1

Consolidated Funding Framework

(CFF) 2018-2019 Support Pack

2

This page left intentionally blank

3

Contents This support pack is intended to be printed as a whole on both sides, so some pages have been left intentionally blank. Individual copies of each item are available on the CCG website and can be found at the following link http://www.enhertsccg.nhs.uk/consolidated-funding-framework-year-2-201819

Item Item Details Page A1 Foreword 5-6 A2 CFF Sign-up Sheet 18-19 7-8

Financial Balance

B1 Financial Balance – Guidance 9

Engagement

C1 Engagement Guidance: Clinical Representation , PPG Engagement and Patient Communication, Collaborative working and Workforce and skills data. 11-12

C2 PPG Engagement Plan Template 13 C3 PPG Engagement Progress Report Template 14 C4 Collaborative Working Project Plan Template 15 C5 Collaborative Working Progress Report Template 16 C6 Collaborative Working Project Evaluation Template 17

Frailty and Care Management D1 Care Planning Guidance 19-22 D2 Catheter Register Guidelines 23-26 D3 GSF/MDT Guidelines 28-31 D4 GSF/MDT Meeting Template 32 D5 Post Death Audit Guidance 34-36 D6 Post Death Audit Report Tool 38-39 D7 Post Death Audit Report access and guidance 40 D8 Mental Health Dementia Care Planning Guidance 42-44

D9 Mental Health Physical Health Check for Serious Mental Health (SMI) Patients 46-50

D10 Diabetes and Diabetes Prevention Guidance and Improvement Plan Template 52-56

Cancer E1 Cancer Guidance 58-59 E2 Cancer Campaign Timetable 60 E3 Practice Cancer Plan Template 62-63 E4 Locality Cancer Plan Template 64 E5 Cancer Quarterly Return Template 66-67 E6 Breast Screening Letter Template 68

Planned Care F1 CCG Pathway and Thresholds Assessment Guidance 70 F2 Medicines Optimisation Guidance 72-76

4

This page left intentionally blank

5

East and North Herts CCG: Consolidated Funding Framework (CFF) 2018-19

Foreword:

Aim and Purpose – This is the second year of the CFF, which is an investment of nearly £6m into primary care and general practice by the CCG Governing Body. The main aim of CFF funding is to give extra capacity to primary care operating in an integrated and collaborative way in order to help address the ever increasing demand and workload on primary care. CFF 2017-18 – This has been reviewed with practices and key changes made to the 2018-19 CFF include, simplification – from 17 clinical sections to 12, simplified reporting and monitoring to reduce practice workload and limited changes/new items. Some areas have been dropped completely such as Children’s A+E frequent attendees. CFF 2018-19 – has been jointly developed during January and February with practice representatives’ patient groups and LMC input. There are limited new elements such as PPG and Locality controlled collaborative working funds. We have tried to build on the successful elements of the 2017-18 CFF and amended funding and monitoring especially where it was not clear what metrics were being used to trigger payments. The CFF has 5 sections: 2 non Clinical (25%) and 3 Clinical (75%) TOTAL £10.10 per patient. Non Clinical Financial Balance £1.50

Engagement £1.0 (4 elements) • LCC per practice • PPG engagement • Workforce returns • Locality

Collaboration Funds

Clinical Frailty/Care Planning £4.75 (6 elements) • CARE Plans New and review • Mental health Dementia SMI Health Checks • Diabetes

NDPP 8 Care Processes

• MDT/GSF Support • Catheter Register • Post Death Audits

Cancer £1.75 (3 elements) • Awareness

Training • Screening

Improvement • Breast • Cervical • Bowel

• Case Review and Pathway/patient experience improvement

Planned Care £1.10 (3 elements) • Practice pathway

compliance • Practice threshold

and referral compliance

• Medicines Management

Mandatory Elements – The 2 mandatory elements remain the same as in 2017/18 namely.

• Pseudonymised data extraction to improve risk stratification and system data integration • Record sharing by consent. Practices to ask patients for consent to share as part of care

planning process and record number of patients who decline to allow sharing. Proper safe record sharing is key to enabling safe integrated working for the benefits of complex comorbidity patients. We are trying to move to a single system care record for the patient and the CFF is attempting to support this major system wide objective.

Item A1 - Foreword

6

New Localities Structure – The CCG Governing Body and the STP are moving towards an integrated care system (ICS) and the Governing Body has re-organised GP leadership roles to enable primary care to lead on this and achieving a more sustainable primary care, as well as integrated place based care linked to the primary care home model. There will be a two tier meeting system from April 2018 for Localities to support the delivery of CCG and system objectives as set out in the CCG Operating Plan for 2018-19. The CFF is supporting practice engagement in each Locality Commissioning Committee which is accountable to the Governing Body for improving the health of their population and ensuring Integrate Care Delivery Boards (ICDB) deliver local service transformation and service performance targets as part of the NHS Constitution and Mandate. Locality Commissioning Committees (LCC) – are formally committees of the Governing Body and will have their own Local Commissioning Plan and priorities for which the local Integrated Care Delivery Board (ICDB) will be the vehicle for delivery. The CFF is intended to empower the LCC and the LCC will be where practices can make a case for exceptionality or special circumstances where CFF payments are concerned. Each LCC will have an oversight role on the CFF and where there are any obvious conflicts of interest issues then the problem will be escalated to the CCG and the Primary Care Committee (PCC) which will act on behalf of the Governing Body on GMS delegation and Locally Enhanced Services including the CFF. It is expected that all practices will be part of their local LCC and attend at least 6 of the 7 planned meetings over the year. Integrated Care Delivery Boards (ICDB) and other GP/Clinical support – The expectation is that Locality practices will agree locally who will represent practices/general practice on the ICDB. The expectation is that between 2 and 4 members will be representing their Locality practices as all practices are not needed at ICDB meetings as well as LCC meetings. A Federation for example may be selected to represent all practices in one ICDB, or practices could chose to attend by town or rural representation. The ICDB is linked to the STP Place Based Care Delivery Board system as well as the CCG – LCC accountability line. CFF 2018-19 – Aligns the incentives for practices with developments in primary care and the GPFV especially the extended access agenda and we hope further innovation and change across the health and social care system will benefit patients such as more MDT working and moving to 30-40 minute appointments for complex frail patients. Monitoring and Reporting – will be done through new Locality Information Packs at each LCC and there will be CCG – wide commissioning workshops to share best practice as well as address problems and issues raised during implementation.

Quarterly Submission Dates – Practices to report back to the CCG on a quarterly basis. The submission dates are as follows:

• Q1 – Monday 16th July 2018 • Q2 – Monday 15th October 2018 • Q3 – Monday 14th January 2019 • Q4 – Monday 15th April 2019

7

Consolidated Funding Framework (CFF) 2017-19 Year 2 – 2018-2019

Practice sign up form

Practice Name

Practice Number

Locality

Practice Declarations As part of the CFF, practices are asked to identify a Lead for the below areas: Please provide the appropriate information, and if during the CFF these positions change within the practices, practices will need to alert the CCG Commissioning team on Enhccg.localities1@nhs.net and advise of the same information for the new lead.

Lead role: GSF Co-ordinator Lead Name Position in Practice Contact email Contact Telephone number Lead role: Diabetes Lead Lead Name Position in Practice Contact email Contact Telephone number Lead role: Cancer Champion Lead Name Position in Practice Contact email Contact Telephone number

Item A2 – CFF Sign-up Sheet 2018-2019

8

I confirm that the practice named overleaf signs up to the Consolidated Funding Framework for 2018/19, and will comply with the core requirements set put in the CFF metrics for 2018/19. The authorised signatory will be the dedicated CFF lead for the practice. I confirm that the practice representatives identified overleaf will comply with the positions and roles assigned to them on behalf of the practice. This declaration confirms that the practice will promote early presentation activities for the Cancer element of the CFF as per the guidance provided. The practice will work with the CCG to promote national and regional cancer campaigns, including Be Clear on cancer, will take part in the cancer case analysis, case reviews and 6 months reviews and education and training throughout the year. The practice will engage with the PPG to help promote and support the campaigns and have a program of activity This declaration confirms that the practice will comply with the CCG Pathways and Implement Thresholds Assessment elements of the Planned Care Section of the CFF Metrics and guidance documentation. Any elements of the CFF the practice will not be signing up to are declared in the table below: Element Reason for abstaining

Authorised Signatory Name (print)

Signature

Date

Contact number

Email

Note: No upfront payment will be provided to practices until they have confirmed their sign up to the CFF including the compulsory element of the metrics ***Please return to the CCG on Enhccg.localities1@nhs.net by 30th April 2018***

9

As stated in the 2018 – 2019 CFF Metrics, the remuneration for the financial balance section is £1.50 (per registered patient). At the end of the financial year, the overall locality spending is to be no greater than its agreed budget measured at the end of year when the Accounts are approved in June 2019.

If a Locality achieves financial balance in 2018/19 (based on assessment by the CCG finance team following submission of end of year accounts), the Locality will be awarded £1.50 per registered patient.

If a locality fails to achieve financial balance in 2018/19, the Locality can be awarded up to 50p per registered patient if it is overspend is less than that recorded in 2017/18.

The funding distribution by Practice will be decided and agreed by the Locality Commissioning Committee.

Financial balance will be monitored and measured by the CCG and reported on following approval of the CCG’s Accounts in June 2019. The locality finance reports will provide an indication throughout the year on how localities are performing.

