Oxfordshire
Clinical Commissioning Group
Elective care Incentive Scheme
(ECIS)
1. Background
OCCG is faced with significant challenges around its stated objective to move resources from secondary
care into primary/community care due to the difficulties in reducing hospital spend. The costs of planned
care in the OUHT budget amount to £84.5M and there are additional costs in hospital services in other
counties but used by Oxfordshire residents.
Practices, meanwhile, are also facing financial constraints which limit the amount of care they can
provide over and above usual GMS services. However, many practices could expand their range of
services and provide suitable alternatives to hospital referrals. The prescribing incentive scheme, which
has been running in Oxfordshire for many years, has provided a successful model to engage practices in
prescribing priorities and changing behaviour with the time and effort rewarded through payments for
achieving certain targets.
Localities and practices have the potential to develop services for their patients. They will be aware of
the patients that are suitable for alternative services and those that would benefit most from services
closer to home.
The proposal set out below aims to follow similar principles to the prescribing incentive scheme.
However, as significant incentive payments cannot be offered unless there is actual activity reduction,
part of this incentive scheme payment would depend on measurable changes in referral rate across the
participating practices.
2. Proposal
To provide a voluntary scheme for practices within localities to work together to pilot innovative ideas
within primary care which results in an alternative to referral to secondary care. These schemes will
enhance care in primary care and cover mainly planned care referrals to acute hospital settings. This
scheme will not apply to referrals for community services. Urgent referrals and 2 week wait referrals
through choose and book will be included if supported by an appropriate safe management plan.
The scheme aims to spread good practice across a locality. It is expected that practices will work
together as a cluster or at locality level to deliver enhanced primary care services.
A menu of ready made, prior approved (through Clinical Ratification) schemes are provided in Appendix
1 that practices/localities can choose to use as part of this incentive scheme if required
3.
Aims of incentive scheme
 To support the CCG strategy of moving care out of hospitals.
 To reduce elective referral rates where appropriate and thereby deliver savings for reinvestment
in primary care as well as help OCCG achieve financial sustainability.
 To encourage practices to deliver reasonable alternatives to referral to hospital by incentivising
their investment of time and effort into promoting optimal primary care management of such
patients
 To provide quality care for patients closer to home
 To provide greater convenience for patients
 To maintain quality of care in a cost effective manner
V 13 - Approved by CCG Executive


4.
To deliver activity savings that may be used to develop expansion of community-based services
that can provide further expansion of alternatives to hospital referral/hospital care.
To promote transfer of activity and resources from secondary care to primary care
Details of an incentive Scheme
 There are ready-made, prior approved schemes that practices/localities can choose to use as
part of their ECIS if required. Up to 3 may be chosen, each attracting a payment of £1000 per
practice to implement at practice level.
 Practices/localities can choose to submit alternative schemes if wished and may also choose a
combination of template schemes and own schemes.
 More innovative projects could also be proposed although would need to gain programme
management support if any OCCG funding beyond the £1000 per scheme was required.
 Practices could choose to pool some or all of their £1000 to provide a new community based
service if this provides an alternative to planned care referrals to hospital specialities.
 Own schemes would need OCCG approval before £1000 is released but the intention is for this
process to be quick and straightforward using the same proforma as the examples shown in
Appendix 1
 Practices should bear in mind there may be more scope to achieve a measurable reduction in
referrals to that speciality compared to last year if several or all of the practices in a locality
choose the same scheme(s) as this shares risk of random inter-year variations in referral rates. A
random fall would obviously work in practices’ favour but a random rise could obscure practice
efforts to optimise patient management in the ECIS.
 If a group of practices in a locality achieve a reduction in actual referrals, this activity reduction
will attract an “outcome” payment related to the first outpatient cost. 50% of this outcome
payment would go to practices (localities could decide how this payment would be distributed
between participating practices) and 25% into a future locality schemes to support the transfer of
resources from secondary care into primary care for patient management in the community. 25%
of the savings will be retained by the CCG to offset the costs of alternative/optimum primary care
management on prescribing and email advice services.
 Clearly, the greatest gains are to be made in high volume specialities and particularly where
practices are not already low referrers although there would be no restriction on low referring
practices applying for the ECIS as the payment of £1000 would be recognised as some support
for any in-house measures already in place and to share any tips/processes/expertise with other
practices.
Examples of maximising optimum primary care
a) Dermatology: use of dermoscopy
b) Dermatology: topical treatment of AKs, superficial BCCs and Bowen’s Disease
c) Gynaecology: heavy menstrual bleeding and IUS
d) Urology: management of overactive bladder, stress and urge incontinence
e) Audiology: practice screening prior to referral for hearing aids
5.
