Contract meeting for Sessional GPs June 2013 Glasgow LMC Dr Patricia Moultrie Glasgow LMC Sessional...

Contract meeting for Sessional GPs

June 2013

Glasgow LMC

Dr Patricia MoultrieGlasgow LMC Sessional GP Representative

What is a Local Medical Committee?

elected committee of local GPselected committee of local GPs

represents GPs in Glasgow and represents GPs in Glasgow and ClydeClyde

provides support and advice to GPs provides support and advice to GPs and practicesand practices

Glasgow LMC

Funding

• voluntary levy paid by all GPs, cost voluntary levy paid by all GPs, cost dependent upon list sizedependent upon list size

• levy also finances the LMC’s levy also finances the LMC’s contribution to the GP Defence Fund contribution to the GP Defence Fund for national GP representationfor national GP representation

Glasgow LMC

Helping individual GPs

• The LMC provides help and advice to assist GPs The LMC provides help and advice to assist GPs steer through the NHS. Such help is available on steer through the NHS. Such help is available on all matters relevant to general practice including:all matters relevant to general practice including:

– Workload issuesWorkload issues– Coping with changeCoping with change– GPs’ remunerationGPs’ remuneration– GPs’ terms and conditions of serviceGPs’ terms and conditions of service– ComplaintsComplaints– Premises/Partnership affairsPremises/Partnership affairs– Any disputes which may occur Any disputes which may occur – Sick doctors and those with performance problemsSick doctors and those with performance problems

Glasgow LMC

National debate and policy setting

Scottish and National Conferences of Scottish and National Conferences of LMCs. Proposals from individual LMCs LMCs. Proposals from individual LMCs across the country are debated across the country are debated alongside those from the GPC.alongside those from the GPC.

The outcome of the debate determines The outcome of the debate determines the framework for the profession’s the framework for the profession’s negotiations at both national and local negotiations at both national and local levels.levels.

Glasgow LMC

Glasgow LMC and Sessional GPs

relationshiprelationship

communicationcommunication

representationrepresentation

informationinformation

common interestcommon interestGlasgow LMC

Contact Glasgow LMC

Dr Patricia Moultrie, Sessional GP Dr Patricia Moultrie, Sessional GP Representative on Representative on

pamoultrie@doctors.org.uk

Mrs Mary Fingland, Office Secretary onMrs Mary Fingland, Office Secretary on mary.fingland@glasgow-lmc.co.uk mary.fingland@glasgow-lmc.co.uk

Glasgow LMC

Components of the Current

GMS ContractAlastair TaylorAlastair Taylor

Vice ChairVice Chair

Glasgow LMCGlasgow LMC

Glasgow LMC

Funding Streams

• Global Sum & MPIGGlobal Sum & MPIG• Quality and Outcomes FrameworkQuality and Outcomes Framework• Enhanced ServicesEnhanced Services• Health Board - administered funds, Health Board - administered funds,

including seniorityincluding seniority• PremisesPremises• IM&TIM&T• Dispensing/personal administration Dispensing/personal administration

of drugs of drugs Glasgow LMC

Global Sum

•Calculated (Scottish Allocation Calculated (Scottish Allocation Formula) to reflect: Formula) to reflect:

•The age and sex structure of the The age and sex structure of the practice population (demography)practice population (demography)

•The additional need of the practice The additional need of the practice population (morbidity and deprivation)population (morbidity and deprivation)

•The rurality and remoteness of the The rurality and remoteness of the practice populationpractice population

•Creates a “Weighted List” to allocate Creates a “Weighted List” to allocate the Global Sumthe Global Sum

Glasgow LMC

Global Sum Covers:• Essential ServicesEssential Services• Additional ServicesAdditional Services• Staff CostsStaff Costs• Locum Reimbursements (for appraisal, Locum Reimbursements (for appraisal,

career development and protected career development and protected time)time)

• The cost of GPs “employers The cost of GPs “employers superannuation” contributions for superannuation” contributions for those funding allocations mapped those funding allocations mapped across from the old red book contract.across from the old red book contract.

