"8649 renegotiation of pms contracts"
Meeting Date Agenda Item Trust Board 26 November 2008 13 Title of paper: Renegotiation of PMS Contracts: Progress Report and Final Documents Summary The PMS Review was initiated in March 2008 as a response to a requirement by the Department of Health that Trusts undertook a review of PMS contracts that focussed on achieving Value For Money. The further intended outcomes of the review were as follows: A comprehensive service specification & performance framework; A consistent & equitable pricing model, ideally a “per patient” tariff; Effective contract & performance management processes; & achievement of TPCT targets & strategic agenda The paper includes: The final draft service specification & performance framework; A financial model, using a “per patient” tariff for baseline budget and a separate arrangement for PMS growth monies; Proposals for transitional arrangements, operational & financial, spanning up to 3 years – including a contingency plan for delays in 2009/10 caused by practices disputing their proposed allocation; Actions to date to engage with PMS practices and the Local Medical Committee (LMC), along with future actions; An implementation timeline. Fit with: Operating Plan Strategic Priorities: Modernising primary care Effective contract management Assurance and governance: The review is intended to establish good assurance & governance of PMS practices. Implications for: 1 Performance and quality: It is envisaged that reviewing & updating PMS objectives will encourage PMS practices to focus on target achievement and quality. Resources/efficiency: The 31 PMS practices had a baseline budget of £12.2m in 2007/08. In addition, growth/developmental funding amounted to £2.4m. This does not include the QoF funds available to PMS practices. Corporate Risk: The TPCT has a duty to strive for value for money in its use of public funds and therefore to explore areas of potential inefficiency. The review process is being carefully managed to ensure that GPs remain engaged with other PCT initiatives, for example the Locality Planning as part of the Primary Care Strategy implementation and PbC initiatives. Legislation: GMS & PMS contracts are contractual arrangements that derive from statute. The Review has identified the need for re-negotiation of the PMS contracts. Equalities: The Review is intended to address the inequity of resource allocation between PMS & GMS practices previously identified. Stakeholder involvement/public relations: Meetings continue with practices and the LMC. Progress updates have been presented throughout to the Board and the PEC. Board action: The Board is asked to approve the documents contained within the report, whilst noting that the LMC has yet to submit some final comments on the specification and some of the targets in the Performance Framework will be amended according to changes in national guidance and local policy. Lead Officer information: Name: James Slater Position: Director of Performance and Primary Care Contact details: 6789 2 1. Purpose of the report 1.1 This paper presents an update on the project to re-negotiate the PMS contracts in Haringey. 1.2 The intention of the project is to achieve the following outcomes: A comprehensive service specification & performance framework; A consistent & equitable pricing model, ideally a “per patient” tariff; Effective contract & performance management processes; & Achievement of TPCT targets & strategic agenda. 1.3 The paper includes: The final draft service specification & performance framework; A financial model, using a “per patient” tariff for baseline budget and a & Proposals for transitional arrangements, operational & financial, spanning up to 3 years – including a contingency plan for delays in 2009/10 caused by practices disputing their proposed allocation; Actions to date to engage with PMS practices and the Local Medical Committee (LMC), along with future actions; A project implementation timeline. 1.4 The Board is asked to approve the proposed operational model (service specification & performance framework), financial model, transitional arrangements & implementation plan. 2. Operational Model - Service Specification & Performance Framework 2.1 PMS is a locally-negotiated block contract for general medical services in primary care. As such, the TPCT has the opportunity to specify exactly what it wants from primary care and manage 30 of its practices to deliver that. 2.2 PCT officers have been working for some months to develop an explicit & detailed service specification & set of performance indicators for general practice. The specification is deliberately ambitious and sets out the TPCTs requirements of a primary care provider capable of delivering the expectations inherent in the BEH Clinical Strategy & “World-class Primary Care”. 2.3 Previous versions have been presented to Clinical Executive & Board for comment. The current version of the specification and supporting performance framework are now attached at Appendix Two. 2.4 It is envisaged that the specification will be amended on annual basis. In particular, newly agreed GMS Enhanced Services will need to be added on a continuing basis (Enhanced Services up to 2008/09 are included in the current specification & tariff). This may result in an increase in the tariff in future years (see below). 3 3. Financial Model – Baseline Funding & Growth Monies 3.1 The intention of the project is to move from a block-funded model, with historic inequities frozen, to an equitable, per-patient model. An analysis of GMS & PMS funding levels in terms of core contract-price and growth money is set out below: Contract Practices Patients (wtd.) Cost GMS 29 114,400 £7.87m PMS baseline only 30 155,100 £12.75m PMS with growth £15.00m 3.2 The range of prices for individual contracts is summarised below: Contract Minimum Average Maximum GMS £53.48 £68.71 £87.10 PMS baseline only £56.56 £82.15 £133.91 PMS with growth £68.76 £96.52 £155.61 Typical APMS £75.00 APMS – Alternative Provider of Medical Services 3.3 The PMS baseline contract scope is broadly comparable with GMS. A range of other income streams available to all practices (e.g. premises reimbursement, QoF, GP seniority) have been excluded for purposes of comparison. 3.4 PMS growth monies were provided specifically to PMS practices in addition to order to employ GPs or Nurse Practitioners to deliver extra services akin to (what are now termed) GMS enhanced services. The degree of compliance by PMS practices with that requirement is still unclear. Growth monies total c£2.3m or £14.37 per patient on average (recurrent funds). 3.5 The proposed PMS model of a consistent service specification & “per patient” tariff will achieve real equity between PMS practices, both in terms of service & income. However, it will not of itself address the inequity between PMS & GMS practices. It is worth noting that the Haringey GMS average contract price at £68-76 is less even than the typical APMS price of £75-00. For illustrative purposes, the cost of putting every GMS practice on c£82 per weighted patient (i.e. the PMS average) is estimated at c£1.6m p.a. 3.6 The proposed PMS financial model is an approach that splits baseline budgets & growth monies, treating these allocations separately and is described below. Baseline Budget 3.7 Baseline budgets will be paid on a fixed-tariff basis, per weighted patient (Carr-Hill formula). The proposed tariff is £82.15, the mean level of current PMS baseline contract prices. This implies that implementing the model will be broadly cost- 4 neutral. In selecting this tariff, a range of comparisons have been made and these are shown below. 3.8 Recent independent sector APMS procurements in London have achieved a contract price of £75.00 per patient. Opinion as to whether this is a realistic price or a “loss-leader” is evenly divided. We estimate that the cost of NHS superannuation & seniority in the GMS/PMS contract to be approximately £3 per patient more than in APMS. Therefore, any like-for-like comparison must take that into account. 3.9 PMS re-negotiations elsewhere in England (e.g. Northumbria, Suffolk) have achieved tariffs rather lower than the APMS. However, the service specifications were less ambitious than the proposed Haringey specification. In addition, deprivation levels suggest that London practices should be better resourced. We have liaised with other London PCTs, but there is genuinely little comparable work done, nor any consensus on approach. 3.10 Current funding levels for Haringey group practices (with c10,000 or more patients) are shown below: Practice £/patient Practice A 82.37 Practice B 79.85 Practice C 83.23 Practice D 79.51 Practice E 68.92 Practice F (GMS) 73.38 Practice G (GMS) 67.63 Practice H (GMS) 74.41 Average Cost 76.16 3.11 Given all the above, it would appear that a tariff of c£82 per weighted patient (excluding growth money) is both appropriate & justifiable. As stated above, the tariff may be amended in future years (over & above inflation) to reflect the incorporation of new Enhanced Services in the Specification. Growth Monies 3.12 Growth monies will be annually monitored and spent on additional clinicians for specific services, possibly on a collaborative basis. Practices will be expected to report on outcomes achieved from the deployment of these monies. Monies not so used or not achieving suitable outcomes will be clawed-back and used for primary care development in Haringey. This arrangement is in place in a number of London PCTs (e.g. Lambeth, Southwark & Lewisham). 3.13 In Haringey, it is clear that some high-performing practices have made good use of the monies to recruit clinicians and set up services for patients. However, other practices have just regarded it as part of the baseline budget. Therefore, there appears to be an opportunity to drive clinical recruitment by practices by enforcing 5 the original requirements of growth money and also to recoup the monies where not complied with. 3.14 One of the benefits of adopting this approach is that funds freed up could be utilised elsewhere in primary care. One such use could be to fund the transition of high- performing GMS practices into the new PMS arrangements. As such, the TPCT could begin to address the GMS-PMS inequity, while also driving up service and making better use of existing primary care funds. 4. Transitional Arrangements – Operational 4.1 Once the TPCT has given formal 3 months notice to the PMS practices of the new service & financial model, the options available to the PMS practices will be as follows: Sign up to provide services as per the PMS specification with effect from 01/04/09; Commit to provide services as per the PMS specification and submit an action plan to achieve that by 01/04/10; Return to a GMS contract with effect from 01/04/09 (at a contract price of c£60 per patient); or Opt to resign from the NHS and operate as a private practice. 4.2 The latter two options are regarded as very unlikely. However, experience elsewhere in the country suggests that threats of resignation may be used as a bargaining position and/or media opportunity. The TPCT will need to have both a carefully prepared public/media position and contingency arrangements for cover. In that context, the new centres at The Laurels, Lordship Lane & Hornsey Central are opportune. 