END

Financial Balance Guidance

Item B1 – Financial Balance Guidance

10

This page left intentionally blank

11

This guidance is designed to be read in tandem with the detail provided in the Metrics. The aim of the engagement section of the CFF is summarised in the metrics. Meeting attendance per se is an inexact measure for assessing engagement, and so while attendance at meetings is important, it is important that other measures of engagements are also covered in this section.

Meeting Attendance

The CCG Localities workshops are new meetings, and will be an opportunity to tackle areas which are of relevance to the entire CCG. The topic areas may cover areas such as diabetes, GDPR, extended access or others, with an aim of sharing best practice either locally or nationally, and enabling learning across the CCG.

Localities may choose to arrange Task and Finish groups to undertake specific agreed pieces of work, for which locality management funds may be used to appropriately reimburse clinical time, as approved by the relevant Locality Commissioning Committee. The Locality Commissioning Committee may choose to approve the funding of locality management funds for agreed Task and Finish Groups through a virtual meeting process (held via conference call facilities with formal recording of the funding request and the decision and approval) should approval be required within a more rapid time frame.

Metrics and other guidance is provided in the Metrics section. All meeting attendance will be monitored via meeting minutes and/or records of attendance.

PPG Engagement and Patient Communication

Practices to improve PPG engagement and encourage use of the ‘building better participation’ toolkit developed by NAPP (the national association for patient participation) which can be found at the below link. http://www.napp.org.uk/

Practices are to use the range of resources available including planning sheets and self-assessments. Building better participation is designed for use by a PPG working alongside its GP practice. You are not expected to work through all four Areas and all their Goals. This tool is designed for you to pick and mix from the Goals, as is appropriate to your PPG and your practice. You may decide to focus on several Goals within some Areas, while not looking at others. If the PPG wants to make use of the four Areas of Building better participation we recommend that, initially, you review them with some PPG members and your practice together. We suggest you concentrate at first on the Goals that are most relevant to your PPG. Things you might discuss with your PPG and practice: • Which Goals are relevant to you to work on? • How you might show you are meeting each Goal? • How you would use the Goals to help set action plans for the year ahead?

Engagement Guidance Item C1 – Engagement Guidance

12

Practices are to complete the PPG engagement plan template based on locality and practice clinical priority areas and submit a copy of the plan at the end of Q1 2018. Practices will then provide evidence of progress in implementing at least 2 key actions at the end of Q4.

An engagement plan template and progress report template will be provided by the CCG.

Collaborative Working

This is not to be used for a service that is already funded from another source. The localities may choose to combine the resources from this section of the CFF with other funding sources if appropriate to enable the delivery of the project.

A written project proposal (Item C4) will be submitted to and formally approved by the Locality Commissioning Committee by the end of Q1. Localities may choose to use another template should they prefer, or to submit additional information, but all key areas contained within the template plan must be addressed in the project plan. Planning and implementation will comply with the CCG policy on remuneration (if relevant to the locality plan).

The project needs to be duration of a minimum of six months and a maximum of 12 months.

A further template is provided (Item C5) for monitoring progress, which localities may use should they find this helpful. An evaluation template (Item C6) is provided which must be used and submitted to the Locality Commissioning Committee at the completion of the project.

Workforce and Skills Data

Practices are to complete the workforce data template, and workforce skills/training needs template as sent out by the Primary Care workforce and Education team directly. These will be sent to practices each quarter, with no fixed template as they will be standardising workforce and skills data collection across the STP so the template may change during the year.

END

13

Item C2 – PPG Engagement Plan

14

Item C3 – PPG Engagement process Report

15

Item C4 – Collaborative Working Project Plan

16

Item C5 – Collaborative working – Progress Report

17

Item C6 – Collaborative working – Evaluation Report

18

This page left intentionally blank

19

Care Planning in Primary Care - CFF 18/19

Background Care and support planning with people with long term conditions (LTC’s) is about better conversations - emphasising the importance of the care and support planning process itself in achieving outcomes, rather than the written care plan that may emerge at the end.

This guidance provides details on which care plan should be used and where to find it. The documents in this guidance are all patient held documents and there is an expectation that these will be given to the patient. In addition, the professional care plan requirements will be met by the use of templates, sharing of information and details of both are provided below.

What do I need to do?

1) Identify your cohort of patients

1.1 Identify the total number of patients that are in need of a care plan as per the list below: Patients who are or are at risk of:

• Frequent attendance at A and E or Ambulatory Care • Pneumonia / LRTI (Lower Respiratory Tract Infections) or regular COPD exacerbation • End stage Long Term Conditions:

o CHF (Congestive Heart Failure) NYHA (New York Heart Association) Stage 3/4 or

o COPD MRC(Medical Research Council) stage 4/5 or O2 therapy or o CKD (Chronic Kidney Disease) Stage 4/5 or rapidly declining neurological

conditions) o Those that exacerbate frequently

• Frequent admissions (greater than or equal to 2 admissions per annum) • End of Life (within the last 12 months of life) or graded as moderately or severely frail • Carers who support very vulnerable patients

Some patients may fall into more than one category - please only count them once.

1.2 From that list of patients confirm how many already have a care plan This will provide your baseline figures

Target numbers are a. New care plans = 70% b. Review of care plans = 30%

Total number of patients Number with a care plan Number without a care plan

X Y Z

Frailty and Care Planning Item D1 Care Planning Guidance

20

Example

a. New care plans = 70% (of 80) = 56 care plans b. Review of care plans = 30% (of 20)= 6 care plans

2) Completing Care Plans

2.1 Which Care Plan? SystmOne - Ardens Users SystmOne - Non Ardens

Users EMIS Web

Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify which condition specific plans the patient needs. - Click on future care planning - Click on Generic Care Plan

(This is the foundation document) - make sure you select the code from the drop down box

- Click on Specific Care plan - this will take you to the self-management plans for specific conditions

Signpost patients (where appropriate) to self-management support on the Health in Herts webpages For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet Further step by step guidance can be on the CCG website

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet to explain how this works

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet

Total number of patients Number with a care plan Number without a care plan

100 20 80

21

3) Next Steps

3.1 Sharing the Care Plan Once you have identified your cohort and completed the care plans, you need to ask for consent from the patient to share information.

With the patient: • Print or email the documents to the patient

With other professionals

• With the permission of the patient, practices can add additional information about specific conditions to the summary care record to make it an enhanced summary care record.

• Once you have selected this read code and saved the record, there is nothing further for you to do as the system will automatically upload the information.

• Patients at S1 practices can consent to having their whole record shared with other S1 users e.g. hospices and this will give a more in depth picture to other health care professionals

• More information can be found here: http://www.hblict.nhs.uk/scr/#toggle-id-8 • The sharing of patient records and care plans/treatment plans is part of the wider “My Care

Record” project • For patients identified with severe frailty, promotion of the summary care record and

activation of this is part of the GMS contract (see section 4.2) • Ardens users can use the “Sharing Records” template to record patient consent - look for

this icon on any of the templates.

3.2 GSF Register • Patients who are end of life or severely frail should be added to the GSF register • These patients should be discussed at the GSF meetings (where appropriate)

4) Payments Payments will be made as follows:

a. New care plans = £150 b. Review of care plans = £50

Read Codes CTV3 (e.g. SystmOne)

EMIS

Personal Care Plan offered XaRB3 9NS5. Offer of Personal Care Plan accepted or Personal Care Plan completed

XaRB2 8CMF.

Personal Care Plan declined XaRB0 8IAe Review of Personal Care Plan XaRB1 8CMC

22

4.1 Change from Previous Year Payments for severe frailty care plans in 2017/18 was £200 as not only was a care plan required, but as part of the care planning process, these patients should have been discussed in the GSF meetings.

The difference of £50 for severe frailty care plans has been moved to support GSF meetings.

4.2 Review of care plans Payment will be made for each review of a care plan. Therefore if a patient is reviewed twice in the year (if required) then the total payment for review will be £100 for the year. For patients who are identified as severe frailty, the GMS contract for 2017/18 states: 7.1 LEVEL OF SKILL 7.7AA.3 Where the Contractor identifies a patient aged 65 or over who is living with severe

frailty, the Contractor will:

7.7AA.3.1 Undertake a clinical review in respect of the patient which includes: (a) An annual review of the patient's medication; and (b) Where appropriate, a discussion with the patient about whether the patient has fallen in the last 12 months.

7.7AA.3.2 provide the patient with any other clinically appropriate interventions; and

7.7AA.3.3 where the patient does not have an enriched Summary Care Record, advise the patient about the benefits of having an enriched Summary Care Record and activate that record at the patient's request.

Care planning for patients identified as severe frailty is technically covered under GMS contract as a care plan is a clinically appropriate intervention. However, for the CFF for this year we are not excluding these patients and the allocations for both new care plans and reviews is intended to support practices with any additional work required.

END

23

Through the Best Practice UTI & Urinary Catheter Care Forum, there have been reports of patients with long-term catheters that have not been referred for appropriate follow-up. The introduction of ‘catheter registers’, which are to be maintained by individual GP practices, will ensure that all patients discharged from hospital with a catheter have the appropriate plans in place for ongoing management and support.

1 Baseline Submission

To initiate this metric, GP practices should identify all existing catheter patients from their clinical systems. A clinical report (for SystmOne and EMIS) has already been published to support this, although practices can opt to develop their own reports. Practices should also check to see if any of the long term catheter patients identified have been referred to the community services (and complete a referral if not).