Data
2
V 13 - Approved by CCG Executive
This will be from the Planned Care data set. The baseline number of referrals would be agreed for the
speciality identified – it will be measured as a total for all practices in a locality signed up to a scheme. It
will be based on 14/15 numbers plus an uplift for demographic growth of 1.3% plus an additional 0.5% to
allow for in year variation (this will be reviewed in April 16)
Monitoring undertaken via CCG to plot any change in referrals. Success will be agreed at March 16 and
March 17.
Achievement will be any reduction in referral numbers at speciality level for the participating practices in
the locality. Success will be a reduction in the total speciality referrals across all practices in the
scheme.
6. Payments
Practices and localities can earn incentive payments through both a process and an outcome payment.
a. Process payment
There would be payment of £1000 per participating practice when a practice either signs up to
one of the prior approved schemes (Appendix 1) or a local scheme is approved. While each
practice would only be funded up to a maximum of £3000 for the planning and achieving
approval, the more schemes a practice proposes, the greater the potential for reduction in
activity.
This will be funded from the demand management budget £243k (which was in place during
14/15)
b. Outcome payment
The average cost of an out patient referral will be assigned to each speciality considered
Example from the planned care data set average costs (measured M1-9 14/15 )are
Dermatology = £165.30
Gastroenterology = £242.85
Gynaecology = £303.81
(data needs verification from CSU)
For every referral reduced from the baseline the practice shall receive
50% costs of the referral for distribution to practices in a locality agreed ratio
25% costs will be added to a locality fund for future investment in primary care scheme
The remaining 25% will remain with the CCG for funding any additional costs from alternative
management and as a saving for the system.
This will be funded from savings generated as a result in a reduction of referrals but shall be to
the maximum level of £500k across all schemes. This will be monitored by the CCG.
The impact of significant practice population changes in year will be considered in exceptional
circumstances
Julie Anderson and Julie Dandridge
3
V 13 - Approved by CCG Executive
Version control:
v1
6/2/15 - JD 1st draft
v2
9/2/15 - JA update
v3
9/2/15 – JD addition of questions for LCDS
v4
17/2/15 – updated following comments from LCD meeting for discussion by CCG executive
v5
19/3/15 – updated following CCG E 24/2/15, meeting with DH and GK 10/3/15, and feedback
through all localities meeting 12/3/15
v6
27/3/15 – updated to take on board JA comments
v7
31/3/15 – update following discussion with LCDS
v8
20/4/15 – correction of two typos identified as part of consultation
v9
30/4/14 – update following consultation and following feedback from CCG E on 28/4/15. Revision
to state that overall referral rate will not be measured. Payment will be made on a reduction in
referrals for the speciality identified at the start of the project
v10
18/5/15 – scheme made simpler, inclusion of prior approved templates and the running of the
scheme over 18months
v11
acceptance of all changes above; clarification that reduction in referrals will be measured at year
end 15/16 and year end 16/17 and outcome payments made at this time; addition of calprotectin
tests hyperlink
v12
addition of review of 0.5% in year variation during April 16; removal of cataract and
gastroenterology prior approved schemes. All remaining schemes are Approved by Clinical
Ratification group
v13
Removal of erroneous cataract and gastroenterology schemes which were still included in body
of text
Appendix 1 – Schemes approved by Clinical Ratification Group on 4th June 15
4
V 13 - Approved by CCG Executive
1. Dermatology: use of dermoscopy
Name of locality
XXXXXXXX
Name of participating practices
Practice A, Practice B and Practice C
Contact details
XXXXXXX
Clinical
area
(speciality
)
Area
Current
managem
ent
Enhanced
GP
managem
ent
How will
you
provide
this
enhanced
level of
GP
managem
ent
Supportin
g
informatio
n
How will
you
ensure
this is
acceptabl
e to
patients?
How will
you
ensure
quality of
service
GP lead for scheme
Dermatology
Management of suspicious skin lesions
Lesions suspicious of squamous cell Ca (SCC) or melanoma are referred under 2WW
system even though some are evident benign on closer inspection with a dermatoscope.
Some other skin lesions are referred as possible basal cell carcinomas but dermoscopy
could have excluded this.
Currently, most GPs do not feel confident at interpreting the microscopic image from
dermoscopy but there are some with dermoscopy training who can interpret the
microscopic appearances and provide in-house advice to colleagues
Dermoscopy of suspect lesions except where clinically necessary to arrange 2WW referral
All dermatology referrals (particularly those considered by locums and GP registrars) to be
discussed and screened in house before any referral is offered to a patient to ensure
optimum GP management has taken place with relevant investigations completed.
