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									                Contract Specification: LES - Enhanced Diabetes Care (GG&C) 2012-13 Final

                                                                                                                28/03/2012
LES - Enhanced Diabetes Care

Contract Mechanism and Specification 2012-13


Introduction

1. All practices are expected to provide essential and those additional services they are contracted to provide to all
their patients. This enhanced service specification outlines the more specialised services to be provided. The
specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are
beyond scope of essential services. No part of the specification by commission, omission or implication defines or
redefines essential or additional services.

This specification deals with Primary Care Services to patients with diabetes and enhances the services provided by
general practices achieving the quality indicator points in this area.


Background

2. From data provided as part of the 2002 Scottish Diabetes Survey, it is apparent that diabetes affects more than
150,000 people in Scotland. In 2002/03, estimated costs within the NHS in Scotland for the treatment of diabetes and
its complications amounted to £320 million. Overall, this expenditure equates to 10% of the entire NHS budget. The
most expensive cost component relates to hospital in-patient treatment for the long-term complications of diabetes.
This does not take account of the significant consequential human and social costs related to diabetes which are less
easily measured.

Diabetes is associated with significant morbidity and early mortality and this presents a considerable challenge to
health care professionals. The complications associated with diabetes include cardiovascular disease, stroke,
blindness, renal failure and lower limb amputation. Many of these complications can be prevented or delayed through
early diagnosis and the provision of effective and integrated care.

Clear direction on how these health challenges can be effectively addressed is set out in the Scottish Diabetes
Framework. This framework was designed to complement the diabetes SIGN Guideline and NHS QIS Clinical
Standards for Diabetes. Its purpose was to provide the mechanisms whereby NHS Boards and ultimately health care
professionals could implement demonstrable improvements in diabetes care.

Taking account of the national standards and guidance, provision of enhanced services for people with Type 2
diabetes in primary care will have the longer term benefits of:

       Long term health gain for people with diabetes
       Reduction of increasing costs of treating complications arising from diabetes

nGMS QOF is limited and does not, for example, address the important factors of diet, exercise and alcohol. The
Diabetes SIGN guideline underlines the importance of a holistic approach. NHS Greater Glasgow & Clyde has
provided services to support smoking cessation, improving eating habits, getting more active and weight
management. The LES will ensure a systematic approach, not only to the medical model, but also to the other risk
factors which can contribute significantly to potential risk reduction. In addition, depression limits an individual’s ability
to change health related behaviours and increases mortality risk. This LES addresses that issue and does not
mandate the pursuit of health related behaviour change until the issue of depression has been addressed.

Diabetes data entered on the LES screens are extracted from Practice clinical systems and held on behalf of
Practices on the NHSGG&C “LES Server” at Gartnavel Royal Hospital. Only two members of the IT Department
Software Development Team have unrestricted access to these data. These data are used for Contract monitoring,
payment and support purposes. Should NHS or any other staff wish access to these data, permission must be sought
for access to anonymised data. Permission is required from the Data Quality Group, a sub-group of the Enhanced
Services & QOF Workgroup, which has LMC representation. Access to data will not be given without due reason and
is not expected to be given for unanonymised patient data.


Scope of this scheme

3. This scheme is for the provision of general medical services and the enhanced services set out at paragraph 5 to
diabetes patients.



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                Contract Specification: LES - Enhanced Diabetes Care (GG&C) 2012-13 Final

                                                                                                           28/03/2012

Aims

4. To ensure that:
    (i) patients with Type 2 diabetes have equal access to an enhanced level of service from practices that is
          designed to ensure that their health needs are appropriately and effectively addressed
    (ii) clinicians are provided with the knowledge, training and resources to enable them to deliver and manage
          effective care for patients with Type diabetes at an enhanced level
    (iii) patients with Type 2 are provided with structured and well organised services
    (iv) the complications associated with diabetes are managed appropriately and prevented where possible