Global Sum Deductions

• For opting out e.gFor opting out e.g– Out of Hours 6.0%Out of Hours 6.0%– Cervical Screening 1.1%Cervical Screening 1.1%

Glasgow LMC

MPIG

• Minimum Practice Income Minimum Practice Income GuaranteeGuarantee

• MPIG = Global Sum via formula+ MPIG = Global Sum via formula+ Correction FactorCorrection Factor

• Correction factor = How much Correction factor = How much greater Global Sum Equivalent was greater Global Sum Equivalent was than Calculated Global Sumthan Calculated Global Sum

Glasgow LMC

Quality Outcomes Framework QOF

• Clinical Areas:Clinical Areas:• Atrial fibrillation, CHD, Heart failure, Atrial fibrillation, CHD, Heart failure,

Hypertension, Peripheral arterial disease, Hypertension, Peripheral arterial disease, Stroke and TIA, Diabetes mellitus, Stroke and TIA, Diabetes mellitus, Hypothyroidism, Asthma, COPD, Dementia, Hypothyroidism, Asthma, COPD, Dementia, Depression, Mental health, Cancer, Chronic Depression, Mental health, Cancer, Chronic kidney disease, Epilepsy, Learning kidney disease, Epilepsy, Learning disabilities, Osteoporosis, Rheumatoid disabilities, Osteoporosis, Rheumatoid arthritis, Palliative care, Cardiovascular arthritis, Palliative care, Cardiovascular disease - primary prevention, Obesity, disease - primary prevention, Obesity, Smoking, Cervical screening, Child health Smoking, Cervical screening, Child health surveillance, Maternity, Sexual healthsurveillance, Maternity, Sexual health

Glasgow LMC

QOF (2)• Quality and productivity (QP) e.g. Quality and productivity (QP) e.g.

Referrals/ACPReferrals/ACP• Patient experience (PE) – 10 min Patient experience (PE) – 10 min

appointmentsappointments• Quality improvement (QI) – Trigger Quality improvement (QI) – Trigger

Tools/Patient Safety QuestionnaireTools/Patient Safety Questionnaire• Medicines management (MM)Medicines management (MM)• Public health (PH) “Blood pressure” Public health (PH) “Blood pressure”

in over 40sin over 40s Glasgow LMC

Enhanced Services

• Directed (DES)Directed (DES)– e.g. Childhood Immunisation, Flu e.g. Childhood Immunisation, Flu

jabs, Extended Hoursjabs, Extended Hours

• Local (LES)Local (LES)– E.g. CDME.g. CDM

Glasgow LMC

Other Streams• Seniority:Seniority:

– starts after 2 years in post (6 yrs starts after 2 years in post (6 yrs reckonable)reckonable)

• PremisesPremises– Cost Rent/Notional RentCost Rent/Notional Rent

• IM&TIM&T– Hardware and Software supplied – to Hardware and Software supplied – to

specificationspecification

• DispensingDispensing– Won’t discuss hereWon’t discuss here

Any Questions for the Panel at the End?Any Questions for the Panel at the End?

Glasgow LMC

Contributing to practices’ contract work

2013/14

Dr John Ip

Glasgow LMC

Importance of QOF

• Significant funding for practicesSignificant funding for practices• Increased levels of workIncreased levels of work• More indicatorsMore indicators• Higher thresholdsHigher thresholds

Glasgow LMC

2013 QOF Changes- RA

• New Rheumatoid Arthritis domainNew Rheumatoid Arthritis domain• 4 indicators total of 18 points4 indicators total of 18 points

Glasgow LMC

2013 QOF Changes- RA

• Register (1 point)Register (1 point)• Annual face to face Review (5 Annual face to face Review (5

points)points)• Assess CVD Risk 30-85 years Assess CVD Risk 30-85 years

using ASSIGN (7 points) using ASSIGN (7 points) • Assess Fracture Risk 50-91 years Assess Fracture Risk 50-91 years

using FRAX (5 points)using FRAX (5 points)

Glasgow LMC

2013 QOF Changes• DiabetesDiabetes

–Annual dietician review (3)Annual dietician review (3)–New patients- referral to Structure New patients- referral to Structure

Learning Programme (11)Learning Programme (11)–ED screening, advice (4) & ED screening, advice (4) &

treatment (6)treatment (6)

• COPDCOPD–OO22 Sat for Grade 3 and above (5) Sat for Grade 3 and above (5)

Glasgow LMC

2013 QOF Changes• DepressionDepression

–Biopsychosocial assessment at Biopsychosocial assessment at time of new diagnosistime of new diagnosis

–10-35 day review after 10-35 day review after diagnosisdiagnosis

• Primary Prevention CVDPrimary Prevention CVD–SCOT-PASQ for patients with SCOT-PASQ for patients with

