Governing Body report
Paper: 5.5
Date
6 May 2014
Title of paper
Commissioning Learning Sets report
Presenter
Dr Rachael Garner, WLCCG
Author
Jude Channon, Locality Manager
Responsible Director
Simon Hope, Deputy Managing Director
Clinical Lead
Dr Rachael Garner, Vice Chair
Confidential
No
The Governing body is asked to:
Note the contents of the report.
Summary of purpose and scope of report
This report provides an overview of the key points of discussion at the CLS meetings in March 2014 and April 2014.
The main agenda items were as follows:
•
•
March: CLSs in 2014/15; evaluation CLS plus buddying scheme; process for raising issues at Chelwest
&Imperial; paeds and Paediatric A&E audit
April: Practice spotlight; CLS Plan 14/15; LES/out of hospital transition; whole systems integrated care;
patient experience; PCMHS; supporting workforce transformation.
Soft Intelligence
March
NE CLS: GP raised an issue regarding a long delay in accessing the MSK service and problems with the transfer of
patients from the old MSK service to new service.
SE CLS: A high volume of DNAs to C&W's ultrasound service noted. It was suggested that this was due to the booking
system
SW CLS: Lack of follow up of results after endoscopies by secondary care
Actions:
MSK – The provider has liaised with the practice to investigate the patient case
DNA’s to C&W’s ultrasound – The Trust has responded by indicating that a dedicated radiology referral email has
been established - caw-tr.radiologyreferrals@nhs.net, the reception area has been altered so more calls can be
handled and there are now extra evening and weekend appointments.
Endoscopy results - PID examples sent to Trust for investigation. Chelwest has responded by indicating that they are
aware of some process and staffing issues with the virtual clinic in Gastroenterology that is tasked with reviewing and
informing GPs of the test results. This matter has now been rectified so the service should have improved since the
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Paper: 5.5
beginning of the year.
April
NC CLS – There is an issue with CLCH’s Single Point of Access – staff finding it hard to get through over the phone.
There also appear to be a large amount of duplicate imaging results being sent from St Mary’s to Practices and long
waits for call back from the ‘Itchy Sneezy Wheezy ‘service.
NW CLS – Confirm what proportion of patients who attend community dermatology are referred on to secondary
care.
SE CLS – Investigate why the service from the Memory Clinic seems to be not meeting some patient’s needs. There
are also reported long waits with this service.
SW CLS – Blood tests sent to Chelwest have gone missing.
NE CLS – MSK would not accept a referral by fax when choose and book was down. The service does not seem to
refer patients on when needed but instead sends them back to their GP to refer. A patient with chronic renal disease
was rejected on the basis that not much could be done for the patient. GP unsure of where to go next.
Actions:
Single point of access - Locality Manager has asked practice for details on the case and will raise this with CLCH
Community dermatology -18/1776 attendances have been onward referred (1%). Monitored monthly by referral
destination and indication by the CCG and the Community Dermatology service provided by Chelsea &Westminster.
Memory clinic - Locality Manager to raise concerns with the CCG's commissioner of the Memory Clinic and review
ways in which the service can be improved.
Chelwest blood tests - The practice has been asked to send details of the cases to the Locality Manager in order to
follow up with the Provider.
MSK Service – The service to be contacted for a response to issues raised above.
Renal service – To be escalated to GP queries
Results of the Paediatric A&E Audit in March
•
•
•
•
•
CLS groups were each given data showing Paediatric A&E Attendances per CLS by Practice
Period: full year forecast outturn for 2013-14 using M6 (Sep) YTD data/6*12
Data Source: SUS Accident and Emergency
Capitation List Size as at 01-07-2013
A&E Criteria: A&E Departments only, patients aged <19yrs
Practices were then asked to answer a series of questions in small groups relating to how they would reduce
paediatric A&E attendances. Practices were also asked to submit two plans per Practice of actions they would be
taking to reduce these attendances as well as allocate tasks to specific individuals and create timelines for their
plans.
COLLATED RESULTS OF PAEDIATRIC A&E AUDIT MARCH 14
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Paper: 5.5
How many A&E attendances were in surgery hours and out of hours?
Frequent
attenders: in
hours
Out of hours
Single
attendance: in
hours
Out of hours
NC
81
NW
72
NE
130
SE
100
SW
73
40%
136
147
184
127
78
60%
34
34
27
39
28
47%
27
56
56
59
34
53%
For frequent attenders, were the clinical reasons for the A&E attendance quite different or was there a trend in
presenting complaints?