In addition to forming the basis of a catheter register, this will ensure that any existing long term catheter patients are receiving the appropriate level of support. For consistency, practices may choose to re-code existing catheter patients using the codes in tables 1 and 2.

At the end of quarter one (and in addition to the standard reporting outlined in this document), practices will need to submit the following baseline figures:

• Number of patients with existing catheters (identified from clinical systems);

• Number of existing long term catheter patients referred to the community as a result of initial review.

2 Identifying Catheter Patients

2.1 Clinical Communications

GP practices should utilise hospital discharge summaries and other clinical communications to identify patients that have left hospital with a catheter in situ. The following codes should then be used to ensure that these individuals are captured on practice registers:

Table 1: SystmOne SystmOne Code (CTV3) SNOMED CT Code (Concept IDs)

Indwelling Catheter

XE0iD

(Indwelling urethral catheter)

266737003

(Indwelling urethral catheter)

Urethral catheter Xa3du

(Urethral catheter)

34759008

(Urethral catheter)

Suprapubic catheter Xa3dh

(Suprapubic catheter)

286861005

(Suprapubic catheter)

Item D2 – Catheter Register Guidance

Catheter Registers (Adults >18 years)

24

Table 2: EMIS Web EMIS Web Code (Read V2) SNOMED CT Code (Concept IDs)

Indwelling Catheter

8D74.

(Indwelling urethral catheter)

266737003

(Indwelling urethral catheter)

Urethral catheter

7B2Bz

(Urethral catheterisation of bladder NOS)

410021007

(Urethral catheterisation)

Suprapubic catheter 8D76.

(Suprapubic catheter in situ)

440311000

(Suprapubic catheter in situ)

*Where the catheter type (i.e. urethral or suprapubic) is not clearly referenced in a discharge summary or clinical communication, practices can opt to use the top level code (‘Indwelling urethral catheter’).

*Using the codes above will enable GP practices to report on the number of patients added to their catheter register during a specified period (e.g. quarter 1).

*The codes in the blue columns will automatically map to SNOMED CT codes (although it should be noted that the current mapping is subject to change).

Note on coding: practices can opt to continue using existing codes, as opposed to the ones above (which have been included in this guidance to support practices to maintain a simple and reportable catheter register). However, it should be noted that this metric may include random practice audits across the year, hence it is important to implement a clear system.

In addition to the above, practices will also need to record (as free text or using existing read codes) whether patients have been:

• supplied with an escalation plan;

• supplied with a catheter passport;

• provided with catheter equipment (e.g. leg bags);

• referred to TWOC clinic (date if known);

• referred to Hertfordshire Community Trust (HCT).

The date and reason for catheter insertion should also be recorded in patient notes. This will enable the community services to manage patients more effectively (including providing a catheter passport where required).

2.2 Consultations

If a patient presents for a consultation with a previously un-documented catheter (i.e. there is no record of the practice being informed that the patient was discharged from hospital with a catheter in situ), GP practices will need to add a code to their record and refer to HCT if required.

25

2.3 Repeat Dispensing

Repeat dispensing of catheter equipment (e.g. leg bags) should also be used as an opportunity to identify and code previously un-documented catheters. Practices can opt to use the existing clinical report (remembering to change the dates and any other relevant variables), or develop their own. It is recommended that practices conduct this review on a regular basis.

2.4 Community Referrals

In addition to maintaining an electronic catheter register, GP practices will need to refer all long term catheter patients to HCT (as per the existing Integrated Community Team referral process), unless there is clear evidence that this action has been undertaken by the organisation that fitted the catheter. This will ensure that no patients are lost to follow-up.

Any long term catheter patients identified in consultations or via clinical reporting should also be referred to HCT if appropriate.

Note: HCT referral forms will need to be populated with sufficient detail before referring (e.g. date of catheter insertion, reason for insertion, etc.).

2.5 CCG Escalations (1)

Any instances where there is no clear evidence of any follow-up arrangements having been made by the organisation that fitted the catheter (e.g. a referral to TWOC or HCT) should be reported to the CCG GP Hotline for escalation. When reporting an issue, practices should supply the following details:

• patient NHS number;

• hospital discharged from (including ward if possible);

• confirmation that the discharge summary or clinical communication does not contain any evidence to suggest that follow-up arrangements have been made for the patient.

It is recommended that GP practices maintain a simple log of all escalations to the CCG (including date, reason for escalation, etc.). This will enable them to complete the quarterly returns spreadsheet.

2.6 CCG Escalations (2)

Any instances where a practice identifies that a patient has a catheter, but there is no record of it being fitted (e.g. in previous clinical communications), should be escalated to the CCG GP Hotline for investigation. For the purposes of quarterly reporting, it is recommended that practices utilise the log discussed above to record any such escalations.

Information required for investigation by the CCG:

• patient NHS number;

• assumed place of discharge with catheter;

• confirmation that practice was not informed of catheter insertion.

26

Note: any catheter patients identified during the baseline review do not need to be reported to the CCG GP Hotline (i.e. if there is no previous record of their catheters being fitted).

3 Removing Patients from Catheter Registers

This metric also requires GP practices to monitor and report on catheter removals. Local providers have therefore been asked to ensure that all successful TWOCs are communicated to practices in writing (i.e. via SystmOne tasking, nhs.net, clinic letters, etc.). Given that HCT is using SystmOne, they have been asked to ensure that all catheter removals are coded as per the table below:

Table 1: SystmOne SystmOne Code (CTV3) SNOMED CT Code (Concept IDs)

Indwelling catheter removed

XE0it

(Indwelling catheter removed)

266768004

(Indwelling catheter removed)

Removal of urethral catheter

7B2B2

(Removal of urethral catheter)

55449009

(Removal of urethral catheter)

Removal of suprapubic catheter

7B2C2

(Removal of suprapubic catheter)

75325006

(Removal of suprapubic catheter)

Those practices currently sharing with HCT should be able to see and report on this activity. However, there may be some occasions when practices need to code catheter removals in order to ensure that registers are kept up to date (e.g. if a local hospital confirms that a catheter has been successfully removed via a clinic letter).

Note: in addition to coding directly into patient records, HCT has been asked to ensure that written confirmation is provided to practices when a catheter is removed. This will ensure consistency across the CCG and enable practices to confirm that registers have been updated. Any instances where a catheter removal has not been coded correctly should be reported to the CCG GP Hotline.

Until interoperability between SystmOne and EMIS Web has been established, EMIS practices will be required to code catheter removals directly into patient records. The table below can be used to support this:

Table 2: EMIS Web EMIS Web Code (Read V2) SNOMED CT Code (Concept IDs)

Removal of urethral catheter

7B2B2

(Removal of urethral catheter)

55449009

(Removal of urethral catheter)

Removal of suprapubic catheter

7B2C2

(Removal of suprapubic catheter)

75325006

(Removal of suprapubic catheter)

Note on coding: practices can opt to continue using existing codes, as opposed to the ones above (which have been included in this guidance to support practices to maintain a simple and

27

reportable catheter register). However, it should be noted that this metric may include random practice audits across the year, hence it is important to implement a clear system.

3.1 CCG Escalations (1)

Any instances where it is discovered that a patient’s catheter has been removed, but the practice was not informed of this, should be reported to the GP Hotline for further investigation.

Information required for escalation by CCG:

• patient NHS number;

• assumed place of catheter removal;

• confirmation that practice was not informed of catheter removal.

4 CCG and Local Providers

In addition to ensuring that directly affected providers understand the requirements of this scheme, the CCG will be working with local hospitals to improve discharge processes. It is therefore anticipated that the number of cases requiring escalation to the CCG will reduce significantly over the next twelve months.

The CCG is also prepared to respond to any issues identified by practices, and provide further guidance where required.

5 Quarterly Reporting

The following metrics will need to be reported to the CCG via the ‘CFF Monitoring Template’:

Metric Reporting Frequency Measurement

Register list size at end of quarter (accounting for additions and removals). Quarterly Count

Number of patients added to register during quarter. Quarterly Count

Number of patients removed from register during quarter.

Quarterly Count

Number of escalations to CCG for incomplete discharge summaries / clinical communications (as per section 2.5).

Quarterly Count

Number of escalations to CCG for previously un-documented catheter insertions / removals.

Quarterly Count

END

28

GSF Meetings - CFF 18/19 Background On average 0.75% of your practice population will die each year.

• Most of these deaths can be predicted. • Identifying patients thought to be in their last years of life enables earlier discussion of their wishes

and improved care at the end of life. • A proactive team approach to the shared care of frail elderly people with multiple co-morbidities,

including cancer, becomes more possible. • Well run meetings support individual clinicians to not only care for their patients better, but to also

care for themselves. • ‘Branding’ the meetings as supportive and ensuring the name of your register includes the term

‘supportive’ can make earlier conversations easier.

What do I need to do?

1) Set up the meetings • Identify and train a committed lead administrator with IT and organisational skills. If a GP cannot

attend, the administrator will share important information. • Involve your team – district nurses, community matrons, GPs, GP trainees, clinical nurse specialists,

practice nurses, community specialist palliative care nurses, palliative care consultants, etc. • Agree to set up a regular team meeting at least every 4-6 weeks lasting at least 60 minutes (it will

vary depending on practice size).