HT diagnose after 1 April 2009HT diagnose after 1 April 2009

Glasgow LMC

Glasgow LMC

2013 QOF Changes

• All 15 month targets are now 12 All 15 month targets are now 12 monthsmonths

• Some thresholds for full Some thresholds for full achievement increased ( 5-10% achievement increased ( 5-10% increase)increase)

Glasgow LMC

Other Contract Work

• Medicines ManagementMedicines Management• ScriptSwitchScriptSwitch• Anticipatory Care Pathways & eKISAnticipatory Care Pathways & eKIS• Polypharmacy ReviewsPolypharmacy Reviews

Glasgow LMC

Glasgow LMC

Tips for EMIS

Correct Coding

• Using TemplatesUsing Templates• Values e.g. BP, BMIValues e.g. BP, BMI• Medication ReviewsMedication Reviews• Smoking Status & adviceSmoking Status & advice

Glasgow LMC

Reviews of Patient

• LARC advice for ContraceptivesLARC advice for Contraceptives• Dementia reviewDementia review

Glasgow LMC

Population Manager

• The Pop up boxesThe Pop up boxes• What do they mean?What do they mean?

Glasgow LMC

Other Tips

• Searching in consultationsSearching in consultations• Audit trail for medicinesAudit trail for medicines

Glasgow LMC

Glasgow LMC

Questions?

Anticipatory Care Planning,Poly-pharmacy and KIS

24th June John Nugent

Clinical Director

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Anticipatory Care Planning, Poly-pharmacy

• Improving Care for Patients at High Risk of Emergency Admission

• ‘…appropriate ACP can improve the quality of care, reduce the risk of medication harm and either (or both) the number of future admissions and lengths of stay…’

• ‘As poly-pharmacy can significantly increase the risks (of admission/harm)…it has been agreed as appropriate to include’

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What is/the point of an ACP?

• Improving the quality of care;• ‘Anticipatory care planning encourages people

to adopt a ‘thinking ahead’ approach and to have greater control and choice by planning for what their preferred support and care interventions would be in the event of a future flare-up or deterioration in their condition, or a carer crisis.’

54

QOF QP

• Identifying patients for ACP and Poly-pharmacy Reviews

• Using a SPARRA risk threshold of between 40% (20%) and 60% will generate a cohort of around 5% of patients in the practice to fulfil the QP006 indicator

• Working down from an ‘upper ceiling’ of those with a 60% risk score will enable the practice to improve outcomes for people most likely to benefit from an Anticipatory Care Plan and a poly-pharmacy review.

• This will complement other local ACP initiatives that target cohorts with greater than 60% SPARRA risk

55

Rationale

• Patients < 60% SPARRA risk more likely to be engaged with the practice team than active on the community nursing caseload i.e. mobile

• Interventions < 60% represent earlier intervention likely to reduce escalation of dependency and to optimise adherence to medicines.

56

Guidance

• Scope to apply clinical judgement to what constitutes 'at risk of emergency admission' ; may be patients who would benefit from an ACP but do not have a risk score within the risk thresholds specified

• The Key Information Summary (KIS); tool by which practices create and share (with consent) ACPs

• Summary of medical history/patient wishes, replaces paper based faxing between GPs and OOH

• More generic version of the electronic Palliative Care Summary (ePCS).

57

Guidance

• Current ePCS patient information will transfer automatically to KIS but needs checked once KIS is switched on (ePCS patients that transfer automatically to KIS will not count as part of the cohort required for QP006 and QP007)

• NHS24, SAS, A&E, OOH and Acute Admission Areas already have access to KIS

• Access in other acute areas/departments depends on Board PMS systems and clinical portal developments

58

Poly-pharmacy

• 50% drugs not taken as prescribed

• 5-17% admissions due to adverse reactions

• If on multiple medications more side effects

• Potential harm of drug may outweigh benefit

QOF QP; QP004(S), 7 points

• QP004(S). The contractor meets internally to review data on emergency admissions, for patients on the contractor's registered list, provided by the NHS Board and the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S)

• Template for reporting will be agreed nationally

60

QOF QP; QP005(S), 17 points

• QP005(S). The contractor participates in an external peer review with either a group of local practices, or practices from within the board area, to compare its data on emergency admissions and to share the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S), and proposes areas for internal practice improvement and service design improvements for the NHS Board.

