PRACTICE BASED COMMISSIONING PLAN
LIVERSEDGE HEALTH CENTRE 2008/2009
Liversedge Health Centre comprises of a partnership of the following three General Practitioners and serves a population of approximately 2500 patients in the Spen locality:
Dr Ghafoor Dr Khan Dr Khaliq
The Partnership has made a significant impact on the primary care services provided to patients registered with the surgery. We have a strong desire to continue with our plans to develop the services further for the benefit of our patients. The practice is now a high achiever of national and local targets and will continue to strive to attain the highest levels. The services will be developed from a platform of staff involvement and patient engagement and will reflect the role of a practice willing to play its part in the wider health agenda. Specifically we will be directly involved in the commissioning and management of non-primary care services through Practice Based Commissioning and will also seek to improve the health of the population by fully engaging in public health and health promotion activities.
Over the past 12 months the Practice has successfully developed GPSI services in dermatology, cognitive behavioural therapy and advanced minor surgery and is currently working towards developing a feasible strategy for managing long term chronic conditions with the advent of a “Long Term Conditions Contact Card” which provides all our patients
with complex long term conditions, sometimes referred to as “revolving door patients” with details on how to contact a doctor from The Partnership, day or night in relation to their disease. The intention is to provide continuity of care and to try and avoid unnecessary contact with secondary care or the out of hour’s services. The Practice has also extended its opening hours since August 2007 to include early mornings, evenings and Saturday surgeries in order to improve patient access. This was developed as a consequence of feedback from patient surveys which identified the need for better access for employed persons and school children in particularly.
Summary of PBC Key Priorities for 2008/09
1. Long term Conditions The Practice is in the process of submitting a business case designed to provide innovative new additional services for the management of patients with long term conditions which include – • Long Term Condition Contact Card (LTC Card) • Joint doctor/nurse led chronic disease management clinics • Diabetes – insulin initiation and management service
2. Mental Health The provision of in-house Cognitive Behavioural Therapy sessions by our current CBT accredited GP partner â€“ Dr Khaliq. It is our desired intention to continue to provide a CBT service for all our patients in 08/09 and furthermore to appraise the feasibility of offering this service to other practices within North Kirklees the following year.
3. Dermatology Service/Advanced Minor Surgery Service
The provision of an in house dermatology service and an advanced minor surgery service to all registered patients in 08/09.
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.
Clinical Prevalence 2006/7 data - NHS Information Centre Extracted from on-line QOF data Percentage of population with pathology Practice population 2400 patients Clinical area Asthma Atrial Fibrillation Cancer Chronic Kidney Disease COPD Coronary Heart Disease Dementia Diabetes Epilepsy Heart Failure Hypertension Hypothyroidism Learning disabilities Mental health Obesity Palliative Care Stroke & TIA
Expressed as numbers of patients Asthma Atrial Fibrillation Cancer Chronic Kidney Disease COPD Coronary Heart Disease Dementia Diabetes Epilepsy Heart Failure Hypertension Hypothyroidism Learning disabilities Mental health Obesity Palliative Care Stroke & TIA
5.65 1.11 0.6 3.36 2.72 6.38 0.6 4 0.68 0.81 15.77 3.36 0.43 0.72 8.5 0.09 2
National 5.88 1.06 0.74 2.03 1.39 4.1 0.4 3.73 0.57 0.71 11.58 2.38 0.26 0.74 7.63 0.09 1.56
5.77 1.29 0.92 2.38 1.43 3.54 0.4 3.66 0.6 0.78 12.49 2.55 0.26 0.71 7.41 0.1 1.61 National Difference
136 27 14 81 65 153 14 96 16 19 378 81 10 17 204 2 48
Please note, rounding will account for any variance
141 25 18 49 33 98 10 90 14 17 278 57 6 18 183 2 37
138 31 22 57 34 85 10 88 14 19 300 61 6 17 178 2 39
-3 -4 -8 24 31 68 5 8 2 1 79 19 4 0 26 0 9
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
Single parent non-dependent children
Single person under 60
Single person aged 60 and above
Couple with dependent children
Couple with non-dependent children
Couple with no children
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.
Employment Status Employed/self-employed full-time
Cleckheaton and Liversedge
Student 16 or over or trainee
Looking after family or home
Long-term sick/unable to work
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 ensure that we understand how services are best delivered and what will encourage the right patients to attend.
Our PBC strategy for 2008/09 is to consolidate in the areas we have focused upon in 2007/08 in order that we may continue to provide better quality additional services to our patients for the forthcoming year. We will continue to provide the services detailed above in 2008/09 and it is our expectation that the significant financial savings we have realised in the past financial year will be replicated in 2008/09.