2) Identify your cohort of patients 2.1 SystmOne Practices Ardens have set up a report on S1 that will pull through all the relevant information you need for your GSF meeting. Even if you are not using the templates, you can still access the report by following these steps:

• Go to Clinical Reporting > Ardens > Meetings > End of Life. • Right click the ‘End of Life Registers’ report > show patients. • Click on Select Output > Pre-defined report output > End of Life > Ok • Right > table > open as CSV

Item D3 – GSF/MDT Guidance

29

NHS NumbName SCR-AI Consent GSF Status TEP DNACPR Anticipatory PrescribingPreffered Place of Care Preffered Place of Death1244 Mrs L On gold standards palliative care 1245 Mrs M On gold standards palliative care 1246 Mrs N On gold standards palliative care 1250 Mr R On gold standards palliative care For resuscitation 1257 Miss Y On gold standards palliative care Not for attempted CPR (cardio 1258 Mrs Z On gold standards palliative care Not for attempted CPR (cardio Preferred place of care - hPreferred place of death: pt u 1259 Colonel Mustard On gold standards palliative care Not for attempted CPR (cardio 1275 Mr C Bing GSF prognostic indicator stage C ( Not for attempted CPR (cardio Issue of palliative care a Preferred place of care - hPreferred place of death: hom1276 Mrs M Gellar GSF prognostic indicator stage C ( Not for resuscitation Issue of palliative care a Preferred place of care - c Preferred place of death: nur 1277 Miss R Green GSF prognostic indicator stage C ( Treatment Escalatio Not for resuscitation Prescription of anticipat Preferred place of care - c Preferred place of death: nur 1242 Mr J GSF prognostic indicator stage B ( 1243 Mr K GSF prognostic indicator stage B ( 1249 Miss Q GSF prognostic indicator stage B ( For attempted cardiopulmona Preferred place of care - hPreferred place of death: hom1256 Miss X GSF prognostic indicator stage B ( Not for attempted CPR (cardio Preferred place of care - c Preferred place of death: care 1270 Mr Dibble GSF prognostic indicator stage B ( Not for resuscitation 1273 Mr Bolt Express consent fo GSF prognostic indicator stage B ( Treatment Escalatio Not for resuscitation Preferred place of care - hPreferred place of death: hom 1279 Mr J Tribiani GSF prognostic indicator stage B ( Not for resuscitation Prescription of palliativ Preferred place of care - c Preferred place of death: nur 1255 Mr W GSF prognostic indicator stage A ( Not for attempted CPR (cardio Preferred place care - pat Preferred place of death: pt u

This will provide you with a table that looks like this:

You can then sort patients by GSF status to help you prioritise the patients to discuss and see what discussions need to take place with the patient e.g. Treatment Escalation Plans, Preferred Place of death.

2.2 EMIS Practices

HBLICT have set up a template for EMIS Practices that will pull through all the relevant information you need for your GSF meeting. Guidance for this can be found at the following link:

D3a - EMIS GSF Report Guidance (HBLICT to provide April 2018)

30

3) during the meeting 3.1 Prioritising Patients

• Needs based RAG coding helps you to organise your meetings, an option is shown here, but others exist:

1) Red – last days of life 2) Amber – last weeks of life or increasing decline 3) Green – last months of life or advancing disease 4) Blue – incurable condition but could live for years, e.g. dementia or frailty.

• Use your own and other staff’s knowledge of the patient and their health status/closeness to death,

prioritise the most unwell. • Use your prioritisation code as a guide to who to discuss first e.g. patients coded red. • You will not need to discuss every patient on the list at every meeting e.g. stable patients coded

green and blue. • Include new additions since the last meeting and anyone else any team member has concerns

about. • Discuss all deaths since the last meeting including deaths of patients who were not on the register

and sudden or unexpected deaths – consider bereavement care needs. 3.2 Agenda

• Plan the meeting; use the agenda as a tool, e.g.: 1) Introductions 2) Red patients (15 mins – include discussion of physical, social, psychological and spiritual

dimensions) 3) Amber patients (30 mins) 4) Green/Blue ‘changing’ patients 5) Review of deaths – celebrating good care and identifying areas to improve 6) Review of relevant admissions/discharges 7) New patients to the register (It is important to record the RAG code at the point of joining the

register). 8) AOB – such as educational points or Significant Event Analysis (SEA, see tip 3.4) 9) Summarise and plan date for next meeting

3.3 Running the meeting

• Chair and run the meeting in a positive and supportive way, the issues dealt with can be challenging, but keep control of time.

• Invite the lead/administrator to ensure GP notes are up to date and accurate, and highlight key areas – especially actions and accountabilities.

• Open the patient record when they are being discussed and add any notes as you go through the list

• Follow up agreed actions and responsibilities – plan the next meeting 3.4 Significant Event Analysis Review outcomes for patients:

• Highlight good practice from ‘good deaths’ • Patients who died in hospital – was this the preferred place of death?

• If not, could the admission have been prevented? • Identify any barriers that prevented a ‘good death’.

• Patients not on the register who died – could they have been identified? • Encourage a culture of trust and learning from each other. • Identify training needs of the team, perhaps formalise SEA every six months to highlight

important issues

31

4) After the meeting • Complete the “GSF meeting record sheet” • Remove the Patient Identifiable data from the spreadsheet (Column A & B) • Send both to the CCG mailbox: ENHCCG.localities1@nhs.net

5) Payments Practices will be paid on completion of the minimum number of meetings held and subject to documentation as requested being submitted to the CCG.

32

GSF Meeting Record Sheet

Date of meeting________________________ Meeting number /8 (you must conduct at least 8 evenly spaced meetings in 12 months. Name of Surgery _______________________ Named GP Lead _____________________________

Please send a copy of this completed sheet to ENHCCG.localities1@nhs.net along with the quarterly submissions.

Staff present: (initials and job roles)

No. of patients discussed ____________________________

Actions:

Provider issues that need addressing:

Further comments:

Item D4 – GSF/MDT Meeting Template

33

This page left intentionally blank

34

Post Death Audits Primary Care - CFF 18/19 Background Post Death Audits (PDA) support the CCG to identify where gaps exist in the palliative and end of life care pathway. They provide the CCG with a snapshot of issues with current provision and areas for improvement. This helps to improve the quality of services for patients.

In 2017/18 practices were asked to identify if the patient was a care home / nursing home resident and which care home this was. This has enabled us to identify care homes that were sending residents to hospital when they were end of life rather than keeping them at the home. We have then been able to work with these homes and provide training on end of life care. As a result we have seen an increase in the numbers of patients achieving their preferred place of death (PPD).

Changes to the Post Death Audit for 2018/19

1) Reporting The CCG have developed a summary report that will be sent to practices on a quarterly basis. This will collate the results of the audit at a CCG, practice and locality level. Practices will then be able to see where they are performing well and where improvements may be made to the end of life care provided.

Separate guidance has been developed to help practices understand the Post Death Audit Reports.

2) Changes to / additional questions

2.1 Care Planning This year we have added the option for practices to state that treatment escalation plans / DNACPR / addition of information to Summary Care Record has been offered but declined by the patient. This will allow for a more accurate reporting of those with and without these elements of an advance care plan.

2.2 GSF register A priority for the CCG is the early identification of palliative and end of life patients. For this reason we have added to the PDA “date the patient was added to the GSF register and RAG

Item D5 – Post Death Audit Guidance

35

code at that time”. This will enable us to provide you with a breakdown of how long before death the patient was identified as end of life.

2.3 Preferred Place of Death (PPD) To enable more accurate recording of the patients PPD, this is no longer a free text box. Instead this will be either a tick box or drop down box (depending on clinical system) and relate to the Read codes within the EoL template.

2.4 PPD - not achieved Again, to enable more accurate recording, PPD not achieved is no longer a free text box. Instead this will be either a tick box or drop down box (depending on clinical system). This will allow the CCG to see where there are issues in the pathways that are stopping patients from achieving their PPD.

3) Completing the Post Death Audits

SystmOne EMIS Web No change from 2017/18 No change from 2017/18

4) Submitting the Post Death Audits

4.1 SystmOne Please run the report (no change from 2017/18) and send to: ENHCCG.localities1@nhs.net 4.2 Emis Please send the completed forms to: ENHCCG.localities1@nhs.net

5) Re-occurring issues from previous years

5.1 Patient identifiable information Please ensure that any submissions you make do not contain NHS numbers or patient names. Instead practices should number each one by creating an identifier consisting of:

• Practice code • Financial Year • Consecutive number

For example: A12345-17/18-1 For practices that submit the PDA as a word document, please use this format to save/name the document and not patient names or initials.

36

Was the patient a residential / nursing care home resident?

If YES, name of residential / nursing care home Date of death?

Was the death unexpected?

Did the patient have an advance care plan?

Was the patient on the GSF register?

Did the patient have an EPaCCS record?

Was preferred place of death (PPD) recorded in the notes?

If Yes, did the patient die in the preferred place of death?

What was the PPD?

If PPD recorded but not achieved, please indicate why?

What was the date of discharge?

What was the cause of death?

What was the main diagnosis for admission?

Were these related?

If the discharge from hospital was related to End of Life, was a clear End of Life Plan in the

Was the admission potentially avoidable?