61

QOF QP; QP006(S), 5 points

• QP006(S). The contractor produces a list of 5 per cent of patients in the practice, who are predicted to be at significant risk of emergency admission or unscheduled care. This list can be produced using a risk profiling tool accessible to practices e.g. SPARRA, or where this is not available/required (by local agreement), alternative arrangements can be agreed between the NHS Board and LMC.

62

QOF QP; QP007(S), 30 points• QP007(S). The contractor identifies a minimum of 15

per cent (in 2014/15, 30 per cent) of those patients from the list produced in indicator QP006(S) who would most benefit from an Anticipatory Care Plan (the ACP must include a poly-pharmacy review), be shared with the local out of hours service and has an appropriate review date. The frequency of each patient’s review should be determined in the light of their clinical and care needs. The contractor will be responsible for ensuring that an appropriate system is in place for monitoring and reviewing the patients identified in this cohort.

63

QOF QP; QP008(S), 10 points

• QP008(S). The contractor holds at least 4 meetings during the year to review the needs of the relevant patients in the practice ACP cohort, to agree any required changes in the patient management and to share learning/ identify learning needs. These meetings should be open to multi-disciplinary professionals who support the practice’s patients

64

QOF QP; QP009(S), 10 points• QP009(S). The contractor produces and submits a

report to the Board before 15 March 2014 on internal practice and wider NHS Board system changes that may benefit patients with Anticipatory Care Plans (ACPs). The report should include Significant Events Reviews (SERs) on 1/1000, to a maximum of 3 patients per practice, of patients with ACPs from the cohort in QP007(S), who were admitted during the QOF year, after their ACP had been created. If less than the required number of patients with ACPs were admitted during the QOF year then the practice should write SERs of the care of an equivalent number of these patients who remained in the community.

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Summary

• Patient centred care; closer to home, reduced harm

• Carers; communication, support• Practices; supports review, professionally

satisfying, reduces ‘chaos’ (use)• Boards; reduced admissions/lengths of stay• Improves interface working• Not about keeping anyone out of hospital who

needs hospital

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Issues - now

• SPARRA; ‘push not pull’• Review and decide who would most benefit• See in surgery/home• KIS; EMIS now, VISION 2 weeks• MDTs; membership, review• Poly-pharmacy review; overlap with LES• ‘Face-to-face’

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Poly-pharmacy; overlap with LES

• Practices should generally only make one claim for payment for a poly-pharmacy medication review, per patient, during 2013/14

• Exceptional cases may arise when an ACP/PP should be developed after a Poly-pharmacy LES review has occurred or vice versa

• Payment can only be claimed on behalf of the same patient for a Poly-pharmacy LES and a ACP poly-pharmacy medication review during 2013/14 if;

a. there are 2 distinct reviews recorded in the patient’s recordb. there is clear clinical justification to demonstrate the need for

a repeat review for the same patient during the lifetime of the 2013/14 Poly-pharmacy LES

Clinical Justification• The clinical justification would include a change in a patient`s

clinical status due to one or more of the following occurring;

1. Hospital admission at least 1 month after the first poly-pharmacy review (ACP/PP or PP LES) had taken place

2. New clinical diagnosis

3. Deterioration in existing clinical condition requiring 3 or more either changes to drug or drug dose (oral or parenteral medication only)

4. Patient needing to go onto the palliative care register

Issues - later

• Role of DN/PN/Pharmacy support?

• Learning?

• Board support?

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Information held on KIS

• Significant Diagnoses and PMH• Prognosis• Medication and allergies• Current Care Needs• Help at home (e.g. Social Services / Care Packages)• Legal Issues (e.g. AWIA, Power of Attorney)• Preferred Place Care• End of Life Care wishes• DNA-CPR information• Free-text Anticipatory Care Plan

Example of a KIS which has been developed over a period of time?

