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NORTH LIVERPOOL PRACTICE BASED COMMISSIONING CONSORTIUM

SERVICE CHANGE PLAN 2010 - 2011

1. Introduction2. Vision

3. Summary of Progress 2009/104. Health Profile5. Priorities and Targets6. Demand Management7. Unplanned Care8. Health Improvement Model9. Medicines Management10.Financial Management11. Incentive Scheme

1. Introduction

Practice based commissioning plays an important part in the future of healthcare inLiverpool through clinical engagement, both as one of the major mechanisms to reduceexpenditure and in developing the infrastructure that will allow the downsizing of localacute trusts.

The previous Service Change Plan was intended to cover 2009-12, providing the PBCconsortia with a degree of stability rather than confining plans to a twelve-month period.However, as the impact of the current UK financial situation has been modelled, it hasbecome clear that the priorities of the PCT and, to some degree, the focus of PBC neededamending. The vision and many of the projects in the 2009 Service Change Plan remainthe same and continue but some of the mechanisms are changing and the urgency todeliver changes in activity and costs is recognised.

2. The Vision for the Consortium

The Consortium believes that practice based commissioning will be a major force for improving services for the foreseeable future. The Consortium is not strictly part of thePCT, but seeks to achieve the same goals; improving the health of the population. This isbest achieved through a partnership approach – the Consortium supports the PCT inachieving key performance targets and the PCT supports the Consortium in developing

local services.

2.1 Principles

The Executive Committee identified a number of principles that should apply to servicescommissioned by the Consortium. These are:

• The Consortium to move towards a neighbourhood approach to care delivery. Each of the four North PBC Neighbourhoods will act as the focus for local provision of healthrelated services. Each Neighbourhood will co-ordinate a network of service providerswithin its locality, matching patient need to service availability including models for

health improvement (eg Health Trainers / Health Homes / Social Prescribing).• Commissioning will focus on appropriate priorities

• Services will be delivered in the appropriate setting and should only be shifted if there

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is a good reason for the change. Standards for care delivery will be mirrored in eachsetting.

• Changes should aim for joined up care and proactive identification of gaps betweenservices

• There should be community engagement and a patient focus

• There should be equity of investment to reduce inequalities in health

• It is the role of the Consortium to support capability and capacity in primary care tosupport the priorities of the Consortium.

3. Summary of North PBC progress 2009/10

3.1 Emergency Admissions

The incentive scheme for 2009-10 set targets for practices to focus on reducingadmissions for ACS conditions. Whilst there is still significant work to do, the Consortiumhas focussed on this area as a part of the 2009/10 Incentive Scheme with a forecast under spend on the planned spend. The Consortium has continued to focus on COPD throughthe Six Step Approach. Following its success within the Consortiuma a further role outprogramme across the 3 other Practice Based Consortia within the PCT is being co-ordinated. Headline figures in terms of success from this project is a 29% reduction inacute exacerbations of COPD in primary care and a 47% reduction in emergencyadmissions (for one Neighbourhood only).

3.2 Referral to secondary care

The 2009/10 incentive scheme set targets for practices to reduce referrals to secondarycare and practices have been encouraged to use peer review as well as review of

correspondence from secondary care post referral, to ensure appropriateness.

The Consortium has focussed on ENT, Urology, Gynaecology, Dermatology, T&O whilstmonitoring progress against general surgery, rheumatology, gastro, vascular, cardiologyand ophthalmology. The Consoritum has achieved reductions in referrals to the agreedspecialties for NORTH PBC overall

Across the 11 specialities the Consortium has an overall under spend. 3.3 Consortium Engagement

This remains strong with more than 75% of general practitioners at monthlyNeighbourhood and quarterly Congress meetings. Additionally, 80% attendances of practice clinical and non clinical staff at the Six Step COPD Project education sessions. Inaddition to an Executive Committee of five general practitioners and 2 practice managers,individual Consortium general practitioners have led on specific pieces of work on behalf of the Executive (eg A&E / cardiology / gastroenterology).

To support deliver of the Service Change Plan, the Consortium has recruited twoNeighbourhood co-ordinators who will support practices to embed the new pathways andways of working. These co-ordinators will also support practices with the systems andprocesses required to deliver improvements in QoF and ISGP scores. The Consortium is

proposing a Reference Guide for practices outlining the Incentive Scheme targets, referraltemplates and pathways to be adhered to as well as other supporting information whichwill be updated on a quarterly basis.

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4. Health Profile of North Liverpool

A key part of the movement towards a neighbourhood approach will be the development of local health profiles. North PBC is made up of wards with significant deprivation and healthissues which reflected in this plan.