Yes The home 01/04/2018 No Yes Yes Yes Yes Care HomeYes The home 01/04/2018 No No No Yes Yes Nursing homeNo 21/06/2018 Yes No No bed in hospice 15/06/2018 Pneumonia Pneumonia Yes Yes NoNo 26/06/2018 No Yes Yes Yes Yes Home Unavoidable admission 10/06/2018 Pneumonia Pneumonia Yes Yes No

5.2 Correct S1 reports On some occasions practices have submitted the wrong reports. This could be due to the way in which the reports are being run and practices experiencing issues should contact the HBLICT helpdesk.

The report should have the headings and look like this:

6) Payments Practices payment based on completed quarterly submissions reviewed by End of Life Working Group. Practices to provide number of deaths and number of post death audits for each month within the quarterly submissions. Practice to analyse the data quarterly and report on the themes and any changes to practice procedures, record of date discussed at the MDT/GSF meetings and agreed actions, time frames and named owner of actions.

37

This page left intentionally blank

38

Post Death Audit Tool

Reference: DoB: Was the patient a residential /

nursing care home resident? Yes

No

Date of death:

If YES, name of residential / nursing care home

Was the death unexpected? Yes No

If No: Was the patient on the GSF register? Yes No

Date added to the GSF register RAG code when added to the GSF Register (e.g. red, amber, green or blue)

Was the patient offered a DNACPR Yes and had one

Yes and declined

No

Was the patient offered an advance care plan? Yes and had one

Yes and declined

No

Did the patient have an EPaCCS record? Yes No Was preferred place of death (PPD) recorded in the notes? Yes No

If Yes, did the patient die in the preferred place of death? Yes No What was the PPD?

Care / Nursing Home Hospice or Home (patient choose both)

Home

Pt unable to express preference

Hospice Patient declined discussion

Hospital If PPD recorded but not achieved, please indicate why?

Admitted to hospice for specialist care - died in hospice

Admitted to hospital by paramedics / 111 / OOH Bed unavailable at hospice Other

Unable to remain at home - rapid deterioration

Unavoidable hospital admission - died in hospital

THE REMAINDER OF THE TOOL ONLY NEEDS COMPLETING IF PATIENT DIED WITHIN 30 DAYS OF DISCHARGE FROM ACUTE HOSPITAL

Item D6 – Post Death Audit Tool

39

What was the date of discharge?

What was the cause of death?

What was the main diagnosis for admission?

Were these related? Yes No

If the discharge was related to End of Life, was a clear End of Life plan in the discharge letter? Yes No

Was the admission potentially avoidable? Yes No

Note that the tool will be available on GP clinical system

Additional guidance for the Post Death Audit tool can be found below:

For SystmOne Practices – D6a Additional Guidance for Post Death Audit tool - SystmOne

For Emis Practices – D6b Additional Guidance for Post Death Audit tool - EMIS

40

Understanding the Post Death Audit Report.

Access to the Post Death Audit report can be found on the CCG website link below

D7a Post Death Audit report

Guidance on how to read and use the Post Death Audit, can be found on the CCG website link below

D7 Post Death Audit Access Guidance

Item D7 – Post Death Audit Access Guidance

41

This page left intentionally blank

42

Dementia Care Planning Guidance Ensure Care Plans are in place and shared for all patients diagnosed with dementia and they are being reviewed annually.

Rationale Patients diagnosed with dementia require robust care plans (and advanced care plans) developed in primary care. Who are cohort within this CFF element? Patients diagnosed with dementia.

Practices are being asked to provide the following to assess impact:

Practices to identify patients diagnosed with dementia who have a care plan in place that has been shared and has been reviewed annually

1) Identify patients diagnosed with Dementia; 2) Patient to have personalised care planning in place that has been shared with partner

organisations/carers 3) Patients with a personalised care plan have had the care plan reviewed within preceding 12

months

How do I record the information?

SystmOne – Ardens Users

SystmOne – Non Ardens Users

EMIS Web

Use the Dementia template to capture key information. - Click on Care Plan - Click on Generic Care

Plan make sure you select the code from the drop down box

Signpost patients (where appropriate) to self-management support on the Health in Herts webpages

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages.

Item D8 – Dementia Care Planning Guidance

43

Reporting Requirements/Frequency

Practices to complete Dementia Register and submit data on a quarterly basis:

1) number of patients on register 2) number of patients on register with a care plan 3) number of patients who have had a review within the preceding 12 months

CCG to review submissions quarterly and report to the Dementia Strategy Group.

Agreed payment for care planning

This payment is for those patients who are not moderately or severely frail and who therefore would be unlikely to otherwise meet the criteria for payment for care plans. Dementia plans will be reimbursed at a rate of £50 and SMI checks will be reimbursed at a rate of £30. Sharing the care plan Once you have identified your cohort and completed the care plans, you need to ask for consent from the patient to share information. With the patient:

• Print or email the documents to the patient With other professionals

• With the permission of the patient, practices can add additional information about specific conditions to the summary care record to make it an enhanced summary care record.

• Once you have selected this read code and saved the record, there is nothing further for you to do as the system will automatically upload the information.

• Patients at S1 practices can consent to having their whole record shared with other S1 users e.g. hospices and this will give a more in depth picture to other health care professionals.

• More information can be found here: http://www.hblict.nhs.uk/scr/#toggle-id-8 • The sharing of patient records and care plans/treatment plans is part of the wider “My Care

Record” project

44

Read Codes

SystmOne (CTV3 Code)

EMIS & Vision (v2

Code)

SNOMED Concept ID Code (SNOMED

replaces Read CTV3 & v2 in all GP

systems during 2018)

Dementia care plan XaaBZ 8CMZ 869791000000101 Dementia care plan agreed XacIx 8CMZ0 956841000000106 Dementia care plan declined XacIz 8CMZ2 956881000000103 Dementia care plan reviewed XacIy 8CMZ1 956861000000107 Dementia care plan review declined XacJ0 8CMZ3 956901000000100 Dementia advance care plan XacLx 8CMe0 959361000000105 Dementia advance care plan agreed XabEk 8CSA 713600001 Dementia advance care plan declined XabEi 8IAe0 956881000000103 Dementia advance care plan review declined XacM2 8IAe2 959461000000102 Review of dementia advance care plan XabEl 8CMG2 956861000000107

END

45

This page left intentionally blank

46

Improving physical health checks for people with severe mental illness (SMI) in primary care

Rationale

In the Five Year Forward View for Mental health1 NHS England committed to lead work to ensure that by 2020/21, people living with severe mental illness (SMI) have their physical health needs met by increasing early detection and expanding access to evidence based physical care assessment and intervention each year. This element of the CFF is to incentivise practices to undertake appropriate and timely physical health assessments to reduce the risk of poor physical health in this population and evidence they have supported patients using available health information and advice services to take up tests and interventions that reduce the risk of preventable health conditions.

Who are the people with SMI?

Patients who are diagnosed with schizophrenia, bi-polar affective disorders and other psychotic disorders. Please note people with SMI may also be identified under other care planning elements of the CFF.

Practices are being asked to provide the following to assess impact:

4) Identify patients on SMI register; 5) Complete the recommended physical health assessments metrics (not covered via QOF

and/or NHS check) annually for patients with SMI: a. Whose care has always been solely in primary care, or b. Who have been discharged from secondary care back to primary care; or c. Who have been in contact with secondary care mental health teams (with shared

care arrangements in place2) for more than 12 months and whose condition has stabilised.

6) Follow-up: offer, delivery of or referral to appropriate NICE recommended interventions: “don’t just screen, intervene”

7) Follow-up: ensure personalised goals and action plan, engagement and psychosocial support are in place to support physical health

What are the health check requirements?

There is overlap with physical health checks currently being incentivised through different funding streams that are offered by primary are i.e. Mental Health Quality Outcomes Framework (QOF) and NHS Health Check for adults between 40-70 years old who have not been diagnosed at risk of specific conditions. 1 https://www.england.nhs.uk/publication/the-five-year-forward-view-for-mental-health/ https://www.england.nhs.uk/publication/improving-physical-healthcare-for-people-living-with-severe-mental-illness-smi-in-primary-care-guidance-for-ccgs/ 2 HPFT Shared care protocol for physical health checks for patients with SMI http://www.hpft.nhs.uk/media/1842/item-13a-physical-health-strategy-final-board-paper.pdf

Item D9 – Physical Health Checks Guidance for SMI Patients

47

For the purpose of payment, for this element of the CFF, practices will only receive payment to complete the outstanding physical health check elements for patients with SMI, that are not covered by QOF and for those patients not eligible for the NHS Health Check. The purpose of the CFF payment is to incentivise primary care to annually deliver the following checks

For patients with SMI aged 40-70 years old eligible for NHS Check - metrics

Full blood count* ECG before starting anti-psychotic medication if: (there is family or personal history of CVD, if a physical health check indicates possible risk (e.g. blood pressure monitoring, if they are taking medication known to cause ECG abnormalities or if they are admitted as an inpatient). Liver function tests* Prolactin* Thyroid function tests Kidney function tests (urea and electrolytes) Serum calcium levels Sexual health and contraception Oral health

(* The following results will be accessible to all clinicians and practitioners via ICE or Pathweb)

For patients with SMI NOT eligible for NHS Health Check - metrics

Family History Smoking Status Illicit Substance misuse BMI or other obesity measure (weight and waist circumference), exercise and diet Total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides HbA1c and fasting glucose or random blood glucose* Full blood count* ECG before starting anti-psychotic medication if: (there is family or personal history of CVD, if a physical health check

48

indicates possible risk (e.g. blood pressure monitoring, if they are taking medication known to cause ECG abnormalities or if they are admitted as an inpatient). Liver function tests* Prolactin* Thyroid function tests Kidney function tests (urea and electrolytes) Serum calcium levels Sexual health and contraception Oral health

How do I record the information?