4.3 Each practice will have the opportunity to make contractual representations internally to the TPCT through its dispute resolution process and possibly also externally to the NHS Litigation Authority (although legal advice is strongly of the opinion that such an external approach will fail). Experience suggests that the net effect of this (intentionally or otherwise) may be to delay the implementation of the PMS model in some practices into later within 2009/10. The TPCT will seek to maintain the integrity of its proposals. 4.4 Notwithstanding the above, one particular anomalous practice to consider is the Broadwater Farm Health Centre. This practice was deliberately well-resourced by the TPCT under the original PMS allocation, in recognition of its special challenges & history. Seven years on, the TPCT will have the difficult & controversial task of forming a view as to its resourcing between 2009 & 2012. The options are: Treat it as other PMS practices within this exercise, resulting in a significant reduction in income spread over 3 years (see below); Maintain current funding, resulting in a recurrent cost-pressure within primary care budgets; 6 A compromise funding arrangement, resulting in a lesser cost-pressure than above. 4.5 It is acknowledged that the operational & financial implications for some practices, particularly a body of predominantly small practices, will promote debate about their future viability. The TPCT position is that this is an opportunity to explore ways of joint working (possibly leading to partnership). 5. Transitional Arrangements – Financial 5.1 The implementation plan envisages that financial transition will be managed over a period of between 1 and 3 years, depending upon practices’ “distance from target”, thus achieving an end-point at 01/04/2011 at the latest. If the process is to be cost- neutral, that may imply delay in “levelling up”, thus perhaps impairing the pace of change. 5.2 A financial model is attached at Appendix Three, setting out 3 broad options for scheduling of “levelling up” and “levelling down”. As stated above, the preferred option is a mixed model based upon distance from target. Detailed financial modelling on transition arrangements is continuing. It is also acknowledged that for some practices, particularly a group of predominantly small practices, the change in income represents a significant reduction. For those reasons, it will not be possible to produce a definitive financial statement until later in 2008. 5.3 In terms of growth monies, all practices will receive their growth monies in 2009/10. In the first six months of that year, the TPCT will establish current use of growth monies and notify practices where removal in 2010 onward is being considered. Practices notified of likely removal will have the opportunity to submit a new proposal, which will be considered for approval by the relevant Collaborative Clinical Director. 5.4 As stated above, there is a risk that some practices, particularly those which face a reduction in income, will attempt to delay implementation. While legal advice is strongly of the view that this will fail, it will take time to resolve the disputes raised. It is therefore recommended that a non-recurrent “risk reserve” of £150K - £500k in 2009/10 be set aside (depending upon the implementation option). This will permit the funding of practices whose budgets while working through any resolution process. 5.5 One practice in West Haringey has recently raised concerns about the use of a deprivation-based formula, suggesting that this will destabilise West Haringey. An analysis of cross-collaborative flows suggests that this is highly unlikely. In fact, the financial model appears to result in a relatively small flow from east to west. While this seems to run contrary to the TPCT intention to invest in the east of the borough, it is not thought significant and attempts to “ring-fence” funding will probably prove counter-productive. 6. Engagement with Practices & LMC 7 6.1 All practices were provided in early August with an early draft of the specification & performance framework and invited to comment. 6.2 In late August, practices were also invited to one of two workshops led by the Medical Director Dr Kheraj. 6.3 In the course of September, October and November, the great majority of PMS practices (all bar four, which have been scheduled) have been visited by their respective Head of Primary Care. Issues raised in such visits have been fed back to the in-house PMS project team or (in the case of other issues) to the relevant TPCT department. 6.4 Once the amended service specification & performance framework and the financial model are approved by the Board, practices will receive updated copies and invitations to further workshops in December. In addition, arrangements will be put in place for practices who wish to raise specific issues to meet TPCT senior officers. 6.5 The existing TPCT dispute resolution procedure will be used to resolve issues with practices that cannot be resolved informally. 6.6 TPCT officers have met regularly with the Chair of the LMC and representatives of the London-wide LMC office. This process is one of sharing information rather than consultation, given the nature of the PMS contract. 7. Next Steps 7.1 Once Board approval has been achieved, PMS practices will be requested to sign up to the new specification for an April 2009 start. Where there is an internal dispute, a July 2009 commencement date may yet be achieved. In the event of external appeal to NHS litigation authority, resolution may take up to a year. 8. Recommendations 8.1 The Board is asked to approve the proposed operational model (service specification & performance framework), financial model, transitional arrangements & implementation plan. It is further asked to note that the specification will be subject to further amendments as national and local guidance and targets change. James Slater Director of Performance & Primary Care November 2008 8 Appendices: 1 Timeline 2 PMS Service Specification, including Performance Framework 3 Financial Analysis of Practice PMS Baseline Budgets 2009-2011 9 Appendix One PMS Review Project Plan May June July August Sept Oct Nov Dec Jan - Mar Preparatory phase Assessment of current information/gap analysis LMC and GPs updated on progress of PMS Review Financial modelling exercise Review of contract position from legal perspective Paper to PEC Paper to May Board Letter to contractors to renegotiate contract Development of specification Development of contract Support Plans Design communications plan Devise contingency plan as part of PCT Business Continuity Plan Negotiations phase Set negotiating objectives and plan Progress update to PEC and September Board Specification to practices for consultation Hold workshops with practices to gain group input Schedule meetings with practices Hold meetings Amend specification and Performance Framework Paper to PEC and November Board, finance model signed off Practices to sign up to new contract and specification Transitional phase Practices give three months notice to revert to GMS Contingency plan revisited for operationalisation implications Contingency preparations made with relevant stakeholders 10 Implementation phase Start of new contractual arrangements Performance-monitoring for new contract/spec 11 Draft Service Specification for PMS Agreements in Haringey Appendix Two A service specification for PMS agreements in Haringey is needed to ensure that we have a clear relationship between the commissioner and provider. The specification provides clarity for all parties on the services that are to be delivered and the responsibilities therein. The service specification has a number of component parts: 1. Main Contract Specification – equally applicable to all PMS agreements and includes the provision of essential and additional services as specified in the GMS contract 2. Developmental Contract Specification – practice specific services that are provided (based on evidence from practice discussions about services provided outwith those described in this specification) 3. Enhanced Services Specification a. Directed Enhanced Services – equally applicable to all PMS agreements and negotiated annually b. Nationally Enhanced Services – practice specific menu of services c. Locally Enhanced Services – practice specific menu of services. The starting point for the specification is the GMC Good Medical Practice Guide, which endorses the broad principles outlined below: “The duties of a doctor registered with the General Medical Council: Make the care of your patient your first concern Protect and promote the health of patients and the public Provide a good standard of practice and care Keep your professional knowledge and skills up to date Recognise and work within the limits of your competence Work with colleagues in the ways that best serve patients' interests Treat patients as individuals and respect their dignity Treat patients politely and considerately 12 Respect patients' right to confidentiality Work in partnership with patients Listen to patients and respond to their concerns and preferences Give patients the information they want or need in a way they can understand Respect patients' right to reach decisions with you about their treatment and care Support patients in caring for themselves to improve and maintain their health Be honest and open and act with integrity Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk Never discriminate unfairly against patients or colleagues Never abuse your patients' trust in you or the public's trust in the profession. You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions”. The specification will be accompanied by a performance management schedule – the Performance Framework Performance Framework - detailing all the performance and activity targets for each practice. This will be monitored by the Primary Care Commissioning Team on a six monthly basis, with data sent to practices on a quarterly basis. 