: Kirklees MC Housing Assessment 2006 Understanding the practice population and the determinants of their health status is essential to providing health services appropriate to their needs. Our direct involvement of patients in the running of the practice and our detailed knowledge of the social fabric that surrounds us ensures that we are best placed to determine the most appropriate requirements for our patients and as such ideally positioned to ensure that health services are actually delivered to those that require it in a timely, efficient and effective manner.

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

Spen 8.5

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 2.2 322

More than 30 mins a day 289 Smoking Weekly – per 1000 14 year olds smoking weekly or more Using Drugs – per 1000 14 year olds

162

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taking drugs monthly Teenage Pregnancies – per 1000

55 45.6

Children in households claiming CTC or WTC per 1000 claiming benefits Achievement at early years foundation stage – per 1000 do not achieve 5 GCSE A*-C inc English and Maths. Males achieve per 1000

236 557

377

Females achieve per 1000

434

Adults JSNA Life Expectancy at Birth Males Life Expectancy at Birth Females Heart Disease aged under 65 – per 1000 Stroke – per 1000 under 65

Spen 76.6 80.2 31 5

Per 1000 over 65 Diabetes – per 1000 over 17

20 (better than Kirklees) 74

Under 65

56

Over 65 130 Depression, Anxiety and nervous illnesses – per 1000 aged over 17 Obesity – per 1000 BMI over 30

205 213

Per 1000 overweight 359 1.09

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

1.55 204 278

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Activity and Finance Information Activity of 2008/9 v 2009/10 shows increases in activity in many areas, this has been compared using the new and old population numbers to ensure a % like for like comparison Activity Chapter Activity 25.00

20.00

15.00

10.00

5.00

0.00 A

B

C

D

E

F

G

H

J

K

08/09 Per '000

L

M

N

P

Q

S

U

M

N

P

Q

S

U

V

W

(blank)

09/10 Per '000

Cost Chapter Activity 25.00

20.00

15.00

10.00

5.00

0.00 A

B

C

D

E

F

G

H

J

08/09 Per '000

K

L

V

W

(blank)

09/10 Per '000

The largest cost area is MSK and therefore this has been chosen as a priority. Other areas with increased costs and activity include: • • •

Skin, Breast and Burns Haematology Nervous system

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These have been selected as a priority and break down as follows: B85612 Categories Analysis, April - September 2008/09 vs 2009/10

Chapter

J

A

S

Category Day Case Elective Non-elective Emergency Day Case Elective Non-elective Emergency Day Case Elective Non-elective Emergency

Activity 08/09 Actual Per '000 1.7 4 1.3 3 0 0.0 6 2.6 0 0.0 1 0.4 0 0.0 0.4 1 0 0.0 0 0.0 0 0.0 1 0.4

09/10 Actual Per '000 9 2.6 8 2.3 13 3.8 1 0.3 2 0.6 0 0.0 1 0.3 10 2.9 13 3.8 3 0.9 0 0.0 3 0.9

% Variance 51% 80% 100% -89% 100% -100% 100% 573% 100% 100% 0% 102%

Activity

Category Activity Variance

J

A

10

S

Emergency

Non-elective

Elective

Day Case

Emergency

Non-elective

Elective

Day Case

Emergency

Non-elective

Elective

Day Case

650% 600% 550% 500% 450% 400% 350% 300% 250% 200% 150% 100% 50% 0% -50% -100%


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

• • • •

Long term Conditions Achieving the Local Incentive Scheme Targets MSK Review of the top 3 activity areas

Commissioning Priorities and Targets Priority area No.1

- Long Term Conditions Management

Aims Ensuring provision of our “Long Term Conditions Service” is a key priority going into 2010/11. We understand that consolidation is integral to long term success in this respect through continued provision of the following services • • •

Long Term Condition Contact Card (LTC Card) Joint doctor/nurse led chronic disease management clinics Diabetes – insulin initiation and management service

To reduce the level of activity in non electives for a cohort of patients (30) identified to be high users of the service, by education and provision of a Long Term Conditions Contact Card and dedicated telephone number to support, rather than emergency action through A&E Issues • •