NC
Yes, there
16
was a trend
No, there
54
was not a
trend
70
NW
32
44
76
NE
Not
completed
Not
completed
SE
72
SW
25
51%
18
24
49%
0
90
49
285
For frequent attenders: by looking at the medical record on your clinical system how many GP practice attendances
has the child had in 2013 (Jan - Dec)?
1-3
NC
21
NW
35
NE
23
SE
32
SW
14
4-6
7-9
10+
16
18
17
25
17
13
26
15
18
15
17
12
9
6
7
35%
26%
21%
19%
356
For frequent attenders, what do you think the reason is for the parent taking the child to A&E instead of the GP
practice?
Convenience
/ease of
access
GP practice
was not
open
NC
5
NW
34
NE
Not
completed
SE
2
SW
8
23%
20
15
7
8
6
26%
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Governing Body report
Paper: 5.5
Anxiety that
GP practice
would not be
able to look
after the
child
18
41
18
18
13
51%
43
90
25
28
27
213
For the single attendance cohort, what were the typical presenting complaints?
Illness
Injury
NC
46
NW
54
NE
49
SE
38
SW
40
57%
24
70
46
100
40
89
38
76
22
62
43%
397
For the single attendance cohort, what were the typical treatments and outcomes?
Discharged
following
investigatio
n&
treatment
Discharged
after
treatment
Discharged
without
investigatio
ns or
treatment
Admitted
NC
8
NW
32
NE
5
SE
19
SW
3
22%
34
3
13
20
15
28%
11
22
17
15
12
26%
6
59
9
66
8
43
34
88
15
45
24%
301
For the single attendance cohort, if the GP practice could have assessed the child, what would have been the most
appropriate clinical pathway?
Seen by GP
Referred to
Paed team
Advised to
go to A&E
NC
34
NW
52
NE
50
SE
32
SW
25
54%
4
2
9
28
10
15%
16
36
21
30
26
31%
355
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Governing Body report
Paper: 5.5
For the single attendance cohort, were there any barriers to accessing the surgery for this child?
Yes
NC
4
NW
24
No
56
66
NE
Not
completed
51
60
100
51
Maybe
SE
0
SW
3
9%
85
43
88%
7
92
3
49
3%
342
In summary, 1522 attendances at paediatric A&E were audited across the CCG. 60% of frequent attenders attended
out of hours and 53% single attenders attended out of hours. For 51% of frequent attenders, there was a trend in
the clinical reason for A&E attendance. For frequent attenders, the majority (35%) had attended their GP practice 13 times in 2013. However, approximately a quarter had attended between 4-6 times and a fifth had attended
between 7 and 9 times and over 10 times! For frequent attendances, the majority (51%) were thought to have
attended A&E because of anxiety that the GP practice would not be able to look after the child. For the single
attendance cohort, 57% attended because of illness and 43% because of injury. For single attenders, 26% were
discharged without investigation or treatment which may imply that attendance was unwarranted. However, the
remaining 74% received an investigation or treatment or were admitted. For the single attendance cohort , if the GP
practice could have assessed the child ,54% would have been assessed in GP, 15% referred to the Paediatric on call
team and 31% advised to go to A&E. For the single attendance cohort, there were not thought to have been barriers
to accessing GP in 88% of cases.
A leaflet for parents is being designed, along with an Oyster card holder, which has a simple chart showing parents
where they should go in different eventualities. Paediatric learning hubs are now up and running at Barlby Road,
Harrow Road, New Elgin Clinic and Portland Road surgeries, with other practices attending at one of these locations.
It was agreed to send out the information from these sessions to all practices, whether or not they attend, in order
that learning can shared. All practices agreed to follow up inappropriate attendances with a letter, enclosing
information about where they can access services. The Childrens team at the CCG is designing a template letter and
awaiting patient feedback for disseminating to Practices.
Other plans for reducing attendances were
to educate parents during 6 week check;
to provide same day access for children
discuss management of paediatric cases at MDT meetings;
go into schools in order to educate parents
write to frequent attenders
Practice Spotlight
CLSs were informed of a new addition to the agenda called the Practice Spotlight. This is a 5 minute slot where
Practices took turns at each CLS meeting to present something to the larger group about the work they were doing.