Summary of main issues

Summary of main issues

Plan of action in event of a deterioration

Summary of main issues

Plan of action in event of a deterioration

Medication that can be used as PRN

Summary of main issues

Plan of action in event of a deterioration

Medication that can be used as PRN

Details of other professionals involved in care

Summary of main issues

Plan of action in event of a deterioration

Medication that can be used as PRN

Details of other professionals involved in care

Contact details of family member

Information available on KIS

SPSP in PC

• Aim is to reduce the number of events which could cause avoidable harm from healthcare delivered in any primary care setting

• “All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016”

Three key workstreams• Leadership and culture improving patient safety through the use of

trigger tools (structured case note reviews) and safety climate surveys • Safer medicines: including the prescribing and monitoring of high risk

medications, such as warfarin and disease-modifying anti-rheumatic drugs (DMARDs) and developing reliable systems for medication reconciliation in the community

• Safe and effective patient care across the interface by focusing on developing reliable systems for handling written and electronic communication and implementing measures to ensure reliable care for patients

GG&C plans for SPSP in PC implementation

• Leadership and Culture: covered by QOF. 11 points to undertake safety climate survey and trigger tool review

• High risk area we are concentrating on is “Safer medicines: developing reliable systems for

medication reconciliation in the community”

Guidance Patient Safety Indicators

Indicator Points

PS 1 The practice conducts two case note reviews, using a validated tool, to detect patient safety incidents, meets to discuss the results, and shares a reflective report on actions and themes that arise from this with the Health Board

6

PS 2 The practice conducts a safety climate survey with all staff,clinical and non-clinical, using a validated tool, meets to discussthe results, and shares a reflective report on actions that arise

from this with the Health Board 5

Adverse Event Causation

AccidentCausation

Technical Factors

Human Factors

SafetyCulture

OperatorBehaviour= +

(30-20%)

(70-80%)

Positive Safety Culture• Safety a Priority • Eliminate “shame and blame”• Accept staff will make errors • Build systems to make care safer• Foster a culture where people can speak up• Team training • Organizational learning from errors and near-misses

Why is a strong Safety Culture Important?

A strong safety culture essential to safe reliable care in any workplace

Francis Report and Culture • There was an atmosphere of fear of adverse repercussions

• There was a lack of openness

• It did not listen sufficiently to its patients and staff or correct deficiencies highlighted

• Above all it failed to tackle an insidious negative culture involving tolerance of poor standards

Francis Report Recommendations• Openness – enabling concerns to be raised and disclosed freely without fear

• Transparency – allowing information about performance and outcomes to be shared

• Candour – ensuring that patients harmed by healthcare are informed

• Replace culture of fear with culture of openness honesty and transparency

• Real involvement of patients in all that is done.

Safety Climate Survey• On line• Practice centred• Measurement• Diagnosis• Catalyst for change

How does the SafeQuest Safety Climate Survey work in practice?

Trigger Review• Reviewing your clinical records is the oldest form of audit!

• Looking for evidence of (undetected) safety incidents/latent risks

• Help you direct safety-related learning and improvement

• Quick and Structured versus Slow and Open

• Clinical triggers help you to navigate your records quickly

• Links with SEA and Quality Improvement

• Evidence for QOF, Appraisal and GPST etc.

• Random sample of 25 patients – high risk groups (e.g. >75 years, multiple morbidity/poly pharmacy)

• Review the last 12-week period only (x2 3mths apart for QOF)

• Takes between 90 minutes to 3-hours

• Tested with large groups of GPs, Practice Nurses and GP Trainees

“Triggers” in Clinical Records

‘‘Triggers’’ are defined as easily identifiable flags, occurrences or prompts in patient records that alert reviewers to actual or potential safety incidents (undetected)

Sections in GP Records Triggers

Clinical encounters (documented consultations)

≥3 consultations in 7 consecutive days

Medication-related (acute and chronic prescribing)

Repeat medication item stopped

Clinical read codes High, medium, low, allergies

New ‘high’ priority or allergy read code

Correspondence SectionSecondary care, other providers

OOH / A&E attendance / Hospital admission

Investigations Requests and results

eGFR reduce <5, Hb < 10.0, INR > 5.0

Medicines Reconciliation

Care Bundles

A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices — generally three tofive — that, when performed collectively and reliably, have been proven toimprove patient outcomes.”

• The steps must all be completed to succeed

• The “all or none” feature is the source of the bundle’s power

• Pass/fail

Medicines Reconciliation – care bundle measures• Has the Immediate Discharge Document (IDD) been workflowed on the day of

receipt?

• Has medicines reconciliation occurred within 2 working days of the IDD being workflowed to the GP?

• Is it documented that any changes to the medication have been acted on?

• Is it documented that any changes to the medication have been discussed with the patient or their representative within 7 days of receipt?

• Have all the above measures been met?

Knowledge Page

hhtp://www.knowlegde.scot.nhs.uk/spsp-ps.aspx