Everyone Counts:
Planning for Patients
(Focus on changes regarding ≥75yrs and those
with complex needs)
1
Key contractual changes for practices
The government has determined that there
will be a specific focus during 14/15 on those
patients aged ≥75 yrs and those with
complex needs
All patients aged ≥75 yrs
to have an accountable
GP.
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For those that need it to
have a comprehensive
and co-ordinated package
of care.
New enhanced service (national)
• There will be a new enhanced service to improve
services for patients with complex health and care
needs and to help reduce avoidable emergency
admissions.
• This will replace the QOF QP domain and the
current enhanced service for risk profiling and care
management and will be funded from the resources
released from these two current schemes.
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New enhanced service (continued)
•
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The key features of the scheme will be for GP practices to:
– Improve practice availability, including same-day telephone
consultations, for all patients at risk of unplanned hospital admission
– Ensure that other clinicians and providers (eg A&E clinicians,
ambulance services) can easily contact the GP practice by telephone
to support decisions relating to hospital transfers or admissions
– Carry out regular risk profiling, with a view to identifying at least two
per cent of adult patients – and any children with complex needs – who
are at high risk of emergency admissions and who will benefit from
more proactive care management
– Provide proactive care and support for at-risk patients through
developing, sharing and regularly reviewing personalised care plans
and by ensuring they have a named accountable GP and care
coordinator
– Work with hospitals to review and improve discharge processes;
– Undertake internal reviews of unplanned admissions/readmissions
Key requirements for CCGs
• To support practices in transforming the care of
patients aged 75 or older and reducing avoidable
admissions by providing funding for practice plans to
do so.
• To provide additional funding to commission additional
services which practices, individually or collectively,
have identified will further support the accountable GP
in improving quality of care for older people.
• This funding should be at around £5 per head of
population for each practice, which broadly equates to
£50 for patient aged 75 and over.
pg14, paragraph 36, Everyone Counts: Planning for Patients 2014/15
to 2018/19
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Practice
Area Team
CCG
Accountable GP
£5/pt investment
Comprehensive
package of care
Care Homes LES
MDT LES
New DES to support
practices to implement
changes
Risk stratification tool
Reduce avoidable admissions
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£5/pt investment provides opportunity for
innovation in primary care to help improve
quality and deliver efficiencies (CCG QIPP
target 14/15 circa £15m on total budget
circa £400m) .
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How does the £5/pt investment fit with existing
programmes?
New CCG
multi-agency
falls work
Admission
prevention
network
Dementia
services
CCG Care
Homes
contract
(LES)
Practice plans to
improve quality of care for
older people
Reduce admissions
£5/pt
CCG funded
Community
Geriatricians
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National Risk
stratification
DES
CCG winter
planning
work
CCG MDT
contract
(LES)
New trust 7
day working
How could the £5/pt investment be used to reduce
admissions?
Regular review of
housebound/socially
isolated patients?
Local/practice
further development
of care homes
service
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Link with other
practices to offer
a new service?
Group together in
localities and
increase opening
hours?
What could £5/pt investment be used… (continued) ?
Increased use of
risk stratification tool
– identify “at risk”
groups? Tool live from
Rapid review of falls
patients not needing
admission?
June/July
Self care education?
Review patients
on complex drug
regimes?
What are your ideas?
Time to innovate…..
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What might outcomes look like?
Improved
patient
experience?
Reduce
avoidable
admissions?
Evidence of
clinical
interventions
made?
Reduce exception
reporting in COPD
A unified approach or a
practice specific approach?
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How can the CCG support your practice
• Meet with practices or locality to talk through
these changes and help develop an action plan.
• Create template for action plan.
• Facilitate training and education.
• IT solutions.
• What else?
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Payment mechanisms
• Payments will be based on list size as of 1st April 14.
• Practices will receive 50% of payment in April 14
upon submission of their action plan.
• ?% will be based on practice achievement?
• ?% will be based on locality achievement?
• ?% if all localities achieve target?
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For discussion
Timescale
By end of February
• CCG to create a template action plan and circulate to
practices.
February – mid March
• Meetings between practices and CCG representatives will
take place over the next four weeks to help support practices.
• Schedule in a March locality meeting, discuss draft plans.
By 31st March
• Practices to submit plans into the CCG by 31st March 14.
14
Tea Break
Break into localities for further
discussion
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Purpose of locality discussions
1. Discuss how we can improve the quality of care for
our patients aged 75yrs and over using the £5/pt
investment. Generate ideas.
2.Discuss together what outcomes might look like.
3. What support practices need the CCG to provide.
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Facilitation of locality discussion
Focus on £5/pt first, other business at the end.
CIA - KB and Lois T
SBS – MS and Claire P
Ipswich – IQ, David B
DHG – PK, Louise H
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