COMMISSIONING PRIORITIES & TARGETS
PRIORITY 1 - The Practice intends to submit a business case for the management of Long Term Conditions
Aims 1. To further develop additional innovative services introduced in 07/08 which include the advent of the LTC contact card, doctor/nurse led chronic disease management clinics and Insulin initiation clinics. 2. To enable the practice to better manage chronic conditions clearly identified as a priority area in the JSNA. 3. To realise a reduction in unscheduled and elective secondary care activity in 08/09 based upon improved management of long term conditions.
Issues / Difficulties The business case has already been submitted to the business case clinic in April 2008 and received positive feedback which will hopefully culminate in re submission and acceptance in June 2008. The main risk is that the practice has invested monies in order to develop new services pending PCT approval of its business case and therefore rejection could have a negative financial impact on the practice.
Current Position / Proposal As mentioned above the business case is due to be re submitted to the business case clinic in June 2008. Expected Outcomes / Performance Indicators The business case contains a number of expected performance measures, which includes analysis of unscheduled and elective care activity and annual prescribing costs. It is envisaged within the business case that better management of long term conditions will result in a significant reduction in both elective and non-elective secondary care activity in 08/09.
PRIORITY 2 - Mental Health Service Aims • • •
To enhance primary care mental health service provision Provide Cognitive Behavioural Therapy sessions Identify mental health risk factors at an early stage thus improving clinical outcome.
Issues The practice understands that there is no commissioning tariff for mental health service provision however wishes to pilot a primary care CBT service in 08/09 and appraise its overall impact on clinical outcome and secondary care activity particularly in those patients with chronic conditions. Current Position The practice currently provides a fortnightly CBT service for all its registered patients.
Expected outcomes • Improved access to Cognitive Behavioural Therapy service. • Reduced hospital admissions and decreased length of stay for patients with concomitant long term physical and mental health conditions.
PRIORITY 3 – In House Dermatology/Advanced Minor Surgery Service Aims •
To provide an in house dermatology service
To provide an advanced minor surgery service
Issues The Advanced Minor Surgery/Dermatology Clinic is of particular value to the Primary Care Trust as it has a direct impact on health expenditure by reducing onward referral to secondary care. The service is provided on a fortnightly basis and provides the following :
In house dermatology referrals to practice GPSI accredited with Cardiff Diploma in Clinical Dermatology
wider excisions of histologically confirmed skin cancers (including basal cell carcinomas and squamous cell carcinomas);
punch excision/biopsies of suspected skin cancers;
removal of in-growing toe nails;
excision of sebaceous cysts;
joint aspirations; and
Expected Outcomes Reduction in secondary care first/follow up outpatient activity for Dermatology and significant reduction in day case (surgical) activity and expenditure envisaged for 08/09. Performance indicators will include annual auditing of clinical outcome in accordance with NICE guidelines and British Association of Dermatology guidelines.
PERFORMANCE MONITORING The Practice intends to implement the following measures to ensure that adequate performance monitoring is effectively in place • •
Provide protected clinical time for all clinicians to attend peer review referral meetings. The Practice will regularly review data on the GP reporting system web browser 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. The Practice will also monitor its prescribing data using online PACT reporting facility and will continue to liaise closely with 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 the PBC locality managers in order to monitor its financial and clinical performance and also will regularly attend the PCT’s commissioning forum meetings.
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 meet quarterly with representatives from the Liversedge Patient Action Group (LPAG).
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;
BSc in Teaching and Education;
we are current trainers of nursing students (Leeds Institute of Nursing)
RISK MANAGEMENT STRATEGY
KEY RISK 1 Business case (Long Term Conditions) is rejected by the PCT which will severely limit the ability of the practice to continue to provide additional services to its patients. KEY RISK 2 Financial savings are not realised as a result of service re design which will undoubtedly question the overall practice PBC strategy. However by ensuring adequate performance
monitoring arrangements are in place increasing costs can be identified promptly and fully investigated at an early stage thus reducing the risk of financial over expenditure.
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.
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 ensures that The Partnership is run effectively and efficiently to meet the standards for better health requirements.
By attending the Kirklees Commissioning Forum meetings and having regular meetings with the PCT’s locality managers, 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
During 2006/07 we held notional budget responsibility for the management of:
un-scheduled care and emergency admissions;
outpatients, including diagnostics; and
During this time we managed to reduce expenditure in unscheduled care, effecting savings of over £60,000 with a reduction in activity of 11.5%. In addition, we effectively broke even (0.006%+) for elective/outpatient and prescribing expenditure. Our current position is that we are performing well against the 2006/07 indicative budget. Analysis of financial data acquired from the GPAS reporting system reveals an approximate £84,000 reduction in overall expenditure for the YTD (Jan 08) As a standalone practice we would wish to discuss with the PCT a plan to be able to retain 70% of our savings which would then be used to finance some of the Primary Care developments such as Minor Injuries Clinic; Out of Hours LTC card; extended opening hours; post discharge telephone follow-up.