13 1 Main Contract Specification Area of Service Specification Purpose Performance Framework /other Measurement Access Opening hours The practice is open for patient consultations for a minimum of Delivery of contracted access standards PF 1.1 45 hours per week within core hours (8am – 6.30pm). No more (Note: branch surgeries/single handed than one half day closing per month practices subject to local agreement) Practice leaflet The contractor provides a practice leaflet to be reviewed at least Information and communication – targeted Statutory contractual every 12 months and amended as necessary to ensure accuracy at patients and explaining how they may requirement access key services Clinical sessions The contractor provides information on the clinical services Baseline for the contract, to enable capacity PF 1.2 available by professional group in each practice planning and benchmarking and to enable challenge should the practice fail to meet core performance standards Home Visits Home visiting service provided on a clinically appropriate basis To ensure access to primary medical to all patients who need it. services on a needs-basis to those patients unable to attend the practice Consultations The contractor provides a range of different methods for patients To offer patients a range of ways Statutory contractual to contact the practice (attendance, telephone, fax, email etc) in requirement which they may seek advice, intervention (practice leaflet) and support Effective Appropriate services for all sensory impaired patients and communication language interpreting services are arranged to meet the needs of patients 14 Area of Service Specification Purpose Performance Framework/other Measurement Main contractual services Essential services The contractor will provide all essential services as defined in the In accordance with GMS GMS regulations Additional The contractor will provide all additional services as defined in In accordance with GMS GMS services the regulations Anti coagulation Provide anti coagulation services to patients in line with level 1 NES specification monitoring National Enhanced Service specification Stop smoking Provide level 1 stop smoking services (over and above QOF) - NES specification see glossary of terms Out of hours care Subject to agreement of practices (and separately negotiated) if choosing to opt back in Clinical and cost Contribute to the PCT medicine management action plan To encourage and incentivise effective, PF 1.6 effective evidence-based use of resources within prescribing cash-limited budgets Patients Suffering The Contractor shall provide a service to patients suffering from The Contractor shall provide services to from Drug Misuse drug misuse including substitute prescribing if appropriate patients with drug misuse and meet the national specification Patients suffering The Contractor shall provide a service to patients suffering from from alcohol abuse alcohol abuse, including signposting to specialist services where appropriate Supporting People The Contractor shall provide a service to any registered patients The Contractor shall manage all patients with Learning and comply with the local service specification identified as having learning difficulties in Difficulties accordance with local specification Diabetes The contractor shall identify, diagnose and provide a service to 80% of registered diabetic managed within its diabetic population in line with patient pathway and service the practice in line with local specification specification, and ensure that a register of all diabetic patients is kept. The contractor will ensure that diabetic patients are referred to the diabetic Retinal Screening Service, and will keep a record of those patients who are to be exempted from the 15 screening service and the reasons for exemption. Heart Failure The Contractor shall identify, diagnose and provide a service to 50% of registered Heart Failure patients non-complex ischemic Heart Failure patients in line with the managed within the practice in line with patient pathway and service specification local specification Chronic The Contractor shall provide a service to patients with COPD in 70% of patients diagnosed with COPD will Obstructive line with patient pathway and service specification be managed within primary care facility Pulmonary and meet the local specification Disease For all Long Term conditions, the contractor should follow the pathways on map of medicine Mental Health The Contractor will ensure that: Common mental The appropriate questionnaires to diagnose and assess the illness severity of depression and anxiety are utilised Local and national prescribing protocols are followed Mental illness is managed appropriately alongside long-term conditions Severe mental Adequate assessment tools utilised illness Appropriate care pathways followed Interface agreement regarding shared care followed Management of the client relationship upon discharge: repeat prescribing, DEPO medication, shared care, appropriate physical health checks Wellbeing and Appropriate advice available on diet, exercise, signposting to Health Promotion Benefits and Employment advice as appropriate Primary Care The Contractor shall undertake screening programmes, in line The Contractor shall achieve targets set out Screening with local protocols, in the following areas: by the PCT in specification and Programme Diabetes commissioning intentions Hypertension CHD Prevalence CVD Risk Smoking and Obesity 16 Case Management The Contractor shall assist in identifying patients who require The Contractor shall evidence the case management and work with Community Matrons to requirements maintain patients at home and reduce need for emergency or Referrals to community matrons unscheduled admission Reduction of emergency admissions Wound The Contractor shall provide basic wound management and The Contractor shall: Management and suture removal including: Suture removal Sutures and skin clip removal post operatively Provide audit for management of wounds Re-dressing or simple packing post operatively Ensure patients do not attend A&E for Simple wounds wound care Promotion of Self The Contractor shall work with patient ‘s in ways that support Refs to EPP Care self-care and self-management including: Refs to Desmond Referral to Expert Patient Programme (EPP) Provision of approved education Referral to structured education programmes e.g. Desmond materials to patients Maternity Services Practices to follow the protocols on Map of Medicine To ensure consistency and adherence with good practice Child Protection GPs to act in accordance with ‘Doctors’ responsibilities in child To protect the wellbeing of children protection cases’, Guidance from the Ethics Department June 2004, available at http://www.bma.org.uk/ap.nsf/Content/childprotection 17 Area of Specification Performance Service Framework /other Measurement Governance QOF Actively participate in QOF PF 1.8 Standards for Demonstrate compliance with core standards for better health (working towards 100% compliance) via PCTs PF 1.9 better health assurance framework. Financial Manage the funds allocated under the contract with due regard to accountability for administration of public funds robustness and in accordance with the PCT anti fraud policy. Information The practice will work in ways that support national and local programmes and use IT in ways that maximally technology facilitate patient care. (PCO support required). The practice work with the PCO as appropriate on programs which improve patient care, such as: Connecting for Health Electronic Pathology ordering Choose and Book Communication and use of NHS mail Electronic prescription service Participation in PCT audits and data collection Minimum data The practice will submit all data required by the PCT as detailed in the service specification in a timely and set accurate fashion (to be developed in 2008/09 as part of the work on the performance management framework) Audits Contribute to a specified number of clinical audits identified in the Audit Programme each year. The audits will include NICE guidelines as a compulsory requirement (to be agreed) Information Practices must have systems in place to support and encourage the regular exchange of up to date and exchange comprehensive information between all those who may be providing care to patients Patient audits Practices must regularly audit a random sample of patient contacts and treatments and appropriate action will be taken on the results of those audits (to be agreed) Patient Practices must regularly audit a random sample of patient’s experiences of the service and appropriate action must experiences be taken on the results of those audits (to be agreed) Complaints Practices must operate a complaints procedure that follows the NHS complaints procedure. Practices must publicise their complaints procedure and publicise the fact that patients may contact the PCT direct if they so wish. They will report anonymized details of each complaint and the manner in which it has been dealt with to the contracting PCT. All complaints must be audited in relation to individual staff so that where necessary, appropriate action can be taken 18 The following pages will be finalised, pending practices signing up to the 5 new Directed Enhanced Services and the finalisation of the Enhanced Services Review currently being undertaken Developmental Specification: please detail here any services that the practice currently provides over and above core GMS and the draft specification (above), indicating whether they are currently funded via any other mechanism e.g. LES . Please return this page (with additional pages and relevant documents as necessary) in order that it can be considered by the TPCT and a constructive discussion undertaken at the PMS Review meetings with practices Area of Service Specification – please attach Purpose 19 3 Enhanced Services specification A Directed Enhanced Services These services will be provided by practices, subject to their continuation nationally as Directed Enhanced Services. These will be remunerated according to pricing detailed in the specification and are subject to change as dictated by the Department of Health Area of Service Specification Access As per Access DES Choice As per Choice and Booking DES Childhood Vaccinations and As per Vaccinations and Immunisations DES immunisations Minor Surgery As per minor surgery DES Influenza As per influenza DES Learning Disability As per DES Ethnicity As per DES Osteoporosis As per DES 20 B Nationally Enhanced Services The PCO may commission from a range of National Enhanced Services (over and above those provided at Level One in the main specification) according to local population needs. Current examples are shown below: Area of Service Specification Near Patient testing For eligible practices Anticoagulation For eligible practices Intra uterine contraceptive device fittings For eligible practices 21 C Local Enhanced Services Practices will provide an agreed selection of the following services (illustrative list: will vary between practices) Area of Service Specification Practice Based Commissioning As per PBC LES. All Practices will participate in Practice based Commissioning Vasectomy For eligible practices Stop smoking services Varies locally Nursing and Residential Home provision 22 Glossary of Terms Caldicott Guardian A person who takes responsibility for, and advises on, all issues relating to the sharing of patient information Choose and Book The system within general practices that allows patients to agree which hospital they will be referred to and allows the patient to book an appointment at that hospital at a time convenient to them CHD Coronary heart disease Community matrons Qualified nurses and other health care professionals who manage and co-ordinate the care of patients with long term conditions in the community and at home in order to prevent illness and admission to hospital Connecting for health NHS Connecting for health came into operation in April 2005. It is an agency of the Department of Health and its purpose is to deliver the National Programme for IT and to maintain the national critical business systems previously provided by the former NHS information authority. It involves the creation of a national spine which would store patient information from a number of services COPD Chronic