Service outline

5. This local enhanced service will fund:
    (i)    the provision of an annual review of Patients with Type 2 Diabetes
    (ii)   completion of the review items which are not included in the Quality and Outcomes framework of the New
           GMS Contract (as agreed by LMC) and record them using the agreed method.
    (iii) maintenance of adequate skills and knowledge to satisfy appraisal as a GP who carries out enhanced
           diabetes care in your practice. Ensure adequate skills and knowledge in employed or subcontracted staff
           who carry out enhanced diabetes care in your practice
    (iv) facilitation of accommodation of other professionals contributing to the Diabetes Annual Review, unless
           other arrangements have been agreed
    (v)    ensure appropriate referral for patients with poorly controlled diabetes or those with complications as per
           the agreed referral document (as agreed between LMC and Diabetes MCN)
    (vi) initial stabilisation of newly diagnosed Type 2 Diabetic patients and referral for education
    (vii) aim for blood pressure target as agreed in local guideline
    (viii) Allow the extraction to the local SCI – DC Clinical Information System of the agreed data set on all patients
           with diabetes on the practice register (As agreed between LMC and Diabetes MCN).


Accreditation

6. Those doctors who satisfy at appraisal and revalidation that they have such continuing medical experience, training
and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally
qualified to do so.

First Level Registered Nurses are accountable for their own practice and must keep abreast of all new developments
relating to their clinical practice. Therefore those nurses delivering the LES must have completed either a Diabetes
diploma course or the 1.5 day Diabetes training course run by NHSGG&C. Those who participate in delivering this
LES as part of their clinical remit are expected to attend, on an annual basis, update training provided by NHSGG&C.


Costs

7. In 2012-13 each practice contracted to provide this service will receive an annual payment of £29 per patient with
type 2 Diabetes (paid quarterly in arrears) for whom the appropriate LES work has been carried out and recorded on
the appropriate computer screens. For payment purposes, the full payment recording level corresponds to 90% or
more of the appropriate LES fields on the CDSS / EMIS template or INPS guideline (as per the payments screen). A
recorded level of 75-89% of the LES fields on the template will attract a payment of £20.00 per patient. A recorded
level of 65-74% of the LES fields on the template will attract a payment of £14.00 per patient. Patients with a recorded
level of the LES fields on the template of under 65% will be deemed not to have had the appropriate LES work carried
out and no payment will be given.

Practices in areas carrying out this LES for the first time will have lower payment thresholds, being 15 percentage
points below those applied to experienced Practices. Thus the full payment threshold will be 75%, with the lower
payment thresholds being 60% and 50%, This will apply only to Practices in an area in the first year that the LES has
been commissioned.

EMIS Practices can use either EMIS or “CS for EMIS” templates (when these become available). Practices with INPS
clinical software will use the “guidelines” developed jointly by NHSGG&C and INPS, or “CS for Vision” templates,
when these become available. NHS Greater Glasgow & Clyde has developed new LES payment screens to enable
Practices to view the activity and payment status of all their patients.



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               Contract Specification: LES - Enhanced Diabetes Care (GG&C) 2012-13 Final

                                                                                                          28/03/2012
An “administration” payment of £5 will be made in respect of CHD patients exception coded as DNA, Housebound
etc., unless the EMIS / CDSS / guideline screens are completed to a level that triggers an achievement payment,
when the appropriate achievement payment will be made.

Initial payments (quarters 1 to 3) will be made where 90% or more of the fields on the LES payment screens are
completed. At year end a payment reconciliation will be carried out and final payment will be made, comprising full,
partial and administration payments.

Both parties will provide a minimum of 3 months notice if they wish to withdraw from
the contract. This 3 month notice period applies unless there are fewer than 3 months remaining in the current
contractual year. In this instance, less than 3 months notice may be given by either party.


Additional Information

8. A combined CHD & Diabetes disease template has been designed to assist those Practices that hold co-morbidity
consultations. This or the separate CHD and Diabetes templates can be used by the Practice Nurse, along with the
HRB template, whichever is easiest for the Nurse.

The major amendments from 2011/12 are as follows:
   a. The weighting of the LES indicator/business rules to reflect the importance of specific indicators and the time
       it might take a Practice Nurse to cover the area. The HRB indicators to be a total of 60% of the indicator
       achievement.
   b. The combined CHD & Diabetes template, for use by Practices that wish it.




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