Participation of Patients to follow the process These patients have been inherited from another practice and will take time to grow the trust to use the service appropriately

Current position • •

The 2009/10 evaluation of this service resulted in minimal non elective activity and therefore additional patients are being added to the service. A benchmark will be taken of all the patients as at April 2010 to be evaluated against in Dec 2010

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Proposal:

Identify 30 further patients to include in this service for 2010/2011 •

Continue to provide service including maintenance of existing patients and expansion to include further cohort of patients for 2010/2011

Support and progress evaluation of service in December 2010

Using the contact card, patients to utilise the Clinical assistance and service, educating them how to self care and use services appropriately

Expected Outcomes/ Performance Indicators:

New cohort of patients for 2010/2011 added to scheme

Demonstrate saving against investment by end of the year/ point of evaluation

Reduced non elective activity and better management of LTC

Priority area No.2 - MSK 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 Issues : • •

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

Current position:

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Our aim is to monitor the “throughput” of MSK activity from primary care into secondary care and where necessary make more efficient this transit by re designing clinical pathways and re validating clinical skills where indicated. The data indicates that in comparison with 08/09 data, there has been a 700% increase in elective activity, resulting in a 792% increase in costs. Elective activity is slightly higher than the cluster average but not significantly. Emergency activity has increased by 267% year on year, resulting in a 737% increase in associated costs. Both activity and costs for emergency activity is higher than the cluster average. Proposal • • • •

Breakdown the split between existing and inherited patients to see where issues may lie between the two Review the data of these patients to identify any coding issues Review the data of these patients to identify and possible pathway suggestions or improvements Work with the PCT wide lead, to implement a new purpose built service

Expected Outcomes/ Performance Indicators: • •

Recommended new service Participation to advise and implement the service

Priority area No. 3 – Achieve Financial Incentive Scheme Aims To participate in as many areas as possible of the FIS to achieve the best outcomes in all areas and achieve the financial reward Issues Some elements of the targets may be outside the direct control of the practice and therefore full achievement may not be reached. Current position Summary of performance in 2009/10 - to be added in April 2010 Proposal •

Review Financial Incentive Scheme for 2010/2011 in detail and identify appropriate leads to progress work in practice. 13


• •

Work with wider PBC PCT team and PBC Facilitator to ensure that all areas of the scheme and practice level requirements in order to fully achieve targets are clearly understood. Carry out actions as required in practice to ensure compliance with the scheme targets Progress against scheme to be discussed regularly with PBC Facilitator

Expected Outcomes/ Performance Indicators

Practice achieve as many points as possible under 2010/2011 PBC Financial Incentive Scheme

Priority area No.4 – Review of Activity Areas Aims Another priority is a review of the three clinical areas attracting the highest activity in 09/10 (excluding MSK) and these have been identified as being in the following specialities – 1. Nervous System 2. Haematology 3. Skin, Breast and Burns It is our intention to evaluate all available data specific to these clinical areas and monitor levels of activity into secondary care in 2010/11 with a view to tailoring services in order to optimise management of these conditions within primary care, closer to patient’s homes and in accordance with recommended clinical guidelines Issues • •

The review of the data may not result in any change to pathway or activity as they are unavoidable Time availability to undertake the reviews may be limited

Current position Chapter J – There has been a 51% increase in day cases, an 80% increase in Elective activity and a 100% increase in non elective activity. However on a positive note emergency care has dropped by 89% Chapter A – There has been a 100% increase in Day cased and a 100% increase in non elective activity however emergency activity has risen by 573% Chapter S – in 08/09 activity in this chapter was minimal with only 1 emergency in this area, this has risen to 3 and day cases and elective has risen from 0 to 13 14


cases. Proposal

• • •

Evaluate all available data specific to these clinical areas Monitor levels of activity into secondary care in 2010/11 Tailor services in order to optimise management of these conditions within primary care, closer to patient’s homes and in accordance with recommended clinical guidelines

Expected Outcomes/ Performance indicators • • •

Identification of changes to best practice Possible identification of coding issues Tailored services for these areas

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Brief outline of rationale for choosing target