Obstructive pulmonary disease Directed Enhanced Services that relate to the provision of medical services that are Services (in relation to under national direction with national specifications and primary medical services) benchmark pricing which all PCTs must commission to cover their relevant population Electronic transfer of The electronic transfer of prescriptions from GP practices to prescriptions pharmacies will allow some of the new pharmacy contract essential services, such as repeat dispensing, to be carried out more efficiently, by using new advances in technology Enhanced services (in These are services that relate to the provision of medical services relation to primary and include: medical services) Essential or additional services delivered to a higher specified standard, for example, extended minor surgery Services not provided through essential or additional services. These might include more specialised services undertaken by GPs or nurses with special interests and allied health professionals and other services at the primary- secondary care interface. They may also include services addressing specific local health needs or requirements. PMSBoardPaperNovember2008 23 Essential services (in These are services that relate to the provision of medical services relations to primary and include: medical services) Management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, including relevant health promotion advice and referral as appropriate, reflecting patient choice wherever possible General management of patients who are terminally ill Management of chronic disease in the manner determined by the practice, in discussion with the patient Expert patient A 6-week education course for people with a particular long-term programme medical condition. Its aim is to enable people to manage their condition as effectively as possible Healthcare commission The Healthcare Commission is a national organisation that sets standards for all NHS organisations and assesses them against those standards Local Enhanced Services Enhanced services that are developed locally. The terms and (in relation to primary conditions of these services will be discussed, negotiated and medical services) agreed locally between the PCT and potential practices, providers and with the involvement of the Local Medical Committee LMC Local Medical Committee. A statutory representative committee for general practitioners LTC Long term conditions – also known as chronic diseases. These are diseases that are treatable but for which there is no cure e.g. diabetes, heart failure, chronic Obstructive pulmonary disease and asthma National enhanced Enhanced services that have national specifications and services (in relation to benchmark pricing but are not directed. These include: primary medical services) Intra partum care Anti coagulation monitoring Intra uterine contraceptive device fitting More specialised drug and alcohol misuse services More specialised sexual health services More specialised depression services Multiple sclerosis services Enhanced care of the terminally ill Enhanced care of the homeless Enhanced services for people with learning disabilities Minor injury services NICE National Institute for Health and Clinical Excellence. A special health authority that promotes the best possible service and effective use of resources within the NHS. It sets clear national standards to improve the quality and consistent of NHS services throughout the country. Out of Hours This refers to The period beginning at 6.30pm on any day from Monday to Thursday and ending at 8am the following day; The period between 6.30pm on Friday and 8am on the following Monday; and Good Friday, Christmas day and bank holidays Practice Based A mechanism that enables groups of practices to work together to Commissioning develop new types of services within primary care to enable patients who may have attended hospital to be cared for in more local settings QOF Quality Outcomes Framework – designed to systematically reward practices on the basis of the quality of care delivered to patients. The framework consists of 4 domains, which represent PMSBoardPaperNovember2008 24 clinical disease areas, organisational aspects of general practice, additional services and patient experience. SHA Strategic Health Authority. The SHA covering Haringey is known as NHS London Stop smoking services: Provision of systematic brief advice about the benefits of level 1, brief intervention stopping smoking and signposting potential quitters into appropriate stop smoking services. This is an effective intervention to give smokers information and access to the range of available stop smoking services Providers will have an understanding of why smokers find it difficult to stop and of the range of treatment options. Providers will give brief advice about the benefits of stopping smoking, make an appropriate referral for those who Stop smoking services: Provision of one-to-one stop smoking “clinic”. Providers will level 2 intermediate understand intervention Smoking demographics The effects of smoking and of stopping The most effective, evidence-based way to help smokers quit How to help clients choose a replacement therapy – NRT or Zyban Common issues experienced by smokers when quitting How to set up a “clinic” and a week by week programme PMSBoardPaperNovember2008 25 Performance Management for Primary Care Contracts in Haringey: Final Draft Section Section Title Page numbers A Introduction 2 B An overview of the Performance Framework Approach 3 C The Performance Framework: contents 4 – 13 D Appendices 1 Summary of Performance Framework 14 – 18 Indicators 2 HealthCare Commission Standards For Better 19 – 21 Health: Guidance 3 Standards for Better Health: checklist 21 – 36 excl. here 4 Support available to practices 37 5 Contractual and Statutory Requirements 38 – 41 6 Contractual Sanctions, Remedy and Removal 42 – 44 7 Minimum Standards for Practice Premises 45 PMSBoardPaperNovember2008 26 A. Introduction The review of PMS contracts in Haringey will include creating a service specification that describes the services that will be provided by practices through their revised PMS contracts. This service specification needs to be supported by a performance management framework and the two documents are similarly structured. The PCT and independent contractors share a common interest in ensuring that primary care services are available to their residents easily and that they are of the highest quality. A shared commitment to ensure that as much care as appropriately possible takes place in non-acute settings gives added impetus to the further development of primary care. Additionally, the 2005 NHS Policy, Commissioning a Patient Led NHS (CAPLNHS), places clear responsibilities on PCTs as commissioners of services. A robust focus on commissioning is required, ensuring that services are appropriately identified, commissioned and performance-managed by PCTs. This applies equally to all providers whether they are independent contractors, NHS Trusts or organizations from the mutual, independent or private sectors. The Health Care Commission has now clarified the extent to which its standards also apply to independent contractors, and takes a special interest in assessing how PCTs as commissioners achieve ensured compliance from independent contractors with their standards. Within the context of PCTs now being required to commission and performance-manage primary care, it is clear that a number of useful performance indicators, including, for example, QOF, access surveys, patient surveys and premises surveys now exist to support this function. Nowhere, however, are these different performance indicators brought together to allow a more balanced assessment of primary care performance and development. In addition, nowhere is this information systematically made available to patients; the PCT is instead subject to random Freedom of Information (FOI) requests. PMSBoardPaperNovember2008 27 B. An Overview of the Performance Framework Approach The purpose of this paper is to bring these indicators together, set out minimum acceptable standards, and the PCT’s approach to improving standards. It is intended that these quality indicators and the assessment of practices based on the indicators will be public information. For new additional capacity (whether APMS, PMS or nGMS), the PCT will seek to commission at the highest level for all indicators, whilst taking a more developmental approach with existing contractors. The PCT aims to ensure that the completion of the Performance Framework is not onerous, and that it can be achieved relatively quickly, with minimal Practice effort required. Each indicator is subject to ongoing change and development over the years, subject to experience in its application. Changes to indicators will be negotiated as contract variations. The Performance Framework will be reviewed annually. The PCT will then agree a series of timetabled improvement milestones with Practices that are challenged, especially focusing on areas that are scored in the lowest level of achievement, i.e. below acceptable minimum standards of practice. The PCT will make a full range of supportive interventions available in such cases. Should the PCT’s formative and facilitative approach result in either lack of cooperation for improvement or lack of progress, the PCT will use its commissioning powers to enforce the required improvement from a contractor. This will include use of remedial notices, and eventually, removal of the contract where there is clear documented evidence of lack of improvement to achieve basic standards. It should be noted however, that the PCT’s overall aim is the improvement of existing contracts in order to ensure that contractual remedy is used as a last resort i.e. only when development support has been explored and documented to have not achieved improvement. (Parties to the discussions about remedial action will include the PCT, Local Medical Committee and Overview and Scrutiny Committee if required). Appendix 6 details further use of contract sanctions and remedy. Most quality indicators will have a banding A, B or C, with the following meaning: Band A: Achievement well above the minimum standard. Band B: Meets the minimum standard Band C: Does not meet the minimum standard – remedial action required In the setting of standards the PCT has attempted to select criterion that have referenced (or absolute) standards rather than peer-referenced standards. This should maximize transparency and minimize the need for appeal. (References inserted in tables – Appendix 1) Most indicators will receive an A, B or C rating, and a Practice will receive a list of all of its ratings for all indicators annually. These will not be aggregated into a single assessment, but will be totalled, such that at a glance it will be easy to ascertain, for example, that out of 30 indicators, a Practice has 14 band As, 10 band Bs and 6 band Cs. Whilst the PCT is keen to encourage all its practices to score level A for all indicators, its development energy and commissioning powers will inevitably be focused on practices with band C scores, prioritizing for attention those with most Band Cs. Bands will be