Practices in each CLS could choose to either volunteer themselves for future dates or be allocated. The North Central
CLS presented a Practice Spotlight on the structure of the new NHS via a video while a South East Practice Spotlight
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Paper: 5.5
focussed on an experience of System 1 migration. The Practice spotlight for the North East was Foodbank.
Chelwest and Imperial Process
The CLSs were informed of the process for raising issues with Chelwest and Imperial relating to their services. The
process described who to contact, at what level and how to keep the CCG informed of the correspondence. The CCG
will keep a log of all cases to monitor the Trusts responses.
Prescribing:
• National forecasting model has been revised.
• NHSBSA confirmed an error in November calculations
• Figures unadjusted for change in APUs and expensive drug spend.
• Overall still a small underspend forecasted at year end. Data shown is for Apr –Dec.
CLS Plan Progress
The monthly data was viewed by all CLSs. It was felt that the target for Non Elective ASC conditions was too high. It
was made clear that the data did not include the 17% adjustments to RSS agreed by the Operational Group and that
would have an impact on the end of year data. CLSs were also pleased that the targets would now move to rate per
1000, particularly in relation to the RSS target. Across the CLSs there was also an interest expressed in understanding
how targets were set and what factors were included in the calculation of ‘weighted population’.
CLS Meetings in 2014/15
The proposed 14/15 CLS plan was presented to each CLS. It is now a LIS (Local Improved Scheme) rather than a LES.
Element 1 – Locality based working. There are both core and optional elements to this part of the LIS. The core
element is worth a total of 3.5K to Practices and is payable if Practices have weekly in-house meetings on referrals
and non-elective admissions; conduct 3 audits per year; provide 4 patient experience quarterly admissions and the
CLS champions complete a template every 6 months outlining progress. Practices can also opt to earn an additional
£1k by agreeing to have 4 buddy meetings per year and follow up actions from these meetings.
Element 2 - Community pathways. The targets for these pathways will increase in the 14/15 CLS plan. The targets are
as follows:
•
•
•
65% of referrals to go to community dermatology
70% of referrals to go to community diabetes and community respiratory (when new services available)
90% of referrals to community MSK
In addition to achieving these, element 2 also requires Practices to audit 5 referrals per year to the rapid response
service and ensure appropriate use of the primary care metal health service. Full details of these are still to be
confirmed. There is £150k available across all pathways for this element.
Element 3 – Referral targets and non-elective admissions. There has been a change to how referral and non-elective
admissions targets are set. The CCG are now using rate per 1000 to set targets. There is £150k available across the
whole CCG area for the referral targets element and £300k available across the whole CCG for achieving the nonelective admissions target. Payment will be 20% CLS achievement and 80% Practice achievement. This is a significant
change from the 13/14 CLS plan. Practice list sizes used to calculate the “per 1000” value will be refreshed every
quarter and will use weighted list sizes not raw list sizes.
Element 4 – Prescribing. There are two parts to this element. Part A (the process part) attracts a payment of £2.6k
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per Practice. To be eligible for this the Practice must agree an improvement and QIPP action plan with the
prescribing link pharmacist by September 2014. Part B (the outcomes part) measures achievement against the
prescribing quality markers and budget savings. Payment is 20% to the CLS and 80% to the Practice. `
To note:
• NHSE have approved the CLS Plan
• Main elements are similar to 2013/14 with some amendments
• Hot topic replaced by a practice item on commissioning (practice spotlight)
• CLS Plan LIS also includes Prescribing Standardisation Scheme
• Co-facilitators encouraged
• Shifting of CCG messages to WLCCG weekly member bulletin
There was a general feeling that the frequency of meetings was too high in relation to the remuneration offered.
Furthermore, CLS groups were uneasy about the steep rise in targets set for community MSK in particular. Many
suggested that there were problems with the access and quality of the MSK service and this would impact on them
being able to reach their targets. Others expressed an interest in being able to understand exactly how the targets
are set as they felt that simply comparing them to neighbouring CCG’s was not the best way to do this.
LES/Out of Hospital (OOH) services transition
The process to enable re-commissioning of services by July was explained together with the timelines and the
decision making groups involved. Practices would be guaranteed of their 13/14 LES income for 14/15 with the
following proviso’s:
• Services where notice to decommission has been given are not included in the Guarantee
• This is a practice income guarantee
• Practices should actively participate in the development of networks
• Before new services are commissioned, practices can claim more than the ES Guaranteed Income, however,
they will need to evidence the additional activity to validate claims
At the point when the new OOH services are commissioned there is the opportunity to earn additional income.
