Contract meeting for Sessional GPs June 2013 Dr Patricia Moultrie Glasgow LMC Sessional GP Representative Glasgow LMC What is a Local Medical Committee? elected committee of local GPs represents GPs in Glasgow and Clyde provides support and advice to GPs and practices Glasgow LMC Funding • voluntary levy paid by all GPs, cost dependent upon list size • levy also finances the LMC’s contribution to the GP Defence Fund for national GP representation Glasgow LMC Helping individual GPs • The LMC provides help and advice to assist GPs steer through the NHS. Such help is available on all matters relevant to general practice including: – – – – – – – – Workload issues Coping with change GPs’ remuneration GPs’ terms and conditions of service Complaints Premises/Partnership affairs Any disputes which may occur Sick doctors and those with performance problems Glasgow LMC National debate and policy setting Scottish and National Conferences of LMCs. Proposals from individual LMCs across the country are debated alongside those from the GPC. The outcome of the debate determines the framework for the profession’s negotiations at both national and local levels. Glasgow LMC Glasgow LMC and Sessional GPs relationship communication representation information common interest Glasgow LMC Contact Glasgow LMC Dr Patricia Moultrie, Sessional GP Representative on pamoultrie@doctors.org.uk Mrs Mary Fingland, Office Secretary on mary.fingland@glasgow-lmc.co.uk Glasgow LMC Components of the Current GMS Contract Alastair Taylor Vice Chair Glasgow LMC Glasgow LMC Funding Streams • • • • Global Sum & MPIG Quality and Outcomes Framework Enhanced Services Health Board - administered funds, including seniority • Premises • IM&T • Dispensing/personal administration of drugs Glasgow LMC Global Sum • Calculated (Scottish Allocation Formula) to reflect: • The age and sex structure of the practice population (demography) • The additional need of the practice population (morbidity and deprivation) • The rurality and remoteness of the practice population • Creates a “Weighted List” to allocate the Global Sum Glasgow LMC Global Sum Covers: • • • • Essential Services Additional Services Staff Costs Locum Reimbursements (for appraisal, career development and protected time) • The cost of GPs “employers superannuation” contributions for those funding allocations mapped across from the old red book contract. Global Sum Deductions • For opting out e.g – Out of Hours 6.0% – Cervical Screening 1.1% Glasgow LMC MPIG • Minimum Practice Income Guarantee • MPIG = Global Sum via formula+ Correction Factor • Correction factor = How much greater Global Sum Equivalent was than Calculated Global Sum Glasgow LMC Quality Outcomes Framework QOF • Clinical Areas: • Atrial fibrillation, CHD, Heart failure, Hypertension, Peripheral arterial disease, Stroke and TIA, Diabetes mellitus, Hypothyroidism, Asthma, COPD, Dementia, Depression, Mental health, Cancer, Chronic kidney disease, Epilepsy, Learning disabilities, Osteoporosis, Rheumatoid arthritis, Palliative care, Cardiovascular disease - primary prevention, Obesity, Smoking, Cervical screening, Child health surveillance, Maternity, Sexual health Glasgow LMC QOF (2) • Quality and productivity (QP) e.g. Referrals/ACP • Patient experience (PE) – 10 min appointments • Quality improvement (QI) – Trigger Tools/Patient Safety Questionnaire • Medicines management (MM) • Public health (PH) “Blood pressure” in over 40s Glasgow LMC Enhanced Services • Directed (DES) – e.g. Childhood Immunisation, Flu jabs, Extended Hours • Local (LES) – E.g. CDM Glasgow LMC Other Streams • Seniority: – starts after 2 years in post (6 yrs reckonable) • Premises – Cost Rent/Notional Rent • IM&T – Hardware and Software supplied – to specification • Dispensing – Won’t discuss here Any Questions for the Panel at the End? Glasgow LMC Contributing to practices’ contract work 2013/14 Dr John Ip Glasgow LMC Importance of QOF • • • • Significant funding for practices Increased levels of work More indicators Higher thresholds Glasgow LMC 2013 QOF Changes- RA • New Rheumatoid Arthritis domain • 4 indicators total of 18 points Glasgow LMC 2013 QOF Changes- RA • Register (1 point) • Annual face to face Review (5 points) • Assess CVD Risk 30-85 years using ASSIGN (7 points) • Assess Fracture Risk 50-91 years using FRAX (5 points) Glasgow LMC 2013 QOF Changes • Diabetes –Annual dietician review (3) –New patients- referral to Structure Learning Programme (11) –ED screening, advice (4) & treatment (6) • COPD –O2 Sat for Grade 3 and above (5) Glasgow LMC 2013 QOF Changes • Depression –Biopsychosocial assessment at time of new diagnosis –10-35 day review after