Detailed actions required to achieve target

LTC

Ensuring Identify 30 further patients to provision of our “Long Term include in this service for 2010/2011 Conditions Service” is a key priority going into 2010/11. We • Continue to provide service understand that including maintenance of existing consolidation is integral to long patients and expansion to include term success in this respect further cohort of patients for through continued 2010/2011 provision of the following services -

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Complet ion Date

Target 1

Description

1 April 2010 - complete

31 March 2011 with evaluation Dec 2010

Nominated lead

Key links

Dr Ghafoor

Performance Analyst and Patients

LTC Lead Planned Care Lead


• •

2

MSK

Long Term Condition Contact Card (LTC Card) Joint doctor/nur se led chronic disease managem ent clinics Diabetes – insulin initiation and managem ent service

One of our main priorities in 2010 is ensuring that our management and more specifically indications for secondary care referral of

Reduced non elective activity

31 March 2011

and better management of LTC

Breakdown the split between existing and inherited patients to see where issues may lie between the two

1 April 2010 - complete

Review the data of these patients to identify any coding issues

30 June 2010

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Dr Khan

Performance Analyst and PBC Manager

Performance Analyst


Musculoskeletal conditions are in line with national evidence-based guidelines.

Our focus on MSK conditions has been prompted by 09/10 financial data 3 Achieve Financial Incentive Scheme

To participate in as many areas as possible of the FIS to achieve the best outcomes in all areas and achieve the financial reward

Review the data of these patients to identify and possible pathway suggestions or improvements Work with the PCT wide lead, to implement a new purpose built service

31 August 2010 – or dependant on Planned Care Programme dates

Review Financial Incentive Scheme for 2010/2011 in detail and identify appropriate leads to progress work in practice Work with wider PBC PCT team and PBC Facilitator to ensure that all areas of the scheme and practice level requirements in order to fully achieve targets are clearly understood.

30 April 2010

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31 March 2011

Planned Care Lead and PBC Manager

Julie Clarke

All Practice Clinicians and PBC Manager / Facilitator PBC Facilitator


4 Top 3 Priority areas of activity and Cost Chapter A Chapter S Chapter J

review of the three clinical areas attracting the highest activity in 09/10 (excluding MSK) and these have been identified as being in the following specialities – 1. Nervous System 2. Haematolo gy 3. Skin, Breast and Burns

Carry out actions as required in practice to ensure compliance with the scheme targets

Progress against scheme to be discussed regularly with PBC Facilitator Evaluate all available data specific to these clinical areas

All Practice Clinicians

Meet priorities as laid out on back page of FIS plan 31 March 2011 Split quarterly

Dr Ghafoor

PBC Facilitator and PBC Manager PBC Team Clinicians Practice team

June September December •

Monitor levels of activity into secondary care in 2010/11

Ongoing

Tailor services in order to optimise management of these conditions within primary care, closer to patient’s homes and in accordance with recommended clinical guidelines

31 March 2011

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Practice team and Performance Analyst Patient and Public Involvement PBC Team


Training and Development We strive to achieve the highest clinical standards through continuing professional training and development as evidenced by the following qualifications within our team: 

Diplomas in Diabetes/Dermatology/Family Planning/Obs and Gynae;



MRCGP;



CBT;



BSc in Teaching and Education;



we are current trainers of nursing students (Leeds Institute of Nursing)

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 Management 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.

The practice recognises the clinical risk concerns which have arisen following the dispersal of Dr Sarathy`s list and has taken steps to ensure that it works in collaboration with the PCTs Clinical Risk Advisor in order to ensure any patient safety issues are addressed in accordance with stipulated governance guidelines.

The practice also recognises the as yet unquantifiable impact the incorporation of Dr Sarathy`s patients will have on its PBC budget for not only this current financial year but also for subsequent years and has taken steps to try to buffer itself from any adversity with regards to this.