5. Priorities and targets – The Approach for 2010/11

The Service Change Plans for all the PBC consortia are based upon the same themes:

• Improving primary care

• Demand management – reduction in planned and unplanned care

• Medicines Management

• Financial management

• Demonstrating the impact of new services

5.1 Improving Primary Care - Improving standards in general practice

The Improving Standards in General Practice indicators remain an important way of judging the quality of primary care services. The indicators have recently been reviewedand changes made.

The Consortium has a role to play in supporting practices to increase their level of achievement on ISiGP, particularly for:

o Clinical and non-clinical QOF – practices with high scores on this indicator have putin place robust systems and processes. We will be working with a number of practices to advise on how to make their systems more effective and will continue tooffer this support.

o ACS conditions – the Consortium will be supporting practices with systems and

process to manage ACS conditions through the communication of pathways andprotocols as well as data validation throughout the year.

The main mechanism for improving achievement of these standards will be through theneighbourhood, Congress, Practice Nursing and Practice manager meetings. The

consortium will use these to roll out pathways and protocols as well as provide educationsessions and review of Neighbourhood progress against agreed targets.

6. Demand Management

6.1 Planned Care

Although referral rates for Liverpool Health Care have reduced, the Consortium is stillabove national rates and further reductions should be possible.

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6.1.2 Gynaecology

This new primary care service procured through the Any Willing Provider model will go liveon 1 April 2010. The service will manage a significant part of common Gynecologicalproblems that are currently being referred to secondary care in a community care setting.The new service will change patient experience by increasing choice, avoiding

unnecessary attendance to secondary care and the associated cost, offer care closer tohome, and increase access to services within a shorter time period. A key component of the Service will be to increase the knowledge and skills of all General Practitioners in themanagement of routine Gynaecology. This will take place through education sessions runby the Providers across Liverpool and via management plans prepared for each patientfollowing their visit. EMIS web will support the information element of the service. Theservice is expected to reduce 4,000 new referrals to Liverpool Women’s Hospital per annum.

6.1.3 Gastroenterology

The North Mersey Dyspepsia Care pathway has been agreed and will be launched duringQuarter 1 2010/11. SC Consortium will adhere to this pathway, a key feature of which isthe testing for the Helicobacter pylori bacteria via the primary care urea breath test service.This is being commissioned for Liverpool patients as a Local Enhanced Service from 1st

May 2010 and should significantly reduce the number of patients referred for a scope andthe number of patients referred for an outpatient appointment.

6.1.4 Vascular

Adherence to the Claudication pathway with ABPI testing in Primary Care. Wherever possible the Consortium will endeavour to provide coverage at Neighbourhood level for this service.

6.1.5 Cardiology

Implementation of the palpitations pathway.

6.1.6 Trauma and orthopedics

The Consortium will continue to utilise T&O services through:-

•

Appropriate utilisation of MCAS• Embedding pathways for the management of upper and lower limbs

• Utilisation of the Locally Enhanced Service for joint injections

6.1.7 Urology

Implementation of agreed pathways and utilisation of LUTS service

6.1.8 Dermatology

Appropriate patients referred to the community based ICATS service

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6.1.9 ENT

Community based ear care clinics

6.1.10 Surgery - Follow up appointments

The value of post-operative follow up has been debated for many years. For manyprocedures there are no agreed follow up criteria, resulting in wide variation inappointment rates between both hospitals and also between surgeons in the samehospital.

There is evidence that, for many procedures, patients without follow up do not have alarger complication rate than those with a routine post-operative appointment. Discussionwith general practitioners indicates that most post-op complications are picked up inprimary care, usually within the first one to two weeks. However, GPs do not have accessto a timely system that allows them to return the patient back to the surgeon if appropriate.For some patients the only way to access a surgeon is through the Emergency

Department.

There is evidence that a number of procedures do not require follow up for the vastmajority of patients. This is supported by the fact that most surgeons have changed their practice and do not routinely follow up many procedures

Liverpool Health Care Consortium is working with surgeons at the Royal to identifyprocedures where a routine follow up appointment is not necessary and to put in place asystem to allow a GP to refer a patient for a same day / next day review by a surgeon,possibly utilising the existing HOT clinic arrangements.

Following a pilot within LHC Consortium, North PBC will adopt this process.

7. Unplanned care

The unplanned element of the Service Change Plan will focus on the Consortium’sapproach to reducing non-elective admissions and AED use by focussing on:

7.1 Patients with multiple admissions

The Consortium has put in place a programme to identify patients with multiple admissionsfor a particular condition. This information is fed back to their GP and the practice is askedto review the patient to make sure they are receiving appropriate treatment and, if necessary, referred to a specialist.

7.2 Patients with multiple attendances at AED

The Consortium audits AED data to identify patients with multiple attendances. Practiceswill be putting processes in place to review these patients as appropriate.