reviewed by the PCT annually, in partnership with practices, with a view to increasing the ambition of each measure. PMSBoardPaperNovember2008 28 C. The Performance Framework The Performance Framework The Performance Framework has been constructed to reflect the contents of the service specification as follows: 1 Main Specification a. Access (see also Access DES) 1.1 Opening hours 1.2 Clinical availability 1.3 Diversion and other access points b. Main contractual services 1.5 Registration 1.6 Medicines Management: Clinically- and cost-effective prescribing 1.7 Public Health Targets -cervical screening, childhood immunisations, influenza c. Governance 1.8 QOF 1.9 Standards for Better Health (Healthcare Commission) 1.91 Environment (premises and decontamination) 2 Contractual and statutory Requirements 3 Enhanced Services and other a. Directed 3.1-3.3 Access 3.4 Patient Views 3.5 Choice and Booking b. National 3.8 As per NES specifications c. Local 3.9 As per LES specifications The following pages describe the data requirements and the Performance Framework standards. Appendix 1 summarizes the information in tabulated form; Appendix 2 contains the Health Care Commission Standards for Better Health table for completion. PMSBoardPaperNovember2008 29 C MAIN SPECIFICATION 1a Access to Services 1.1 Opening Hours The contractual regulations define core hours as: “Monday to Friday 8.00 am to 6.30 pm except Good Friday, Christmas Day and Bank Holidays. It is the responsibility of the contractor to ensure, and if need be, fund cover for, the provision of essential services during these core hours.” Particular attention will be paid by the PCT to the arrangements for access to medical treatment in the hours that are core but are not surgery or clinic hours. It is proposed therefore that the following banding will apply to opening hours: Band A: Open in excess of 45 hours during core hours and has clear cover arrangements in place for when the surgery is closed. Band B: Offers the minimum of 45 hours during core hours and has clear cover arrangements in place for when the surgery is closed. Band C: Opening times are unclear, less than core, or has unclear cover arrangements in place for when the surgery is closed, or has opening hours subject to contractor variation without agreement of the PCT. Note: branch surgeries/single handed practices subject to separate agreement. 1.2 Clinical availability for patients The PCT contracts with practices, rather than individual performers. However, ‘Our Health, Our Care, Our Say drew attention to the wide variation in the distribution of general practitioners. It explains: “research also shows that those areas with the poorest health outcomes are also those with the fewest GPs”. Given the priority of tacking health inequalities within Haringey, it is incumbent upon primary care commissioners to ensure that general practitioners’ resources are adequately distributed and reflect the need for us to tackle local variations. The White paper classifies any area with a doctor:patient ratio of less than 57 wte: 100,000 weighted population as under-doctored. Additionally, the bottom 10% of PCTs, with ratios of 40.6 to 47.5 have been targeted for remedial action, including centralized procurement of APMS suppliers if there is no improvement within twelve months. 1.3 Diversion and other access points Primary care contractors have met the challenge of access targets in Haringey, and practices have demonstrated sustainability in achieving these standards. However within the totality of health resources, use of other facilities should be considered in order to ensure adequate access in primary care and to address inappropriate use of these other resources. Use of other providers such as Accident and Emergency Departments or Walk in Centres (WIC) to meet the primary care needs of patients affects contracts with these providers i.e. Acute Trusts PMSBoardPaperNovember2008 30 As part of its commitment to help Practice Based Commissioners understand the behaviour of their patients in these other services, regular data is supplied to practices to enable them to review their performance. Whilst it is acknowledged that there is not a straightforward relationship between practice performance and attendance at the WIC, which may for example be influenced by factors such as proximity and bus routes, the PCT will want practices with attendance at the WIC greater than 1% of its registered list per month to review this activity and establish an action plan to improve access at its own practice. Similarly practice based commissioners will want to review activity at A+E to ensure that unnecessary attendances are not absorbing resources that could be better used to develop services in primary care settings. 1b Main contractual Services 1.5 Registration The regulations around registration of a patient who lives within the agreed and contracted practice boundary area are clear, and the PCT is therefore proposing only two bandings for this standard. The PCT is aware that there is ambiguity at national level in relation to ‘open but full lists’. However, in terms of registering patients, given that the impact is the same as a closed list, this is the reason for proposing only 2 bandings. Band A: Practices fully complying with the contractual registration requirements Band C: Those practices not complying with registration requirements through being open but full, only registering certain types of patients, or operating a waiting list or other restrictive practices 1.6 Clinically and cost effective prescribing Indicator Low Cost Statins % of simvastatin and pravastatin items as % of all statin Band A ≥75% items Band B 65% - 74% Band C ≤64% Rationale: Cost effective prescribing, included in national NHS Productivity indicators Source: PPD Toolkit PPIs % of low cost PPIs (generic) as % of total PPI items Band A ≥87% Band B 81% - 86% Rationale: Cost effective prescribing, likely to be Band C <80% included in national Better Care, Better Value indicator for prescribing Source: EPACT (will be in PPD Toolkit) PMSBoardPaperNovember2008 31 Angiotensin Receptor Blockers (ARBs) % of ARB items as % of total items in BNF section 2.5.5 Band A ≤20% Band B 21-44% Rationale: Cost effective prescribing, likely to be Band C ≥45% included in national Better Care, Better Value indicator for prescribing Source: EPACT (will be in PPD Toolkit) Antibiotics Antibiotic BNF section 5.1 items /STAR PU (Annual figure) Band A ≤0.80 Band B 1.86 – 0.81 Rationale: Better quality prescribing (reduce antibiotic Band C ≥1.85 resistance). Included in the Healthcare Commission Indicators for PCTs Source: PPD Toolkit Healthcare Commission Indicator Generic prescribing Band A ≥80% % generic prescribing Band B 76% - 79% Band C ≤75% Rationale: Cost effective prescribing. Source: PPD Toolkit Drugs acting on benzodiazepine receptors BNF section 4.1 ADQs per STAR-PU (Annual figure) Rationale: Better quality prescribing (reduced side effects Band A ≤4 by not prescribing long term, NICE guidance Band B 4.1 – 6.9 implementation monitoring). Included in the Healthcare Band C ≥7 Commission Indicators for PCTs Source: PPD Toolkit Healthcare Commission Indicator NSAIDs Oral NSAIDs ADQs per STAR PU (Annual figure) Band A ≤2.3 Band B 2.4 – 3.4 Rationale: Better quality prescribing (reduced side effects Band C ≥3.5 by not high volumes long term). Source: PPD Toolkit Prescribing Indicator 1.7 Public Health targets – to be increased, awaiting figures from public health Cervical screening rates as defined by Exeter data. Band A: >90% & within 4% of previous year’s performance Band B: >80% Band C: <80% Immunisation rate for children aged 1 who have been immunized for diphtheria, tetanus, polio, pertussis, haemophilus influenza type b (Hib) Band A: Achieves above 90 % Band C: Does not achieve 90 %. Immunisation rate for children aged 2 who have been immunized for pneumococcal infection (PCV) Band A: Achieves above 90 % Band C: Does not achieve 90 %. Immunisation rate for children aged 2 who have been immunized for haemophilus influenza type b (Hib), meningitis C (MenC) Band A: Achieves above 90 % Band C: Does not achieve 90 %. PMSBoardPaperNovember2008 32 Immunisation rate for children aged 2 who have been immunized for measles, mumps and rubella (MMR) Band A: Achieves above 90 % Band C: Does not achieve 90 %. Immunisation rate for children aged 5 who have been immunized for diphtheria, tetanus, polio, pertussis, haemophilus influenza type b (Hib) Band A: Achieves above 90 % Band C: Does not achieve 90 %. Immunisation rate for children aged 5 who have been immunized for measles, mumps and rubella (MMR) Band A: Achieves above 90 % Band C: Does not achieve 90 %. Immunisation rate for children aged 13 to 18 who have been immunized with a booster dose of tetanus, diphtheria and polio Band A: Achieves above 85 % Band C: Does not achieve 85 %. Influenza vaccine per Miquest data search There is considerable variation in performance at practice level on this indicator. It is proposed therefore to introduce the following banding: Band A: Achieves above 80 % Band C: Does not achieve 80%. 1c Governance 1.8 Quality and Outcomes Framework The quality of services in primary care is acknowledged to be high and much improved as demonstrated by practices high Quality and Outcomes Framework (QOF) achievement.. Practices are banded according to achievement across clinical and non-clinical areas as follows: Band A: >90% achievement Band B: >80% achievement Band C: < 80% achievement 1.9 Level of Compliance with Health Care Commission Standards For Better Health Health Care Commission (HCC) standards have been produced by the Department of Health with the aim to move the health care system from one that is driven by targets to one in which standard are the means to deliver continuous improvements in quality. As a consequence of this change in direction and emphasis, PCT are exploring ways of supporting the introduction of quality and performance standard to general practices. The HCC’s standards are set out at Appendix 3 and now apply to all providers of healthcare in England. The HCC and the PCT are aware that the standards may be onerous for some providers. By completing the HCC template in Appendix 1 the PCT will be able to identify and prioritize the additional resources, facilitation and educational support required in a consistent way to enable practices to implement actions plans as part of their continued development. Where there are highlighted link areas, such as statutory of contractual requirements and QOF domains that are the same as the standards, practice will be able to build on work already undertaken. PMSBoardPaperNovember2008 33 Our aim is full compliance with these comprehensive and established standards, however to start this process, the proposal is for a developmental approach as follows. Each HCC standard will be scored as follows: Level 1 – the practice can demonstrate that the standard is being met and that acceptable evidence can be produced. Level 2 – the practice is aware of the standard and is currently working towards meeting it. Level 3 – the practice does not currently meet this standard and has not started to work towards this. The total score for a practice (for core