diagnosis • Primary Prevention CVD –SCOT-PASQ for patients with HT diagnose after 1 April 2009 Glasgow LMC Glasgow LMC 2013 QOF Changes • All 15 month targets are now 12 months • Some thresholds for full achievement increased ( 5-10% increase) Glasgow LMC Other Contract Work • • • • Medicines Management ScriptSwitch Anticipatory Care Pathways & eKIS Polypharmacy Reviews Glasgow LMC Tips for EMIS Glasgow LMC Correct Coding • • • • Using Templates Values e.g. BP, BMI Medication Reviews Smoking Status & advice Glasgow LMC Reviews of Patient • LARC advice for Contraceptives • Dementia review Glasgow LMC Population Manager • The Pop up boxes • What do they mean? Glasgow LMC Other Tips • Searching in consultations • Audit trail for medicines Glasgow LMC Questions? Glasgow LMC Anticipatory Care Planning, Poly-pharmacy and KIS 24th June John Nugent Clinical Director 52 Anticipatory Care Planning, Polypharmacy • Improving Care for Patients at High Risk of Emergency Admission • ‘…appropriate ACP can improve the quality of care, reduce the risk of medication harm and either (or both) the number of future admissions and lengths of stay…’ • ‘As poly-pharmacy can significantly increase the risks (of admission/harm)…it has been agreed as appropriate to include’ 53 What is/the point of an ACP? • Improving the quality of care; • ‘Anticipatory care planning encourages people to adopt a ‘thinking ahead’ approach and to have greater control and choice by planning for what their preferred support and care interventions would be in the event of a future flare-up or deterioration in their condition, or a carer crisis.’ 54 QOF QP • Identifying patients for ACP and Poly-pharmacy Reviews • Using a SPARRA risk threshold of between 40% (20%) and 60% will generate a cohort of around 5% of patients in the practice to fulfil the QP006 indicator • Working down from an ‘upper ceiling’ of those with a 60% risk score will enable the practice to improve outcomes for people most likely to benefit from an Anticipatory Care Plan and a poly-pharmacy review. • This will complement other local ACP initiatives that target cohorts with greater than 60% SPARRA risk 55 Rationale • Patients < 60% SPARRA risk more likely to be engaged with the practice team than active on the community nursing caseload i.e. mobile • Interventions < 60% represent earlier intervention likely to reduce escalation of dependency and to optimise adherence to medicines. 56 Guidance • Scope to apply clinical judgement to what constitutes 'at risk of emergency admission' ; may be patients who would benefit from an ACP but do not have a risk score within the risk thresholds specified • The Key Information Summary (KIS); tool by which practices create and share (with consent) ACPs • Summary of medical history/patient wishes, replaces paper based faxing between GPs and OOH • More generic version of the electronic Palliative Care Summary (ePCS). 57 Guidance • Current ePCS patient information will transfer automatically to KIS but needs checked once KIS is switched on (ePCS patients that transfer automatically to KIS will not count as part of the cohort required for QP006 and QP007) • NHS24, SAS, A&E, OOH and Acute Admission Areas already have access to KIS • Access in other acute areas/departments depends on Board PMS systems and clinical portal developments 58 Poly-pharmacy • 50% drugs not taken as prescribed • 5-17% admissions due to adverse reactions • If on multiple medications more side effects • Potential harm of drug may outweigh benefit QOF QP; QP004(S), 7 points • QP004(S). The contractor meets internally to review data on emergency admissions, for patients on the contractor's registered list, provided by the NHS Board and the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S) • Template for reporting will be agreed nationally 60 QOF QP; QP005(S), 17 points • QP005(S). The contractor participates in an external peer review with either a group of local practices, or practices from within the board area, to compare its data on emergency admissions and to share the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S), and proposes areas for internal practice improvement and service design improvements for the NHS Board. 