SystmOne – Ardens Users

SystmOne – Non Ardens Users

EMIS Web

Ardens does not have a specific template so please use the TPP Mental Health Physical Review template. This template also capturese the QOF requirements and will automatically populate. Will also capture: Follow-up: offer/refer to appropriate NICE intervention – use of the template to read code interventions undertaken/referred to from practice In addition to recording the QOF care programme approach review codes, please complete a personalised care plan use the read codes below to record this element.

Use the TPP Mental Health Physical Review template

EMISWEB Please use national Mental Health Physical Review template.

49

Reporting Requirements/Frequency

Practices to complete SMI Register and submit physical health check data at month 6 (October 2018) for financial year 2018/19. The CCG expectation is that practices will have completed half (50%) of the CFF physical health checks for their eligible patients on the SMI register and demonstrate:

1) Number of patients on SMI register

2) Number with physical health check completed in preceding 12 months

3) Number offered/referred to associated interventions

4) Number with personalised goals and action plan for physical health in place

Practices to repeat audit/data submission at year end showing improvement in physical health checks for people with SMI at the end of the year.

Sharing the personalised goals and action plan

Copy to patient and copy to HPFT/other professionals where appropriate

Next Steps

Refer to the HPFT share care protocol for physical health checks for people with SMI – http://www.hpft.nhs.uk/media/1842/item-13a-physical-health-strategy-final-board-paper.pdf

Read codes

SystmOne (CTV3 Code)

EMIS & Vision (v2

Code)

SNOMED Concept ID Code (SNOMED

replaces Read CTV3 & v2 in all GP

systems during 2018)

Mental health annual physical examination done XaJON 9H9 408404002 Goals and action plan Goal identification Ua1LR 67L 225294001 Review of Patient Goals XaXfH 8CMX 775501000000108

Care Plan documentation

SystmOne - Ardens Users SystmOne - Non Ardens Users

EMIS Web

Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES to set patient

Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned

50

which condition specific plans the patient needs. - Click on future care

planning - Click on Patient Goals

and set goals relating to physical health with patient

Signpost patients (where appropriate) to self-management support on the Health in Herts webpages

goals. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages.

admissions DES to set patient goals. Signpost patients (where appropriate) to self-management support on the Health in Herts webpages.

END

51

This page left intentionally blank

52

Diabetes and Diabetes prevention Guidance 1. Practices participating in Diabetes CFF agree to deliver all elements of enhanced diabetes care. Participating practices would have signed up to this as part of the sign-up sheet (Item A2)

2. Each practice should appoint a Diabetes Champion to lead the practice in relation to the diabetes agenda and delivery against the Consolidated Funding Framework (CFF) key outcomes. This can be GP or Nurse led and will also provide representation at locality level where required. An outline of the role is provided on the following page.

3. Each practice should review their performance against the expected outcomes below to identify areas to achieve all targets using NDA baseline data for 2016/17 that will be found here:

D10a Diabetes Baselines

4. Each practice should produce a plan of improvement utilising the input from the annual HCT/Consultant practice visit.

5. Using the template D10c - Diabetes Improvement Plan provided the improvement plan should set out:

• An assessment of performance and any progress to date

• Identify areas of improvement, intervention planned and a target date for delivery

• Barriers to achievement

6. The plan should include timescales and any year to date implementation progress at point of submission. The plan should be submitted to the CCG by 30th June 2018

Eight Care Processes

Completion of all 8 care processes across ENHCCG is currently at 28.1% of Type 1 and 38.7% of Type 2 diabetes patients. By the end of the year, under the CFF each practice must have delivered all 8 care processes to 60% of Type1 and 2 diabetes patients. The care processes are outlined in Appendix 4.

NICE Treatment Targets

In ENHCCG the average for achievement of all three NICE treatment targets (HbA1c <58, BP <140/80, Cholesterol <5) is 41.7% of Type 2 diabetes patients and 18.5% for Type 1 patients. By the end of the year each practice must achieve 60% of Type1 and 2 diabetes patients meeting this triple target.

Item D10 – Diabetes and Diabetes Prevention Guidance and Improvement Plan

53

CFF Diabetes Champion – Outline of Role

Each practice to identify a Clinical Diabetes Champion to lead the practice in relation to the diabetes agenda and delivery against the Consolidated Funding Framework (CFF) key outcomes. This can be GP or Nurse led and will also provide representation at locality level where required.

Key tasks to include:

• Provide clinical leadership in co-ordinating practice input into the annual practice diabetes plan developed from the Annual HCT/Consultant visit.

• Ensure practice has an up to date and complete diabetes register.

• Ensure systems are in place for detecting and diagnosing people with diabetes and people at risk of developing diabetes.

• To share learning, themes, outcomes and good practice at locality and practice level, and to identify practice training needs to be incorporated into the practice education plan

• Encourage use of Cambridge Diabetes Education Programme to upskill clinical practitioners.

• Using the quarterly locality reports, to provide update to the practice on performance, progress and issues

• To lead the practice and ensure competence in delivering essential diabetes care, including care planning

• To ensure clinical staff are able to carry out patient foot checks and that these are done on a regular basis or at least annually.

• To lead the practice to improve implementation of 8 health care checks and increase the percentage of patients meeting diabetes care goals: BP < 140/80 mmHg; Cholesterol < 5mmol/L or lower and HbA1c < 7.5 %.

54

55

National Diabetes Audit and Diabetes Nine Health Care Checks and Treatment Targets

The National Diabetes Audit (NDA) is a national clinical audit. Each year, the NDA collects information from GP practices and hospitals about the care they provide for people with diabetes. The audit collects information about the quality of care provided to patients by the NHS. The reason why the NDA collects this information and produces reports is to:

• highlight where diabetes care is good and meets national guidelines

• show where care needs to improve

HbA1c (blood test for glucose control)

Blood Pressure (measurement for cardiovascular risk)

Serum Cholesterol (blood test for cardiovascular risk)

Serum Creatinine (blood test for kidney function)

Urine Albumin/Creatinine Ratio (urine test for kidney function)

Foot Risk Surveillance (foot examination for foot ulcer risk)

Body Mass Index (measurement for cardiovascular risk)

Smoking History (question for cardiovascular risk)

Digital Retinal Screening (photographic eye test for eye risk) – delivered by NHSE

Diabetes Treatment Targets

The targets are:

• an HbA1c of 58mmol/mol (or 7.5%) or less ,

• A total cholesterol level of below 5mmol/l

• Blood pressure reading of less than 140/80mm/Hg1

Why are diabetes healthcare checks and treatment targets important?

A person with diabetes has prolonged periods of time with higher than normal glucose levels, or high blood cholesterol or blood pressure; this can eventually cause problems. These include health complications, such as blindness, kidney failure, amputation, heart disease and stroke.

This is the main reason why it is essential that everyone with diabetes receives the nine healthcare checks every year. The results of the checks can show whether they are at risk of developing health complications and whether they have developed the earliest stages of complications. For example, the blood pressure check will show if a person needs medication to bring their blood pressure level down. Or a foot check may show an increased risk of ulcers, which may require regular follow-up with a podiatrist.

56

National Diabetes Prevention Programme – Initial Assessment (IA) Targets 2018/19

There are currently five million people in England at high risk of developing Type 2 diabetes. If these trends persist, one in three people will be obese by 2034 and one in 10 will develop Type 2 diabetes.

There is strong international evidence which demonstrates how behavioural interventions, which support people to maintain a healthy weight and be more active, can significantly, reduce the risk of developing the condition.

The Healthier You: NHS Diabetes Prevention Programme (NHS DPP) identifies those at high risk and refers them onto a behaviour change programme

https://preventing-diabetes.co.uk/referrers/hertfordshire/

10d - Diabetes NDPP IA Targets

National Diabetes Audit Specification Codes 2016/17.

Care Processes should be recorded in clinical systems using the identified Read Codes identified as part of the NDA Primary Care Extraction Specification 2016/2017.

10e - NDA Specification Codes 2016/17

57

This page left intentionally blank

58

Promoting Early presentation activities

Practices to work with the CCG and practice PPG members to promote the national campaigns within the practice and locally (self-certify using the enclosed sheet). PPG members in the past have held stalls in the waiting areas, local shopping centres, library and other community settings.

Timetable of campaign events: see Item E2 – Cancer Campaign Timetable

Template to evidence of practice campaigns and activities undertaken can be found here Cancer Campaign Timetable

Improve Cancer Screening uptake

Baselines will remain the same as August 2016 for Cervical, Bowel and Breast Cancer and can be found here Cancer Screening baseline Report

Nationally published data will be provided by the CCG on a quarterly basis, this will be for the previous 2 quarters or the latest that NHSE are able to share.

Current data: Will be published in May as item E1c Latest Cancer Screening Data on the CCG Website.