standards) will then be translated into a Band, as follows: Band Apractices achieving 80% and above of assessment requirements at level 1 Band B practices achieving 65 – 79% of assessment requirements at level 1 Band Cpractices achieving less than 65% of assessment requirements at level 1 1.91 Environment Premises The full requirements for standards pertaining to premises, as noted in the nGMS contract, are contained in Appendix 7. The Banding for this standard is as follows: Band A: Fully compliant Band B: Fully compliant on all but two areas, both of which are capable of remedy Band C: Not compliant with all minimum standards, or with breaches not capable of remedy. In addition, the PCT from time to time undertakes a premises audit of primary care premises. The Estates Department at the PCT would be responsible for this indicator where the building is owned or managed by the PCT. Decontamination In order to comply with HSC 2000/032 “Decontamination of Medical Devices” and The Health Act 2006 the PCT must ensure that arrangements are in place for all primary care providers of services to be compliant with the decontamination requirements of the Medical Devices Directive (MDD) 93/42/EEC. This is a requirement for general practice from March 2007. To this end the PCT is systematically undertaking a review of clinical equipment, infection control and decontamination processes in primary care provider premises. Practices must be compliant with regulations. Practices will be scored as being either compliant or non-compliant. There will only be two bands for this standard. Band A: Compliant Band C: Non-compliant PMSBoardPaperNovember2008 34 2 Contractual and Statutory Requirements The nGMS contract allows for a variety of basic standards, such as each Practice having an up to date practice leaflet, each one having a complaints procedure, conforming to the Data Protection Act, etc. A full list of requirements is appended at Appendix 5. For the purposes of banding, it is proposed that any Practice not delivering basic contractual requirements and which is incapable of remedy within 12 weeks of assessment shall be banded Band C for this section. The basic national standards are an absolute requirement, and therefore only two bandings will be available for this standard: A for fully compliant; C for not compliant. PMSBoardPaperNovember2008 35 3 Enhanced Services Specification 3a Directed Enhanced Services and other 3.1 National Access measures - PCAS As part of the commitment to delivering the 2006-7 and 2007-8 Access DES, practices will be taking part in the revised monthly/quarterly PCAS survey. This monthly survey takes place to assess the extent to which patients can see a GP within 48 hours, and the extent to which they can book an appointment in advance. It is proposed that the following banding applies: Band A: Meets the PCAS standards 100% of the time Band B: Meets the PCAS standards >90% of the time Band C: Meets the PCAS standards < 90% of the time. 3.2 National Patient Survey From 2007 an externally commissioned survey will also seek patient views as part of the negotiated revisions to the primary care contracts. Currently, performance is variable in patient surveys, and the PCT will want to focus on those practices where scores give cause for concern, i.e. are more than 10 % below the national or PCT averages. The survey asked five questions of patients about their experience when accessing primary care services. Four of these questions related to access to primary care and the other question related to recalling a conversation about choice when a patient needed to be referred to a secondary care provider 3.3 Extended Hours (LES) The PCT is offering an interim local enhanced service for Extended Hours in the absence of the anticipated Direct Enhanced Service. Sign up to this ILES is optional but encouraged. The PCT has adopted a flexible approach with practices proposals for extended hours as we recognise that the requirements of each practice's registered patients is likely to be different and there is the need to ensure that any additional service being offered reflects patients needs. Generally proposals would be approved if the practice were to offer sessions of 1 1/2 hours or longer except when offered prior to 8.00a.m or by smaller practices, that concurrent working was evidenced by patient demand or where there are security issues. Practices also confirm that the additional hours will be advertised and communicated to patients and that there has been no reduction in clinical availability during core hours. It is proposed therefore that the following banding will apply to opening hours: Band A: Providing extended hours Band C: Not providing extended hours 3.4 Patient Views The views of patients are critical to the continued success of the NHS, and it is important that we strive to gain views firm our diverse and varied population. The PCT will continue to monitor complaints and improve processes to prevent recurrences. Because the PCT regards complaints as an important source of information for improvement, it does not intent to set standards around the numbers of complaints. Rather complaints should be encouraged as a valuable learning source for all. PMSBoardPaperNovember2008 36 The exception to this is where there are a large number of patient complaints combined with other indicators (contained within this paper) that all not is well. In these circumstances the PCT will wish to take into account patterns of complaints in seeking to validate other sources of concern. More proactive patient involvement should be rewarded, and the PCT is pleased that all practices currently take part in its annual GPAQ survey as part of QOF. From next year an externally commissioned survey will also seek patient views as part of the negotiated revisions to the NGMS contract. Currently, performance is variable in patient surveys, and the PCT will want to focus on those practices where scores give cause of concern, i.e. are more than 10% below the national or Haringey PCT averages. Good practice would suggest that practices should administer the GPAQ and other questionnaires fairly and act on its results, and feedback these results to their patients. The more proactive practices will either have individual patient groups or meetings, or a bespoke leaflet setting out actions arising from a survey so that patients know their views are being acted upon. The following banding in proposed for patient views: Band A: 90% or more overall satisfaction rating Band B: 80-89.99% overall satisfaction rating Band C: 89.99% and below overall satisfaction rating And for acting upon patient views: Band A: Monitors complaints actively, has a robust GPAQ action plan, and has mechanism, either in writing or through a group, for communicating improvements to patients and has other methods for actively seeing the views of patients and responding to those views. Band B: Monitors complaints actively, has a robust GPAQ action plan Band C: Does not have an effective GPAQ action plan Business continuity planning is noted as a statuary requirement for small businesses rather than a contractual requirement 3.5 Choice and Booking Local Enhanced Service This enhanced service was initially for one year only. It has now been extended for 2009/10 as an enhanced service. Practice achievement, in part, will be measured on the outcome of a national patient survey where a patient recalls choice being offered when referred elsewhere for care and this will be considered in terms of performance separately in this document. Practice achievement below relates to the number of referrals by a practice that result in that referral being converted into a Unique Booking Reference Number (UBRN) The above choice and booking targets will be banded as follows: Band A: fully meets the LES criteria and receives full payment PMSBoardPaperNovember2008 37 Band B: partially meets the LES criteria and receives full payment Band C: does not meet the LES criteria and does not receive payment PMSBoardPaperNovember2008 38 Appendix 1 SUMMARY OF PERFORMANCE FRAMEWORK INDICATORS Area & No Description Data Source Band A Band B Band C Rationale Your band Main Service Specification 1a Access 1.1 Opening Compliance with contractual Practice visits >45 hours =45 hours Unclear or National hours requirements for opening and has clear and has clear less than core requirement hours arrangements arrangements when closed when closed 1.2 Clinical Availability 1.3 Diversion and other access points 1b Main contractual services 1.5 Compliance with contractual FHSA Compliant Non National Registration requirements compliant requirement 1.6 Medicines Achievement of clinically and All level 1 All level 1 Does not management cost effective prescribing and 3 and 2 achieve all of targets as identified indicators of indicators of level 1 or level 2 level 2 none of level 2 1.7 Public Health Targets Cervical Percentage of eligible patients Exeter >90% >80% <80% Local target screening whose notes record that a cervical smear has been undertaken in the last five years PMSBoardPaperNovember2008 39 Immunisations Immunisation rate for children > 90% <90% PCT target aged 1 who have been immunized for diphtheria, tetanus, polio, pertussis, haemophilus influenza type b (Hib) Immunisation rate for children aged 2 who > 90% <90% PCT target have been immunized for pneumococcal infection (PCV) Immunisation rate for > 90% <90% PCT target children aged 2 who have been immunized for haemophilus influenza type b (Hib), meningitis C (MenC) Immunisation rate for > 90% <90% PCT target children aged 2 who have been immunized for measles, mumps and rubella (MMR) Immunisation rate for children > 90% <90% PCT target aged 5 who have been immunized for diphtheria, tetanus, polio, pertussis, haemophilus influenza type b (Hib) Immunisation rate for > 90% <90% PCT target children aged 5 who have been immunized for measles, mumps and rubella (MMR) PMSBoardPaperNovember2008 40 Immunisation rate for children aged 13 to >85% <85% PCT target 18 who have been immunized with a booster dose of tetanus, diphtheria and polio Influenza Influenza vaccine >80% <80% PCT target Governance 1.8 QOF Percentage of maximum QOF >90% >80% <80% National QOF points achieved framework 1.9 Health Care Percentage compliance with Annual >80% >65% <65% National commission Standards the Core standards, level 1 Contract requirement For Better Health review 1.91 Environment Premises Premises Compliant Compliant Non audit in all but 2 compliant areas that can be remedied Decontamination Premises Compliant Non National audit compliant requirement PMSBoardPaperNovember2008 41 SUMMARY OF PERFORMANCE FRAMEWORK INDICATORS Area & No Description Data Source Band A Band B Band C Rationale Your band 2 Contractual and Statutory Requirements 3 Enhanced Services and other 3.1-3.3 Access Compliance with PCAS STEIS/ >95% >75% <75% National PCAS standards and standards PCAS target extended hours 48 hour target Percentage of patients who PCAS Fully meets Partially Does not National see a GP within 48 hours DES meets DES meet DES target 24 hour target Percentage of patients who PCAS Fully meets Partially Does not National see a PCT within 48 hours DES meets DES meet DES target Telephone access