61 QOF QP; QP006(S), 5 points • QP006(S). The contractor produces a list of 5 per cent of patients in the practice, who are predicted to be at significant risk of emergency admission or unscheduled care. This list can be produced using a risk profiling tool accessible to practices e.g. SPARRA, or where this is not available/required (by local agreement), alternative arrangements can be agreed between the NHS Board and LMC. 62 QOF QP; QP007(S), 30 points • QP007(S). The contractor identifies a minimum of 15 per cent (in 2014/15, 30 per cent) of those patients from the list produced in indicator QP006(S) who would most benefit from an Anticipatory Care Plan (the ACP must include a poly-pharmacy review), be shared with the local out of hours service and has an appropriate review date. The frequency of each patient’s review should be determined in the light of their clinical and care needs. The contractor will be responsible for ensuring that an appropriate system is in place for monitoring and reviewing the patients identified in this cohort. 63 QOF QP; QP008(S), 10 points • QP008(S). The contractor holds at least 4 meetings during the year to review the needs of the relevant patients in the practice ACP cohort, to agree any required changes in the patient management and to share learning/ identify learning needs. These meetings should be open to multi-disciplinary professionals who support the practice’s patients 64 QOF QP; QP009(S), 10 points • QP009(S). The contractor produces and submits a report to the Board before 15 March 2014 on internal practice and wider NHS Board system changes that may benefit patients with Anticipatory Care Plans (ACPs). The report should include Significant Events Reviews (SERs) on 1/1000, to a maximum of 3 patients per practice, of patients with ACPs from the cohort in QP007(S), who were admitted during the QOF year, after their ACP had been created. If less than the required number of patients with ACPs were admitted during the QOF year then the practice should write SERs of the care of an equivalent number of these patients who remained in the community. 65 Summary • Patient centred care; closer to home, reduced harm • Carers; communication, support • Practices; supports review, professionally satisfying, reduces ‘chaos’ (use) • Boards; reduced admissions/lengths of stay • Improves interface working • Not about keeping anyone out of hospital who needs hospital 66 Issues - now • • • • • • • SPARRA; ‘push not pull’ Review and decide who would most benefit See in surgery/home KIS; EMIS now, VISION 2 weeks MDTs; membership, review Poly-pharmacy review; overlap with LES ‘Face-to-face’ 67 Poly-pharmacy; overlap with LES • Practices should generally only make one claim for payment for a poly-pharmacy medication review, per patient, during 2013/14 • Exceptional cases may arise when an ACP/PP should be developed after a Poly-pharmacy LES review has occurred or vice versa • Payment can only be claimed on behalf of the same patient for a Poly-pharmacy LES and a ACP poly-pharmacy medication review during 2013/14 if; a. there are 2 distinct reviews recorded in the patient’s record b. there is clear clinical justification to demonstrate the need for a repeat review for the same patient during the lifetime of the 2013/14 Poly-pharmacy LES Clinical Justification • The clinical justification would include a change in a patient`s clinical status due to one or more of the following occurring; 1. Hospital admission at least 1 month after the first polypharmacy review (ACP/PP or PP LES) had taken place 2. New clinical diagnosis 3. Deterioration in existing clinical condition requiring 3 or more either changes to drug or drug dose (oral or parenteral medication only) 4. Patient needing to go onto the palliative care register Issues - later • Role of DN/PN/Pharmacy support? • Learning? • Board support? 70 Information held on KIS • Significant Diagnoses and PMH • Prognosis • Medication and allergies • Current Care Needs • Help at home (e.g. Social Services / Care Packages) • Legal Issues (e.g. AWIA, Power of Attorney) • Preferred Place Care • End of Life Care wishes • DNA-CPR information • Free-text Anticipatory Care Plan Example of a KIS which has been developed over a period of time? Summary of main issues Summary of main issues Plan of action in event of a deterioration Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN Details of other professionals involved in care Summary of main issues Plan of action in event of a deterioration Medication that can be used as PRN Details of other professionals involved in care Contact details of family member Information available on KIS Patient Safety Indicators Sessional GPs Dr Paul Ryan, Clinical Director, NE Sector SPSP in PC • Aim is to reduce the number of events which could cause avoidable harm from healthcare delivered in any primary care setting • “All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016” Three key workstreams • Leadership and culture improving patient safety through the use of trigger tools (structured case note reviews) and safety climate surveys • Safer medicines: including