Performance Monitoring The Practice intends to implement the following measures to ensure that adequate performance monitoring is effectively in place •

The Practice will regularly review data on the GP reporting system web browser 20


to identify referral patterns or trends. Analysis of the data will also allow the Practice to identify trends in secondary care activity and will facilitate drill though and retrieval of useful patient specific activity and financial information. We will continue to provide protected clinical time for all clinicians to attend peer review referral meetings on a monthly basis which will act as a platform for both monitoring of clinical activity but also a useful resource for consolidation of evidence-based best clinical practice. The Practice will monitor its prescribing data using online PACT reporting facility and` will continue to liaise closely with the PCT’s prescribing advisor to ensure that the prescribing is evidence based and in line with best clinical practice. The Practice will meet regularly with its designated PBC commissioning manager in order to monitor its financial and clinical performance and will also regularly attend the PCT’s commissioning college meetings. The Practice will evaluate the interim and annual progress of its LTC service in accordance with the PCTs regulatory guidelines and submit all such reports formally in writing to the PCTs finance and performance monitoring committee for scrutiny and feedback.

Patient and Public Involvement The Practice has been and will continue to be directly involved in patient consultation on the provision of primary care services provided from Liversedge Health Centre. The formation of the Liversedge Patient Action Group (LPAG) in 2007 will continue to be a vital channel which will help to ensure that the practice thoroughly explains Practice Based Commissioning to patients and receives appropriate feedback from patients to ensure that service redesign measures are delivered in accordance with their expectations. The practice PBC clinical lead will continue to meet quarterly with representatives from the Liversedge Patient Action Group (LPAG) and minutes of each meeting will be made available in an open and unrestricted manner. A new and innovative concept will be implemented in 2010/11 in order to enhance patient and public involvement. Questionnaires will be sent to a cohort of selective patients who have been identified as being managed and referred into secondary care for a clinical condition which fits into one of the following four speciality areas (i.e. “KEY PBC PRIORITY AREAS”) : 1. 2. 3. 4.

Musculoskeletal Nervous system Skin, Breast and Burns Haematology

It is envisaged that by attaining feedback on actual patient experience within each of the four selected PBC priority areas the practice will be best placed to tailor service pathways to meet the requirements and expectations of its patients. Two levels of involvement will take place:

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• •

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

Best Practice We as a practice operate in conjunction with the PCT within a Clinical Governance framework that involves: 

having a designated practice Clinical Governance Lead – Dr Ghafoor;



regular attendance at Clinical Governance Lead and PCT meetings;



participation in Clinical Managers/Assistants;



meeting performance targets within the QOF framework including development of long term conditions management protocols and Significant Event analysis;



adherence to evidence based clinical and cost effective best practice within available resources;



adherence to NICE prescribing guidelines. We have regular meetings with the PCT prescribing advisor, during which the appropriateness of prescribing is considered and new drugs and therapeutics are assessed for inclusion within our formulary;



annual assessment of practice performance against Healthcare commission core standards by way of NHS patient surveys and patient involvement forums (Liversedge Patient Action Group);



implementation of risk management protocols at practice level in order to identify areas of risk (clinical, financial and operational) and to establish high levels of safety for patient care and to reduce the risks of injury to patients, staff and visitors;



CPD (Continued Professional Development) of all staff and compliance with the GP appraisal scheme; and



aspiring to the highest standards of probity and accountability.

Audit

in

conjunction

with

PCT

Audit

This Clinical Governance framework functions in partnership with the PCT and other local and national organisations. It enables us to effectively manage risk and maintain robust governance arrangements that ensure that The Partnership is run effectively and efficiently to meet the standards for better health requirements.

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By attending the Kirklees Commissioning College meetings and having regular meetings with the PCT’s PBC Manager, it is anticipated that the Practice will be able to benchmark its performance against that of local consortia and other stand alone Practices.

Use of Freed Up Resources The FUR generated in 2008/09 has helped to finance delivery of the LTC Service to the patients registered with LHC for a further 2 years following successful re evaluation. It is envisaged however that due to the incorporation of the vast majority of Dr Sarathy`s list size in March 2009 there will be a reversal of the past three year trend of under spend and consequent realisation of FUR in adverse favour of an overspend in 2010/11. This is both an unfortunate as well unavoidable reality which we will strive arduously to rectify for subsequent years by focussing on our key PBC priority areas.

I confirm that this plan is an accurate representation of the practice’s intentions for PBC for 2010/2011. Signed:

Dr Ghafoor

Dr Khan

_____________________________ Julie Clarke – Practice Manager

Date:________________________

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