City & Hackney CCG
Long Term Conditions Programme Board
C&H CCG Service specification for
management of long term conditions in primary
care 2015/16
Clinical Commissioning Forum, February 2015
Building on success…
2
Budget 2015/16
£3,386,449 (an increase of £924,750 on 2014/15)
Context the TOTAL budget for QOF is £2.6m
Contract is with Confederation to ensure 100% cover
All targets are to be set post 31st Mar 2015 informed by 2014/15 AND
2013/14 performance
Exception reporting allowed for more indicators; CEG to validate
exception reporting on a random sample of practices
“Time to Talk” Q4 2014/15 was worth £166k…
3
Prevalences – just 4!
4
A7
CKD
A7.1
CKD (new)
A12
At risk of diabetes
A13
At risk of CVD
Extended Consultations
5
C1
Extended consultation for adults newly
diagnosed with diabetes within last 12m
C2
Extended consultation for adults newly
diagnosed with COPD within last 12m
(NEW)
Annual Reviews
D1a Complete annual review (all 10 elements) for patients on at risk of
diabetes register within last 12m
D1b Complete annual review (all 9 elements) for patients on at risk of CVD
register within last 12m
D1e Patients at risk of CVD (>20% 10 year risk) prescribed statin (NEW)
D2 Complete annual review for patients on diabetes register not coded
as being under hospital care within last 12m
D3 Complete annual review for patients on heart failure register within
last 12m
D4 Two complete bi-annual reviews for patients on COPD register (severe
and very severe COPD FEV1 % predicted ≤ 50%) within last 12m
D5 Two complete bi-annual reviews for patients on asthma register
(severe asthma step 4 and 5 ONLY) within last 12m
6
Care Planning
7
E1
Face to face pre-conceptual counselling for patients on
diabetes register (women aged 16-45 with exclusions for
sterilised, hysterectomy, etc) within last 24m
E3
% of patients on diabetes register having a care plan
documented within last 12m
E4
% of patients on COPD register having a care plan
documented within last 12m
E5
% of patients on asthma register (step 2 and above ONLY)
having an asthma action plan documented within last 12m
Treatment: Blood pressure (QOF NOT NICE)
F1
F2
F4
CKD002: Patients on CKD (Stage 3-5) register ≤140/85
(12m) (DROPPED FROM QOF)
STIA003: Patients on stroke/TIA register ≤150/90 (12m)
F5
DM002: Patients on diabetes register ≤150/90 (12m)
F6
DM003: Patients on diabetes register ≤140/80 (12m)
F7
PAD002: Patients on PAD register ≤150/90 (12m)
F3
8
HYP006: Patients on hypertension register ≤150/90
(12m)
CHD002: Patients on CHD register ≤150/90 (12m)
Treatment: Cholesterol
9
G6
CVD: CHD/stroke/TIA/PAD/AF
<75: atorvastatin 80mg
>75: either atorvastatin 40mg or 80mg
G7
Diabetes:
Type 2: <10% CVD risk: no statin unless other CVD risk factors
Type 2: ≥10% CVD risk: atorvastatin 20mg: increase up to
80mg with other risk factors
Type 1: >10 years duration/age 40 year/nephropathy
atorvastatin 20mg increase up to 80mg if other risks
Treatment: HbA1c
H1
10
Patients on diabetes register with an
HbA1c less than 12%
Treatment: Atrial Fibrillation
J1
11
Patients on atrial fibrillation register (CHADS2-VASc
score of 1+ ONLY) treated with oral anticoagulation therapy (warfarin or one of the new
OAC drugs, unless contraindicated using HAS-BLED
score)
Patients feeling supported to manage their LTCs
K1
K3
M1
12
DM014: The percentage of patients newly diagnosed with
diabetes, on the register, in the preceding 1 April to 31
March who have a record of being referred to a structured
education programme within 9 months after entry on to the
diabetes register
The number of people on the GP list at 31 March (2015) with
COPD and MRC Dyspnoea Scale >=3 in the preceding 12
months who have been referred to, or who have attended,
a pulmonary rehabilitation programme at any time (new
diagnoses only)
The GPC to deliver at least 15,755 extended consultations
in-line with the Time to Talk specification with all practices
delivering at least 25% of their own calculated share
Cancer
13
N1
Time for Cancer
The GPC to deliver at least 400 extended consultations in-line with the Time for
Cancer specification
N2
Bowel cancer screening
The GPC will ensure that all practices have processes and resources in place to
support the national bowel screening programme:
-Patient literature and other communication materials to encourage uptake
-Proactive contact to those patients turning 60 to endorse the screening
-Using DNA information, contact non-returners of the bowel screening kit –
explanation and support offered to complete the test
N3
2 week wait cancer referral “safety-netting”
The GPC to ensure that each practice has:
-A system to ensure the dispatch of all 2 week wait referrals within 24hrs of the
patient consultation
-A system to make all diagnostic referrals where cancer is suspected within 24
hours of the patient consultation
-A systems that ensures all 2 week wait referrals are coded
-A system for tracking/following-up all 2 week wait referrals
-Is using the template for recording of all the above
-A system to ensure that information on 2 week wait referral pathways,
diagnostic testing and local pathways is available to locums and new registrars
Other
Q1
Q2
Q3
Q4
Q5
Q6
14
% of patients with an LTC who smoke attending smoking
cessation services
All practices to take part in the National Diabetes Audit and
National CKD Audit
All practices to refer pts with a LTC to exercise on referral –
practice target is at least 7.5% of size of hypertension register at
1st Apr (all pts with an LTC to be considered for referral not just
pts with hypertension)
The % of pts on the CKD register with hypertension and
proteinuria who are currently treated with an ACE-I or ARB (EX
QOF)
The % of pts on the CKD register whose noted have a record of
a urine albumin:creatinine ratio (or protein: creatinine ratio) test
in the preceding 12 months (EX QOF)
Confederation to audit practice response to AKI alerts
Dropped
A1
A2
A3
A4
A5
A6
A8
A9
A10
A11
K2
L1
G5
G2
G3
G4
B1
B2
E2
15
At risk of DM/CVD
COPD
Asthma
Diabetes
Heart failure
Hypertension
Stroke/TIA
Atrial fibrillation
PAD
CHD
People with new CHD referred to cardiac rehabilitation
Engage in a joint premature CVD mortality audit with HUHFT
TC: Patients on CHD register ≤5 (12m)
TC: Patients on stroke (non-haemorrhagic)/TIA register ≤5 (12m)
TC: Patients on PAD register ≤5 (12m)
TC: Patients on diabetes register ≤5 (12m)
65+ and LTC with a record of pulse rhythm (regular/irregular) within last 12m
65+ and without LTC with a record of pulse rhythm (regular/irregular) within
last 36m
Patients on diabetes register (newly diagnosed ONLY) having a care plan
documented within last 12m