the prescribing and monitoring of high risk medications, such as warfarin and disease-modifying anti-rheumatic drugs (DMARDs) and developing reliable systems for medication reconciliation in the community • Safe and effective patient care across the interface by focusing on developing reliable systems for handling written and electronic communication and implementing measures to ensure reliable care for patients GG&C plans for SPSP in PC implementation • Leadership and Culture: covered by QOF. 11 points to undertake safety climate survey and trigger tool review • High risk area we are concentrating on is “Safer medicines: developing reliable systems for medication reconciliation in the community” Guidance Patient Safety Indicators Indicator PS 1 PS 2 The practice conducts two case note reviews, using a validated tool, to detect patient safety incidents, meets to discuss the results, and shares a reflective report on actions and themes that arise from this with the Health Board The practice conducts a safety climate survey with all staff, clinical and non-clinical, using a validated tool, meets to discuss the results, and shares a reflective report on actions that arise from this with the Health Board Points 6 5 Adverse Event Causation Technical Factors (30-20%) Accident Causation (70-80%) Human Factors = Safety Culture + Operator Behaviour Positive Safety Culture • • • • • • • Safety a Priority Eliminate “shame and blame” Accept staff will make errors Build systems to make care safer Foster a culture where people can speak up Team training Organizational learning from errors and near-misses Why is a strong Safety Culture Important? A strong safety culture essential to safe reliable care in any workplace Francis Report and Culture • There was an atmosphere of fear of adverse repercussions • There was a lack of openness • It did not listen sufficiently to its patients and staff or correct deficiencies highlighted • Above all it failed to tackle an insidious negative culture involving tolerance of poor standards Francis Report Recommendations • Openness – enabling concerns to be raised and disclosed freely without fear • Transparency – allowing information about performance and outcomes to be shared • Candour – ensuring that patients harmed by healthcare are informed • Replace culture of fear with culture of openness honesty and transparency • Real involvement of patients in all that is done. Safety Climate Survey • • • • • On line Practice centred Measurement Diagnosis Catalyst for change How does the SafeQuest Safety Climate Survey work in practice? Trigger Review • Reviewing your clinical records is the oldest form of audit! • Looking for evidence of (undetected) safety incidents/latent risks • Help you direct safety-related learning and improvement • Quick and Structured versus Slow and Open • Clinical triggers help you to navigate your records quickly • Links with SEA and Quality Improvement • Evidence for QOF, Appraisal and GPST etc. • Random sample of 25 patients – high risk groups (e.g. >75 years, multiple morbidity/poly pharmacy) • Review the last 12-week period only (x2 3mths apart for QOF) • Takes between 90 minutes to 3-hours • Tested with large groups of GPs, Practice Nurses and GP Trainees “Triggers” in Clinical Records ‘‘Triggers’’ are defined as easily identifiable flags, occurrences or prompts in patient records that alert reviewers to actual or potential safety incidents (undetected) Sections in GP Records Triggers Clinical encounters (documented consultations) ≥3 consultations in 7 consecutive days Medication-related (acute and chronic prescribing) Repeat medication item stopped Clinical read codes High, medium, low, allergies New ‘high’ priority or allergy read code Correspondence Section Secondary care, other providers OOH / A&E attendance / Hospital admission Investigations Requests and results eGFR reduce <5, Hb < 10.0, INR > 5.0 Medicines Reconciliation Care Bundles A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.” • The steps must all be completed to succeed • The “all or none” feature is the source of the bundle’s power • Pass/fail Medicines Reconciliation – care bundle measures • Has the Immediate Discharge Document (IDD) been workflowed on the day of receipt? • Has medicines reconciliation occurred within 2 working days of the IDD being workflowed to the GP? • Is it documented that any changes to the medication have been acted on? • Is it documented that any changes to the medication have been discussed with the patient or their representative within 7 days of receipt? • Have all the above measures been met? Knowledge Page hhtp://www.knowlegde.scot.nhs.uk/spsp-ps.aspx