Van dates: https://www.bhbss.nhs.uk/WhenwescreenNoColumn.aspx?sub=2&top=3

Breast Screening contact details: https://www.bhbss.nhs.uk/userpageNoColumn.aspx?ContentID=Where&sub=1&top=3

Cancer case Analysis

Establish a system in practices for GPs to formally review their newly diagnosed cancer patients in these top 5 areas: Upper GI, lung, breast, colorectal and urological. The case note review should be undertaken by the referring/usual GP. We are using the National Cancer Diagnosis Audit Template (NCDA) in readiness for 2019. Please note that the data on the NCDA for this year will remain with the practices and will not be shared with the CCG, this will aide in preparing the quarterly locality report which will be shared with the locality and the CCG, no patient identifiable data will be shared. The Cancer Case Analysis Template can be found as item E1d NCDA Data Collection Template on the CCG website.

The Clinical Cancer Champion will ensure that this process is followed and all lessons learnt, changes to processes and required actions will be discussed as a practice. Any gaps and training need should be addressed and agreed as a locality to add to future training events.

The Clinical Champions from each practice will meet quarterly and discuss the themes and outcomes of their practice and collate into a locality report, including the results from the questionnaires. This report should be presented at a locality meeting sharing good practices and identify training needs, this report will then be sent to the CCG on a quarterly basis.

Cancer Guidance

Item E1 – Cancer Guidance

59

Practice plan template: (deadline 30.06.18)

Locality plan template: (deadline 30.06.18)

6 month review – as required by QOF, the practice should review all their newly diagnosed cancer patients at 6 months, and the CCG would like the practices to encourage their patient to complete a patient experience questionnaire, this will enable the CCG to highlight the patient experience, whether they were seen within the national time scales and the quality of care received.

Questionnaires can be found here, please print off some copies for those patients that do not have internet access (word format to follow) https://www.surveymonkey.co.uk/r/ENHcancerPE

Education and training for the locality

Locality Clinical Cancer Champions, Nurse Tutor and workforce leads to highlight the training needs of their practices/locality and arrange for these to be added to the locality education events agenda.

The CCG workforce leads will also advise the localities of the items to be covered in their Target events as per the Protected Learning Time policy.

60

Item E2 – Cancer Campaign Timetable East and North Herts CCG: Cancer CFF Reporting Template 2018/2019 Promoting Early Presentation and Recognition of Symptoms

Quarter 3 Evaluation Report 2018/19:

Campaign Evidence of activities undertaken by the practice Bowel Cancer Awareness Month April

Sun Awareness week – Skin Cancer 14th – 20th May

Cervical Screening Awareness Week June

European Head & Neck Cancer Week 12th – 19th Sept

Breast Cancer Awareness Month October

Lung Cancer Awareness Month November

BE CLEAR ON CANCER campaign World Cancer Day – 4th Feb

Any other campaigns:

Practice Name:……………………………………………………….

Completed by (name): ……………………………………………………….. (to be completed by the Practice Clinical Champion- see role outline)

Signature: ……………………………………………………………………………………

61

This page left intentionally blank

62

Item E3 – Practice Cancer Plan Template

Practice Cancer Plan – Deadline for completion and submission by 30th June 2018

Name of Practice

Name of person completing the plan document

What is the practice plan to increase public awareness of signs and symptoms of Cancer. Reduce premature mortality and morbidity relating to cancer.

How will the practice achieve more people being diagnosed via screening and 2ww referrals rather than following an emergency admission?

What actions will the practice take to target screening in the hard to reach groups and which groups are they?

How will the practice achieve their screening targets?

• Consider what the target is,

• what additional percentage the practice needs to achieve,

• How will this be achieved?

Bowel (including patients who DNA their colonoscopy appointment following a positive bowel screening result: Breast:

63

• What will be done differently to contact non-responders?

Cervical:

How will the practice ensure that the clinicians maintain and improve their clinical knowledge and skills, and admin staff training and awareness?

Cancer Case Analysis What is the practice system for formally reviewing newly diagnosed upper GI, lung, breast, colorectal and urological cancer patients?

6 months review of newly diagnosed patients What is the practice plan and how will the patients be encouraged to complete the CCG patient experience questionnaires?

Please submit to Localities inbox: ENHCCG.localities1@nhs.net at the end of Q1

64

Item E4 –Locality Cancer Plan Locality Cancer Plan (To be completed jointly by the Practice Clinical Champions- see role outline) Deadline for completion and submission by End of Q1 Name of locality

What is the locality plan to increase public awareness of signs and symptoms of cancer. Reduce premature mortality and morbidity relating to cancer.

How will the locality achieve more people being diagnosed via screening and 2ww referrals rather than following emergency admissions? State the current rates and what the goal will be.

What actions will the locality take to target screening in the hard to reach groups and which groups are they? State what the achievement will be.

How will the locality work together to achieve the screening targets? How will the variation in practices be addressed?

How will the locality ensure that the clinicians maintain and improve their clinical knowledge and skills, and admin staff training and awareness?

Please submit to Localities inbox: ENHCCG.localities1@nhs.net End of Q1

65

This page left intentionally blank

66

Item E5 – Locality quarterly submission report

Quarterly Locality Cancer report / CCG submission template 2018/2019 (To be completed jointly by the Practice Clinical Champions- see role outline) Locality

Name of person completing the plan document

Dates of meetings with all the Clinical Cancer Champions in the Quarter

Which practices were not present?

Date report was presented to the Locality

Date report sent to the CCG Also confirm which quarter the data relates to:

Bowel Screening target What was the baseline for the locality: What is the percentage now and has it improved (date of data)? Actions to be taken:

Breast Screening target What was the baseline for the locality: What is the percentage now has it improved (date of data)? Actions to be taken:

Cervical Screening target What was the baseline for the locality: What is the percentage now has it improved (date of data)? Actions to be taken:

How many patients in the locality were diagnosed via screening?

How many were diagnosed following an emergency Admission?

67

What actions were taken as a locality to screen the “hard to reach group”?

What training and education needs were identified?

Was this information escalated and to who? What are the dates for the education events?

State the next campaigns and what the locality are planning.

Locality data for Qtr Breast Colorectal Urological Upper GI Lung Number of new cases

Number of case reviews completed

Number of emergency presentations

Key learning points from the cases

Key actions taken from cases

How many QOF 6 month reviews were carried out in the Quarter for the locality

Analysis of the patient experience data supplied by the CCG.

Include how many collated, what were the themes, what lessons can be learnt from the patient’s experience, are new processes identified and in place?

Please submit to Localities inbox: ENHCCG.localities1@nhs.net each quarter

68

Item E6 – Breast Screening Letter Template

BREAST TEMPLATE: FOLLOW UP WITH DEFAULTERS

Private & Confidential

Title Initial Last Name

Home Address House Name/Flat Number

Home Address Number and Street

Home Address Village

Home Address Town Home Address Postcode

Dear Title Surname

I am writing to you because I noticed that you have not attended a recent breast screening appointment.

At our Practice, we very much support this NHS screening programme and encourage all women who are eligible to participate. We know that screening can detect changes in the breast before they develop into Cancer and this has contributed towards the prevention of lengthy and difficult treatments whilst it has also helped to save many lives.

As such we would encourage you to consider taking up your breast screening invitation as soon as possible. Whether or not you take up your screening is your choice but if you have not responded to letters from the breast screening service or are over 70 years of age and would like to make an appointment you can do so by contacting

the breast screening unit directly on 01582 497599. If the breast screening unit has left your town, you will still be able to go to a neighbouring location. Make sure you ask the operator where the unit will be and book a location convenient for you. You do not need to wait for the screening unit to come back to your local town – it could be as long as 3 years before it returns.

You can also access their webpage at www.bhbss.nhs.uk if you have any other queries or concerns about the test, the process of screening and the feedback of results and potential recall.

If, after careful consideration, you still decide not to take up your breast screening invitation, please contact the screening centre, via the number above, so that we can update our healthcare records.

Yours sincerely

Dr Free Text Prompt

END

69

This page left intentionally blank

70

CCG Pathway and Thresholds Assessment Guidance

As part of the Sign up to the CFF, Practices have agreed they will ensuring that the clinicians comply with the requirements of the pathways, including use of referral criteria, appropriate referral forms, and undertake appropriate tests before referral. Practices will offer patients options which will allow them to meet their goals with self-care and self-management, and follow the Shared Decision Making guidelines. Validation of the prior approval requests against referral activity, assessment of variation in referrals, will be audited by the CCG, and practices will be contacted if non-compliance incidents are identified.

Practices are to comply with CCG Fit for Surgery policy, prior approval processes, CCG referral thresholds guidance, and shared decision making guidance.

By signing up to the CFF, practices have confirmed that they are using CCG thresholds for referral where specified and providing appropriate pre-referral tests and using appropriate referral forms, as specified either in the pathways, Ardens or on the referral threshold/peer review section of the website (latter currently under development); and use of NICE approved shared decision making tools when specified in a pathway.

The following links to the CCG website have been provided for practices to review regularly as new guidance is developed throughout the year.

• Pathways can be found here: http://www.enhertsccg.nhs.uk/pathways and leaflet templates can be found here: http://www.enhertsccg.nhs.uk/pathway-leaflets

• Guidance and Policies can be found here: http://www.enhertsccg.nhs.uk/ccg-guidance-and-policies-final

• Referral Forms and Templates can be found here: http://www.enhertsccg.nhs.uk/pathways/referrals

• Shared Decision Making can be found here: http://www.enhertsccg.nhs.uk/shared-decision-making

• IFR Information can be found here: http://www.enhertsccg.nhs.uk/ifr

Planned Care Guidance

Item F1 – CCG Pathway and Thresholds Assessment Guidance

71

This page left intentionally blank

72

Medicine Optimisation Guidance CFF MO metric area 1

Reducing the overall prescribing of antibacterial prescription items per STAR PU (Specific Therapeutic Patient Unit) –This takes into account the demographics of patients receiving a therapy).