Patient Fully meets Partially Does not National survey DES meets DES meet DES target Advanced booking Percentage of patients that PCAS Fully meets Partially Does not National can book advanced DES meets DES meet DES target appointments Preferred health care Percentage of patients that Patient Fully meets Partially Does not National professional see GP of choice survey DES meets DES meet DES target 3.4Patient Views 3.5 Choice Percentage of first consultant URBN Fully meets Partially Does not National Choice & Booking out patient referrals made numbers DES meets DES meet DES target LES using the Choose and Book system PMSBoardPaperNovember2008 42 Appendix 2 In the interests of space, the full list of Healthcare Commission Standards has not been re-included here. These are available on request GUIDANCE TO COMPLETE HEALTHCARE COMMISSION STANDARDS FOR BETTER HEALTH CHECKLIST – GENERAL PRACTICE In the NHS, care is provided by or purchased (commissioned) on behalf of patients by NHS trusts. The boards that manage these trusts are responsible for ensuring that the care they deliver meets the Government’s standards. The annual health check recognises this, in that the PCT board is asked to make a declaration about the performance of their trusts against the standards. The Healthcare Commission exists to promote improvements in the quality of healthcare and public health through independent, authoritative, patient- centred assessments of the performance of those who provide services. The new system, or annual health check, measures performance of NHS organisations referenced to the Healthcare Commission standards. The standards cover issues of concern to the public, patients and those who look after them such as safety, patient focus and clinical effectiveness in the healthcare organisation. They are more broadly based than the targets previously used. PMSBoardPaperNovember2008 43 The approach is intended to be the start of a process that will provide a broad and rich assessment of performance. The objective is to improve outcomes for patients and the public now and in the future by: actively involving and engaging patients and the public in our assessments and reviews ensuring that basic standards are being met for everyone promoting improvements in health and healthcare promoting the narrowing of inequalities in the health of different groups in the population All healthcare organisations, (PCT’s, Mental Health Trusts and Hospital Trusts) have been asked to complete a return to the Healthcare Commission from April 2005. From April 2006, PCT’s are responsible for ensuring that independent contractors meet the Healthcare Commission core standards. It is recognised that it will take time to develop systems of engagement and assessment that achieve all these goals. Therefore, the PCT will focus on ensuring that basic standards are being met. The following checklist is designed to assist practices in assessing their own ability to meet the HCC standards; to identify where support is required and assess training need and both the PCT and Practices should ensure that they learn from this information, so that they can improve activities and performance in the future. How do I complete this Checklist? Set out on the following pages are a number of questions, which need to be answered to meet the Healthcare Commission basic standards. You will be required to self assess the practice against the checklist providing a score between 1 and 3. What do the scores mean? Level 1 – the practice can demonstrate that standard is being met and that acceptable evidence can be produced Level 2 – the practice is aware of the standard and is currently working towards meeting it. Level 3 – the practice does not currently meet this standard and has not started to work towards this. PMSBoardPaperNovember2008 44 There will be evidence needed for all of the standards questions. Some of this is already held by the PCT and will be marked as such in the link/evidence columns of the checklist. You will need to produce evidence/information for those questions you have indicated that the practice is at level 1. Please state what the evidence/information is, and where it can be found. Level 2 is identifying that the practice is aware that they need to do this and is making plans to actually get this process underway. For example, if you routinely receive and read the SAB’s alerts at the practice but do not currently reply to them, as you didn’t know you had to, you may prefer to put level 2. The “action needed” column will need to be completed. Level 3 is not classed as fail or poor performer. Using the above example of SAB’s alerts, it may be that they are being sent to an inappropriate person at the practice, possibly at a wrong email address or even not being sent at all. Unless you identify this as an issue by indicating the practice is at level 3, the Primary Care Team will remain unaware, and unable to help you put this right. This may not be an action for the practice, and it is possibly that the practice is unaware of what action to take. In these circumstances, please complete the “action needed” column where appropriate, or use that space for comments. Practices are responsible for undertaking this assessment. The PCT will be providing support for all practices and their Clinical Governance leads in completing the assessment and developing action plans, through specific training events and individual support via the Primary Care Team. SUPPORT AVAILABLE TO PRACTICES Appendix 4 1. GP appraisal and funding for a lead GP appraiser and a continuing GP appraiser support group with input from the London Deanery GP tutor 2. Implementation of the Quality and Outcomes Framework in the GP contract (QoF) 3. Comprehensive range of mandatory and skills and competency specific training courses for nursing, healthcare assistants and non clinical staff 4. Management Development Training for Practice Managers 5. Access to PCT policies for use in practices 6. Occupational health service access for GPs and practice staff 7. Support from Primary Care Team 8. Medical Director PMSBoardPaperNovember2008 45 9. PEC 10. LMC / PCT liaison 11. IT support and training including the provision of templates 12. CRB checks on all GPs 13. Links with the local Deanery 14. Pharmacists’ support on medication reviews and medicines management 15. AIR incident reporting for GP practices and support for SUIs and Significant Event Audits 16. Support on estates issues 17. Targeted visits to practices causing concern 18. A process of scrutiny and sign off of applications to join the performers list, in liaison with the Primary Care Support Services 19. Ad hoc educational events 20. Contractual visits from Primary Care Managers 21. GP clinical leads in specific disease areas 22. Clinical Directors via PbC collaboratives PMSBoardPaperNovember2008 46 Appendix 5 APMS, nGMS AND PMS CONTRACTUAL AND STATUTORY REQUIREMENTS Annual Return and Review Clause 416 The Contractor shall submit an annual return relating to the agreement to the PCT which shall require the same categories of information from all persons who hold contracts with the PCT. Following receipt of the return referred to in clause 416, the PCT shall arrange with the Contractor an annual review of its performance in relation to the agreement. The PCT shall prepare a draft record of the review referred to in clause 417 for comment by the Contractor and, having regard to such comments, shall produce a final written record of the review. A copy of the final record shall be sent to the Contractor. Provision of Information Clause 404 Subject to clause 405, the Contractor shall, at the request of the PCT, produce to the PCT or to a person authorised by it, to access, on request - 404.1 any information which is reasonably required by the PCT for the purposed of in connection with the agreement and 404.2 any other information which is reasonably required in connection with the PCT’s functions 405 The contractor shall not be required to comply with any request made in accordance with clause 404 unless it has been made by the PCT in accordance with directions made by the Secretary of State under section 17 of the Act (Secretary of State’s directions: exercise of functions) Summary of other contractual and statutory requirements 1. The practice provides patients with a leaflet which is available to patients and includes: - practice opening hours - whether an appointments system is operated by the practice for doctor and nurse - appointments - how to access a doctor or nurse - a description of the services provided by all members of the team and how patients can - obtain them - how to obtain repeat prescriptions - how to make a complaint or comment on the provision of service - a description of patients' rights and responsibilities - how the practice uses personal health information. 2. The practice has an agreed procedure for handling patients’ complaints which complies with the NHS complaints procedure and is advertised to the patients. 3. Where patients are requesting to join the practice list, the practice does not discriminate on the grounds of: 3.1 race, gender, social class, age, religion, sexual orientation or appearance 3.2 disability or medical condition. 4. The practice adheres to the requirements of the Medicines Act for the storage, prescribing, dispensing, recording and disposal of drugs including controlled drugs. 5. Batch numbers are recorded for all vaccines administered. PMSBoardPaperNovember2008 47 6. The practice has a policy for consent to the treatment of children that conforms to the current Children’s Act or equivalent legislation. 7. The premises, equipment and arrangements for infection control and decontamination meet the minimum national standards. 8 The practice ensures that all healthcare professionals who are employed by the practice are currently registered with the relevant professional body on the appropriate part(s) of its Register(s) and that any employed general practitioner is a member of a recognised medical defence organisation and registered on a primary care performers list (or equivalent). 9. All professionals working in the practice are covered by appropriate indemnity insurance. 10. All doctors have an annual appraisal. 11. The practice has a system to allow patients access to their records on request in accordance with current legislation. 12. There is a designated individual (data controller) responsible for confidentiality. 13. If the records are computerised there are mechanisms to ensure that the data are transferred when patients leave the practice. 14. If the team uses a computer, it is registered under, and conforms to the provisions of the Data Protection Act. 15. The practice has a written procedure for the electronic transmission of patient at which is in line with national policy. 16. The practice complies with current legislation on employment rights and discrimination. 17. All staff have written terms and conditions of employment conforming to or exceeding the statutory minimum. 18. The practice meets the statutory requirements of the Health & Safety at Work Act and complies with the current Approved Code of Practice in Management of Health and Safety at Work Regulations. 