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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
Mrs Mary Fingland, Office Secretary onMrs Mary Fingland, Office Secretary on [email protected] [email protected]
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
52
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’
53
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.
65
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
66
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’
67
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?
70
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