Where services are decommissioned or no longer provided by a practice, income is still guaranteed during
2014/2015 i.e. March 31st 2015
WLCCG Whole Systems Integrated Care Early Adopters update
This process enhances the already existing PPF case management work and builds on PPF progress to date. The
proposed model of care is:
•
•
•
Putting Patients First (PPF) initiative – proactive multidisciplinary case management of complex frail elderly
people over 75.
Emergency Admissions - older fit patients who after a hospital admission receive a new acute diagnosis such
as an MI, CVA or cancer will be pro-actively case managed by an appropriate member of the MDT
Urgent and Emergency Care Pathway – ensuring appropriate response for patients when they are in a crisis.
Improve communication between LAS and Practices by use of System1 IT care plans to enable decisions to
be made about need for admission.
The focus over the next 6/8 weeks is:
• Establish a WS Steering Group to ensure representation from all providers and a clear transparent decision
making process.
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Paper: 5.5
•
•
•
•
1 GP from North and 1 GP from South
Steering Group Objective; to agree an Outline Business Plan (OBP) with all Providers by May 19th and a Full
Business Plan (FBP) by Oct 2014.
This will include agreeing a model of care, which is co designed with service users and the development of a
capitated funding model
4 workshops will be organised between now and end of May – dates to follow asap
Across the CLSs there was a need expressed to understand exactly how networks would work and to generally learn
a bit more about them. In the North West, there was an interest expressed in exploring how they could work
together as a network and the group would ask that the CCG consider funding this dedicated time away from the
Practice. In the North Central CLS questions were raised as to whether this work overlapped with the over 75 DES
and the expectations for caring for Over 75’s set out in the New GP Contract. Practices questioned whether they
could sign up for both the LES and the whole systems work.
Patient Experience
For quarter 4, 37 out of 54 practices submitted their quarterly responses and 345 individual patient responses were
received, although there was variation between practices and CLSs. Overall, most patients were positive about the
services they received. Just under half of the patients provided negative or OK feedback. The majority of the
negative responses related to administration of appointments or attitude of staff across a range of providers. The
results will be presented to the Quality, Patient Safety and Risk Committee (QPSR). There were two issues raised
about maternity aftercare that raised concern namely no midwife arranged for patients when discharged.
CLS Plus Buddying Scheme
16 buddy meetings have now taken place between 35 practices. 38 Practices are part of the CLS Plus scheme (92%).
1 buddy group (3 Practices) has failed to supply a meeting date despite numerous requests. Actions from the
meetings are being followed-up by the locality team. Feedback from members has on the whole been very positive
about the scheme and it is intended that the scheme will be continued into 2014/15 as part of the CLS Plan. Concern
was raised that no-one had yet signed up to the scheme for 14/15 and that quarter 1 buddy visits may not be able to
happen as a result.
Primary Care Mental Health Service
The PCMHS needs increased referrals from Practices. Investment in the PCMHS has led to a decrease in waiting
times to 15 days across all surgeries for all treatments. The PCMHS will be changing the way it reaches out to harder
to engage groups including Older Adults and BME communities.
SMI (SSOC) LES Sign up
SMI (shifting settings) LES aims to :
•
•
•
•
Support practices to manage the transfer of patients from CNWL with safer discharge processes
Provide enhanced support for stable SMI patients historically held in CMHTs
Continue the commitment to shared care prescribing
CCG Quality premium : Step down target
Whole systems – SMI proposal
Practices were asked to indicate their interest in learning more about the pilot or in being involved in developing the
SMI proposal.
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Paper: 5.5
Shaping a healthier future
Practices were encouraged to discuss their workforce issues and suggest ideas for areas of investment of HENWL
monies. Practice nursing was seen as an area needing more resources in terms of training and recruitment as well as
customer service training and HR. It was made clear that mandatory training was not included in what would be
commissioned as this was the responsibility of the employer (the Practice) to provide. Practices and CLSs were
encouraged to send their ideas to the workforce and transformation team.
Quality & Safety/ Patient Engagement/ Impact on patient services:
N/A
Financial and resource implications
N/A
Equality / Human Rights / Privacy impact analysis
N/A
Risk
N/A
Supporting documents
N/A
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
Date discussed
Outcome
N/A
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