19. Vaccines are stored in accordance with manufacturers’ instructions. 20. Individual healthcare professionals should be able to demonstrate that they comply with the national child protection guidance, and should provide at least one critical event analysis regarding concerns about a child’s welfare if appropriate. 21. All practices have in place systems of clinical governance which enable quality assurance of its services and promote quality improvement and enhanced patient safety. The underpinning structures within the practice, which will assure embedding of clinical governance through a nominated clinical governance lead. 22. For minor surgery, patients consent to any surgical procedures including wart cautery and joint injections is recorded. 23. For vaccination and immunisation, consent to immunisation, or contraindications if they exist, are recorded in the records. PMSBoardPaperNovember2008 48 24. For vaccination and immunisation, fridges in which vaccines are stored have a maximum thermometer daily readings take place on working days. 25. For vaccination and immunisation, staff involved in administering vaccines are trained in the recognition of anaphylaxis and able to administer appropriate first-line treatment when it occurs. General Practice Standards on Human Resources The Standard General Medical Services Contract (Part 14) outlines the regulations in respect of persons who perform services. This states that no medical practitioner shall perform medical services under the Contract unless he is: a) included in a medical performers list for a PCT in England b) not suspended from the list or from the Medical Register c) not subject to interim suspension This does not apply in the case of a medical practitioner who is - employed by an NHS Trust or NHS Foundation Trust who is providing primary medical services at the practice premises; or - provisionally registered under certain sections of the Medical Act acting in the course of his employment in a resident medical capacity in an approved medical practice; or - a GP Registrar within the first two months of his training period. No health care professional other than one to whom the above applies shall perform clinical services under the Contract unless he is registered with his relevant professional body and his registration is not currently suspended. Where the registration (or for a medical practitioner inclusion in a primary care list) is subject to conditions, the onus is on the Contractor to ensure compliance with these conditions, in so far as they are relevant to the Contract. Finally no health care professional shall perform any clinical services unless he has the clinical experience and training as are necessary to enable him to perform such services. Conditions for Employment/Engagement This states that the Contractor shall not employ or engage a medical practitioner unless: a) the practitioner has provided it with the name and address of the PCT on whose medical performer’s list he appears; and b) the Contractor has checked that he meets the requirements for a medical practitioner performing medical services outlined above c) the practitioner has provided two clinical references, relating to two recent posts and which may include any current post the Contractor has checked and is satisfied with the references d) the Contractor has taken reasonable care to satisfy to itself that the person in question: - is suitably qualified and competent - is academically and vocationally qualified; - has undertaken the necessary education and training; and - possesses the necessary previous employment or work experience) to discharge the duties for which he is to be employed or engaged and furthermore will give each employee reasonably opportunities to undertake appropriate training to maintain that employee’s competence. PMSBoardPaperNovember2008 49 Terms and Conditions of Service The Contractor shall only offer employment to a general medical practitioner on terms and conditions which are no less favourable than those contained in the ‘Model Terms and Conditions of Service for a Salaried GP employed by a GMS practice’ in the second blue book. Compliance with Legislation and Guidance Part 22 of the Standard GMS Contract states that the Contractor shall comply with all relevant legislation and have regard to all relevant guidance issued by the PCT, NHS London Strategic Health Authority or Secretary of State PMSBoardPaperNovember2008 50 Appendix 6 CONTRACTUAL SANCTION, REMEDY AND REMOVAL Where the Contractor has breached the Contract, but the breach is capable of remedy, the PCT can serve a remedial notice requiring the breach to be remedied. The remedial notice must specify: - details of the breach - the steps the Contractor must take in order to remedy the breach; and - the notice period, which should be no shorter than 28 days unless patient safety or material loss is at stake. If the Contractor is in breach of obligation and a remedial notice has been issued, the PCT may withhold or deduct monies which would otherwise be available under the Contract in respect of that obligation which is the subject of the default. If following a breach or remedial notice, the Contractor repeats the breach that was the subject of the remedial notice or otherwise breaches the Contract resulting in a further remedial notice; the PCT may serve notice to terminate the Contract. Contract Sanctions This refers to: - termination of specified reciprocal obligations under the Contract - suspension of specified reciprocal obligations under the Contract for a period of six months; or - withholding or deduction of monies payable under the Contract The PCT may impose any of these sanctions where it would otherwise be entitled to terminate the Contract and where it is ‘reasonably’ satisfied that the sanction to be imposed is appropriate and proportionate to the circumstances giving rise to the PCT’s entitlement to terminate the Contract. However the sanction imposed must not have the effect of terminating or suspending any obligation on the Contractor to provide essential services. If the PCT decides to impose a Contract sanction it must notify the Contractor of: - the sanction it intends to impose; - the date on which it will be imposed (at least 28 days after notification unless patient safety or material loss is at stake); and - an explanation of the effect of the imposition of that sanction. However, the Contractor may refer, if they wish, the imposition of a sanction to the NHS disputes resolution procedure. Contract Termination The PCT may serve notice to terminate the Contract forthwith if: PMSBoardPaperNovember2008 51 - there is a breach of contract and as a result of the breach patient safety is at serious risk or the Contractors financial situation is such that the PCT is at risk of material financial loss; or - does not satisfy the conditions under Part 14 or - is subject to national disqualification; or - disqualified or suspended by any licensing body anywhere in the world (other than an interim suspension order pending investigation or suspension on the grounds of ill health); or - removed or refused admission to a primary care list because of insufficiency, fraud or unsuitability - been convicted of murder or an offence under schedule 1 of the Children’s or Young Person’s Act; or - has been convicted of a criminal offence requiring imprisonment for over six months; - an event happens that makes it unlawful for the business to continue or - he has refused to comply with a request from the PCT to be medically examined on the grounds that he is incapable of adequately providing services under the contract; or - where written information provided to the PCT by the Contractor is untrue or inaccurate. In these circumstances, the PCT would be responsible for arranging alternative care for the patients on the practice list. PMSBoardPaperNovember2008 52 Appendix 7 MINIMUM STANDARDS FOR PRACTICE PREMISES 1. As regards the design or construction of the premises, or of the approach or access to the premises, to which the payments relate, the contractor must comply with any obligations it has to its own members (where applicable), staff, contractors and to persons to whom it provides primary medical services under the Health and Safety at Work Act 1974 (and legislation under that Act) and the Disability Discrimination Act 1995. The requirements of the 1995 Act include taking such steps as are reasonable to– a)provide for ease of access to the premises and ease of movement within the premises for all users of the premises (including wheelchair users); b) provide adequate sound and visual systems for the hearing and visually impaired; and c)remove barriers to the employment of disabled people. 2. Adequate facilities should also be provided for the elderly and young children, including nappy- changing and feeding facilities. There should also be adequate lavatory and hand hygiene facilities, which meet appropriate infection control standards. 3. If the premises have a treatment room, this should be properly equipped. An additional treatment room may be required where enhanced minor injury services are provided. 4. The arrangements for instrument decontamination should comply with national guidelines as appropriate to primary care. 5. The premises should have a properly equipped consulting room for use by the practitioners with adequate arrangements to ensure the privacy of consultations and the right of patients to personal privacy when dressing or undressing, either in a separate examination room or in a screened-off area around an examination couch within the treatment room or the consulting room. However, in the case of branch surgeries, this standard need not be fully met if the contractor provides outlying consultation facilities using premises usually used for other purposes, and these meet with the approval of the PCT. 6. The access arrangements for the building should be convenient for all users. 7. There should be washbasins connected to running hot and cold water (ideally distributed through elbow, knee or sensor-operated taps) in consulting rooms and treatment areas. 8. There should be adequate internal waiting areas with– a) enough seating to meet all normal requirements, either in the reception area or elsewhere; and b) the facility for patients to communicate confidentially with reception staff, including by telephone. 9. There should be adequate standards of lighting, heating and ventilation. 10. The premises, fittings and furniture should be in good repair and (when being used for the provision of primary medical services) clean and hygienic. 11. The arrangements for the storage and disposal of clinical waste should comply with current legislative requirements and national guidelines. PMSBoardPaperNovember2008 53 12. There should be adequate fire precautions, including provision for safe exit from the premises, designed in accordance with the Building Regulations agreed with the local fire authority. 13. There should be adequate security for drugs, records, prescription pads and pads of doctors’ statements. 14. If the premises are to be used for minor surgery or the treatment of minor injuries, there should be a room suitably equipped for the procedures to be carried out. PMSBoardPaperNovember2008 54