Practice will ensure dermatoscope available to examine suitable lesions in more detail and
take a high quality image with a camera or smartphone attachment.
This image, along with a normal photo to identify the site and a close-up photo with clinical
details will be sent to email dermatology (all within nhs.net) for advice to ensure an
obviously benign lesion is not inadvertently referred
oxon.dermatologyadvice@nhs.net
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Dermatology/skin%20cancer/D
ermoscopy%20email%20advice%20service%20%20suggested%20algorithm.pdf
Patients will be counselled and verbal consent for dermoscopy obtained and recorded in
patient record. Patient choice will be respected if a dermatology referral is still requested.
By following process outlined above including full documentation in patient record
5
V 13 - Approved by CCG Executive
2. Dermatology: topical treatment of AKs, superficial BCCs and Bowen’s Disease
Name of locality
XXXXXXXX
Name of participating practices
Practice A, Practice B and Practice C
Contact details
XXXXXXX
Clinical area
(speciality)
Area
GP lead for scheme
Dermatology
Management of actinic keratosis, superficial and some nodular basal cell
carcinomas and Bowen’s disease
Current
Many AKs and Bowen’s disease are inadvertently referred to dermatology because GPs
management are concerned they may represent an early skin cancer.
Enhanced
Topical Efudix (5-fluoro-uracil cream) is an effective treatment for AKs, superficial and
GP
small nodular BCCs and Bowen’s disease.
management
How will you All dermatology referrals (particularly those considered by locums and GP registrars) to
provide this be discussed and screened in house before any referral is offered to a patient to ensure
enhanced
optimum GP management has taken place with relevant investigations completed.
level of GP
Patients could be offered this treatment with appropriate counselling/advice leaflet:
management
(http://www.ouh.nhs.uk/patient-guide/leaflets/files%5C5566efudix.pdf)
Supporting
information
How will you
ensure this
is
acceptable
to patients?
How will you
ensure
quality of
service
Dermoscopy could be used to send images to email dermatology for advice or
discussion with more experienced GP colleagues in house if required before treatment is
offered where there is considerably diagnostic uncertainty.
Patients should return 6 weeks after the end of their treatment to ensure there is
documentation that the lesion has cleared.
NICE Guidelines about use of topical agents for superficial BCCs.
Supporting evidence from the following:
Cochrane Skin Group. Victoria, Australia - Gupta AK, Paquet M, Villanueva E, Brintnell W.
Interventions for actinic keratoses. Cochrane Database of Systematic Reviews 2012, Issue 12. Art.
No.: CD004415. DOI: 10.1002/14651858.CD004415.pub2.
Cochrane Skin Group, Nottingham, UK Bath
Interventions for basal cell carcinoma of the skin.
Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD003412. DOI:
10.1002/14651858.CD003412.pub2.
Interventions for cutaneous Bowen’s disease.
Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007281. DOI:
10.1002/14651858.CD007281.pub2.
Patients will be counselled about the various options including standard dermatology
referral and patient choice will be respected. A patient information leaflet
(http://www.ouh.nhs.uk/patient-guide/leaflets/files%5C5566efudix.pdf)
will be provided to explain and advise on the course of the expected treatment for topical
agents
By following process outlined above including full documentation in patient record
6
V 13 - Approved by CCG Executive
3. Gynaecology: heavy menstrual bleeding and IUS
Name of locality
XXXXXXXX
Name of participating practices
Practice A, Practice B and Practice C
Contact details
XXXXXXX
Clinical area
(speciality)
Area
Current
management
Enhanced GP
management
GP lead for scheme
Gynaecology
Heavy menstrual bleeding
Should be according to OCCG guidelines:
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Forms/AllItems.aspx?Ro
otFolder=%2fGeneralPractice%2fClinicalGuidelines%2fGynaecology%2fHeavy%20
Menstrual%20Bleeding&FolderCTID=0x012000C3354102274DEC48AFCB33AE053
30A81&View=%7b3C86D97E%2d1153%2d4538%2dA63D%2d9F0EF83EC32D%7d
but some practices do not have suitably qualified GPs able to insert IUS
In-house scrutiny of potential gynaecology referrals before any referral actioned
using the current Heavy menstrual bleeding guidelines
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Gynaecology/Heavy%20
Menstrual%20Bleeding/Guidelines%20for%20Heavy%20Menstrual%20Bleeding%20
Primary%20Care%20Pathway_V6.pdf
Provision of IUS
How will you
provide this
enhanced
level of GP
management
Supporting
information
How will you
ensure this is
acceptable to
patients?