Why are we focussing on this?

Work to develop and deliver this Quality Premium target directly responds to the ambitions set by Government following the O’Neill Review on Antimicrobial Resistance (May, 2016). These ambitions include a: • 50% reduction of Gram Negative Bloodstream Infections (GNBSIs) by 2020. • 50% reduction of the number of inappropriate antibiotic prescriptions by 2020. It also enables work to support the UK 5 Year AMR Strategy (2013-2018), which states that there are few public health issues of greater importance than antimicrobial resistance (AMR) in terms of impact on society. Infections are increasingly developing that cannot be treated and the rapid spread of multi-drug resistant bacteria means that we could be close to reaching a point where it is not possible to prevent or treat everyday infections or diseases. Achieving the QP target at CCG level will generate a quality payment to the organisation.

What is the achievement threshold?

<=0.965 items per antibacterial STAR-PU. Practice baseline data for illustration will be provided. (Jan to Dec 2017)

What do practices need to do?

Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to:

• The latest version of Herts Guidance for the Management of Infection in Primary Care available here (this is also available as a smartphone app).

• Suite of other resources in relation to treating infections including tackling antimicrobial resistance, restricted antibiotics, UTIs in care homes, tips for self-care here

If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection. Learning resources can be found in the TARGET Antibiotic Toolkit available here: http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/target-antibiotic-toolkit.aspx How will patients be identified? Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for antibacterials and review whether continued prescribing is appropriate.

Item F2 – Medicines Optimisation Guidance

73

How will payment be achieved?

10p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.

Prescribing will be monitored by PMOT using epact/epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.

CFF MO metric area 2

Reducing prescribing of trimethoprim to patients >= 70 years

Why are we focussing on this?

NHSE reports that the age group with the highest rates of E. coli bacteraemia in England have been observed amongst the elderly (75 years and over). PHE data for E coli blood stream infections stated that 50% cases related to the urogenital tract, and in these 72% occurred in patients >65years, and 64% of patients had reported at least one UTI in the previous 12 months. A significant proportion of the rise in cases may be due to patients being prescribed inappropriate antibiotics, resulting in relapsing infections. However, there remains a difficult balance between the clinical management of UTIs and the empiric prescribing of broad-spectrum antimicrobials due to increasing resistance to narrow spectrum antibiotics which limits available treatment options. This indicator works to increase the appropriate use of nitrofurantoin as 1st line choice for the empirical management of UTI in primary care settings, and support a reduction in inappropriate prescribing of trimethoprim which is reported to have a significantly higher rate of non-susceptibility in ‘at risk’ groups. Achieving the QP target at CCG level will generate a quality payment to the organisation, but it is accepted that prescribing nitrofurantoin in place of trimethoprim will create a cost-pressure. What is the achievement threshold?

>=35% reduction in number of prescription items for trimethoprim from baseline (June 2015-May 2016 as defined by NHSE QP). Practice latest data for illustration will be provided (Jan to Dec 2017).

What do practices need to do?

Unless contra-indicated or susceptibility testing shows resistance, nitrofurantoin should be the first-line antimicrobial agent used in managing urinary tract infections. They should ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content and have access to:

• Herts Guidance for the Management of Infection in Primary Care available here (also available as a smartphone app). Included is updated guidance on the management of UTIs.

• Suite of other resources in relation to treating infections including UTIs in care homes, tips for self-care here

If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection.

74

How will patients be identified? Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for trimethoprim and review whether continued prescribing is appropriate.

How will payment be achieved?

10p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.

Prescribing will be monitored by PMOT using epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.

CFF MO metric area 3

Ensure appropriate prescribing of broad spectrum antibiotics in primary care.

Why are we focussing on this?

The purpose is to maintain an improvement in appropriate antibiotic prescribing in primary care, in particular broad spectrum antibiotics. Evidence suggests that antimicrobial resistance (AMR) is driven by over-using antibiotics and prescribing them inappropriately. Reducing the inappropriate use of antibiotics will delay the development of antimicrobial resistance that leads to patient harm from infections that are harder and more costly to treat. Reducing inappropriate antibiotic use will also protect patients from healthcare acquired infections such as Clostridium difficile infections. Broad spectrum antibiotics, such as co-amoxiclav, cephalosporins and quinolones, should be prescribed in line with prescribing guidelines and local microbiology advice. This indicator has been part of the CCG Improvement Assessment Framework for CCGs in 2017-18.

What is the achievement threshold?

<=10% of total antibacterial items prescribed to be for cephalosporin, quinolone or co-amoxiclav antibacterials. Practice latest data for illustration will be provided (Jan to Dec 2017).

What do practices need to do?

Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to:

• The latest version of Herts Guidance for the Management of Infection in Primary Care available here (this is also available as a smartphone app).

• Suite of other resources in relation to treating infections including tackling antimicrobial resistance, restricted antibiotics, UTIs in care homes, tips for self-care here

Practices should respond to requests for root cause analysis of community- acquired c. diff cases and share learning gained with all prescribers.

75

If prescribing rate is already at the threshold at baseline this should be maintained or further improved where possible. For practices above the threshold, clinicians should review their approach to the management of infection. Learning resources can be found in the TARGET Antibiotic Toolkit available here: http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/target-antibiotic-toolkit.aspx How will patients be identified? Most cases will be acute presentations, requiring a prescribing decision at point of care. Practices can also search their clinical system for patients who have long term prophylactic prescriptions for cephalosporins, quinolones or co-amoxiclav and review whether continued prescribing is appropriate.

How will payment be achieved?

5p per registered patient – If the achievement threshold is reached for the twelve month period ending March 31st 2019. This payment is lower because it has been used as a KPI in recent years. Practices will be paid 50% upfront and the final 50% will be paid upon achievement.

Prescribing will be monitored by PMOT using epact/ epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice.

CFF MO metric area 4

These relate to items which should not be routinely prescribed in primary care

Why are we focussing on this?

This element relates to the recently published guidance from NHSE on what CCGs should consider in respect of the de-prescribing of drugs deemed to have low clinical value. There are 18 in total on the list but some will require additional services in order to de-prescribe and provide suitable alternatives in some cases. There are 7 where no routine exceptions to prescribing have been identified by NHSE and PCMMG agreed these could be the focus of de-prescribing initially. Not all practices would have to do work on all of these drugs in order to achieve the target, and payment is regarded as recognition of good clinical practice and for not initiating new prescriptions. Those achieving in-year would receive the payment in recognition of the additional workload generated by the implementation of the guidance. The 7 areas covered are: Co-proxamol Omega –3 fatty acid compounds Rubefacients (excluding topical NSAIDs) Lutein and Antioxidants Herbal medicines Glucosamine & Chondroitin Homeopathy The estimated annual spend on these is in excess of £212K across the CCG.

76

What is the achievement threshold?

By the end of Q3 2018-19 there should be zero prescribing in each of the seven NHSE categories of low-value medicines.

Practice latest data for illustration will be provided (Oct to Dec 2017). Where a practice with usage of these medicines in Q4 can demonstrate that a patient has joined their list on or after January 1st 2018 and was already prescribed one of these medicines at that point then this will be ignored on the understanding that a review of the prescribing is taking place as soon as possible.

What do practices need to do?

Ensure that all GPs, GP trainees, locums, non-medical prescribers and other clinical staff are aware of the content of, and have access to: https://www.england.nhs.uk/wp-content/uploads/2017/11/items-which-should-not-be-routinely-precscribed-in-pc-ccg-guidance.pdf Specifically, no new prescriptions for these 7 drugs/categories should be initiated. Patients already using any of the listed drugs need to have them de-prescribed. With the exception of co-proxamol, patients can purchase the medicines over the counter if they wish to continue with them. However, it is recognised that alternative options may need to be prescribed for chronic use, e.g. topical non-steroidal anti-inflammatory agent (if appropriate) in place of a rubefacient, alternative analgesic in place of co-proxamol or advice given e.g. dietary advice in place of omega-3 compounds and lutein antioxidants. How will patients be identified? Practices can search their clinical system to identify patients with a repeat template for prescriptions for drugs in the seven categories. Because of the delay in receiving prescription data from NHSBSA practices are advised to run searches for all 7 categories on a monthly basis so that any new prescribing can be identified promptly after any initial de-prescribing initiatives have taken place.

How will payment be achieved?

5p per registered patient for de-prescribing/ maintaining zero prescribing of co-proxamol 5p per registered patient for de-prescribing/maintaining zero prescribing of omega-3 compounds 5p per registered patient for de-prescribing/maintaining zero prescribing of rubefacients (excluding topical NSAIDs), lutein and antioxidants, herbal medicines, glucosamine & chondroitin, homeopathic products. Practices will be paid 50% upfront and the final 50% will be paid upon achievement. Prescribing will be monitored by PMOT using epact/ epact2 on a monthly basis and data shared with practices. No submission of information will be required from the practice unless they wish to appeal usage for new patients in Q4. It should be noted that data on prescribing runs two months behind, thus prescribing in March 2019 will not be scrutinised until May 2019.

END OF SUPPORT PACK