Process of encouraging use of patient decision aids
Eg http://sdm.rightcare.nhs.uk/pda/menorrhagia/
Patient should be asked to print out the decision process summary to show they
have engaged with this process
All gynaecology referrals (particularly those considered by locums and GP registrars)
to be discussed and screened in house before any referral is offered to a patient to
ensure optimum GP management has taken place with relevant investigations
completed.
Patients who could benefit from an IUS would be offered this, either through the local
family planning service (who have a contract variation to pay for IUS for heavy
menstrual bleeding even where contraception is not required) or by referral to a local
GP in another practice willing to offer this service on behalf of other practices. The
GP providing the service would be able to claim the IUS insertion fee and the
referring practice may benefit from activity reduction payment if gynaecology
referrals fall.
Patients reluctant to try optimum primary care management or with failed treatment
should be offered gynaecology referral but counselled about the possible surgical
interventions and effects on their fertility (if this is an issue). Such patients should
also be asked to complete a decision aid before a referral is actioned.
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Gynaecology/Heavy%20Menstr
ual%20Bleeding/Guidelines%20for%20Heavy%20Menstrual%20Bleeding%20Primary%20Car
e%20Pathway_V6.pdf
Patients will be counselled about the various options including standard gynaecology
referral and patient choice will be respected.
7
V 13 - Approved by CCG Executive
How will you
By following guidelines and processes outlined above
ensure
quality of
service
8
V 13 - Approved by CCG Executive
4. Urology: management of overactive bladder, stress and urge incontinence
Name of locality
XXXXXXXX
Name of participating practices
Practice A, Practice B and Practice C
Contact details
XXXXXXX
GP lead for scheme
Clinical area
(speciality)
Area
Urology
Current
management
Enhanced GP
management
How will you
provide this
enhanced
level of GP
management
Varied management with differing levels of primary care intervention prior to referral.
Management of overactive bladder (OAB) in males and females, stress and
urge incontinence in females
The management of overactive bladder is suitable in primary care without needing
onward referral once chronic retention has been excluded.
All urogynaecology and urology referrals for Lower Urinary Tract Symptoms (LUTS)
related to the above (particularly those considered by locums and GP registrars) to
be discussed and screened in house before any referral is offered to a patient to
ensure optimum GP management has taken place with relevant investigations
completed.
Fluid input/output (bladder diary) + urine screen for infection etc Bladder studies can
exclude chronic retention if required
Patients will be referred to the community Continence Advisory Service and any new
OCCG Bladder and Bowel pathway redesign that starts operation mid year will be
rapidly adopted and followed. Engagement in the community service would need to
be completed before any onward referral to hospital care.
Management is by patient advice and trail of suitable medication-there are new
guidelines now available on the OCCG intranet as below.
Supporting
information
Patient decision aids should be used if referral is being considered for any surgical
intervention including botox
http://occg.oxnet.nhs.uk/GeneralPractice/ClinicalGuidelines/Gynaecology/Urogynaec
ology/The%20Management%20of%20overactive%20bladder%20version%201%202
%20%20March%202015.pdf
Urinary Incontinence in females: http://www.nice.org.uk/guidance/cg171/chapter/1recommendations
How will you
ensure this is
acceptable to
patients?
How will you
ensure
quality of
service
Urinary Incontinence in males: http://www.nice.org.uk/guidance/cg97/chapter/1recommendations
Patients will be counselled about the various options including standard
urogynaecology referral and patient choice will be respected.
By following guidelines and processes outlined above
9
V 13 - Approved by CCG Executive
5. Audiology: screening hearing aid referrals
Name of locality
XXXXXXXX
Name of participating practices
Practice A, Practice B and Practice C
Contact details
XXXXXXX
GP lead for scheme
Clinical area
(speciality)
Area
Audiology
Current
management
Most requests for referral are generated by patients and usually agreed by their GP
after checking the ear canals are clear
Enhanced GP
management
How will you
provide this
enhanced
level of GP
management
The practice would arrange a digital audiogram in house to define the hearing loss
and use patient decision aids to inform decision about referral for hearing aids
All audiology referrals (particularly those considered by locums and GP registrars)
to be discussed and screened in house before any referral is offered to a patient to
ensure optimum GP management has taken place with relevant investigations
completed.
Supporting
information
How will you
ensure this is
acceptable to
patients?
Currently researching appropriate decision aid
How will you
ensure
quality of
service
By following process outlined above including full documentation in patient record
Management of presbyacusis and other gradual hearing loss
Patients will be counselled about the various options including waiting until hearing
deteriorates enough to warrant a hearing aid and patient choice will be respected.
10