7.3 In Hours Attendances at Aintree AED

In partnership with Sefton and Knowsley PCTs and Aintree Hospital, a retrospective studywill take place during May 2010 to understand the detail behind the data of 7 days

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attendances at the A&E department. This will be combined with a patient questionnaire tounderstand patient choice of venue for unplanned care. The results of this study will feedinto the QIPP Urgent Care Programme for consideration of a model of care to reduce inhours attendances which should be treated elsewhere.

7.4 Zero length of stay

North PBC will audit to identify whether there are particular conditions that account for zeroLOS and, if so, develop means to reduce the incidence.

7.5 ACS conditions not covered by major projects

The list of ACS conditions includes admissions for a number of problems which may causesizeable numbers of admissions but which have not been considered by the Consortiumas the focus has been on admissions due to long term conditions. The Neighbourhoodswill review each of these areas through sampling patient records to identify potentialprimary care issues and, if appropriate, develop guidance on primary care management.

7.6 Heart failure

Liverpool Health Care is leading a project to improve the quality of care and managementof patients with heart failure.

Objectives

o To reduce the number of emergency admissions and readmissions due to heart

failure, relative to the recorded prevalenceo To improve the quality of life of patients with heart failure

o To reduce unnecessary costs

In 2009 a pathway way agreed and the aim for 2010 is to implement this pathway. This willtake place in two phases.

The initial phase, of approximately six months, involves the establishment of thenecessary infrastructure to deliver high quality care and management of heart failure

o Improved diagnostic processes

o Disease registerso Support for self care

o Clear roles and responsibilities for all services and staffing groups

o Clinician competencies, particularly for practice nurses

o Optimal drug therapy

o Referral to, and discharge from, different services

o Development and implementation of management plans

This will involve:

o Agreeing measures of success, KPIs and mechanisms for data collectiono Accurate disease registers in primary care

o Defining and supporting practice nurse and specialist nurse competencies

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o Monitoring and improving prescribing

o Referral criteria and processes to reduce inappropriate referrals to specialist

serviceso Referral criteria and processes to improve appropriate use of HFSN team

o Aligning community nurses with the HFSN team

o Identifying the impact of the pathway on all clinician groups

o Establishing pathways for non-emergency admissionso Defining content for standardised patient education

o IT solutions for transfer of clinical data between secondary care clinicians and

between secondary care and primary care

The second phase involves the mainstreaming of processes developed in the first phaseacross all practices. Some changes may not be complete or may not have delivered therequired outcomes and may require further input.

Currently the HFSN team accept referrals for patients with LVSD. In the first phase on the

programme the team will accept all newly diagnosed heart failure patients from the tenpilot practices. Rolling out wider criteria for the second phase will only be undertaken aspart of a review of the service specification and contractual changes.

The Steering Group will not expect major changes in the outcome measures from the firstphase of the project. Ongoing audit of KPIs in the second phase should demonstrateimprovement in outcome as well as process indicators.

7.7 COPD

Since 2008 the Consortium has focussed on COPD utilising the Six Levels approach. This

will continue in 2010-11 with the aims of:

• Reducing the number of emergency admissions for COPD

• Reducing the mortality rate for COPD

As the Six Level approach comes to an end within the Consortium, consolidation isrequired to ensure the early wins are sustained. The key to management of COPD is theeffective use of inhaled medication. Review of COPD patients will be the main focus of theMedicines Management Team support to North Liverpool PBC through 2010 as well asembedding the pathways to develop from the COPD QIPP group.

In October 2009, the focus for COPD shifted to a city wide footprint (Royal and Aintreefacing) and in December 2009 moved to a North Mersey approach as part of the QIPPagenda which Liverpool PCT is heavily involved in. This has resulted in a change of focusfor the Liverpool PCT Project Team for COPD and the need to define a clear model of carefor COPD patients in Liverpool. More detail in relation to the COPD work proposed for 2010/11 can be found in section 7.2.1.

Alongside this, work is underway to define the model of care for COPD patients inLiverpool in line with the development of the general practice specification. The pathways

and the Liverpool model of care for COPD will be formally agreed by April 2010 and it isanticipated this will take a period of 12 – 15 months to implement and any benefits to berealised. In order to meet the timescales of the QIPP programme, there are a number of “quick wins” to be identified which will achieve the goals set i.e. a reduction of 10% overall

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cost by December 2010. A process for deciding these areas of work has been developedalong with criteria for selection and this will be led by the members of the clinical pathwayswork stream and presented to the QIPP Management board in April 2010 for approval.

Each consortium will be required to fully participate in the implementation of the model of care. Practices will do this by effectively managing COPD patients in line with agreed

standards of care and to the agreed clinical pathway.

7.8 Diabetes

The Consortium will implement the North Mersey Pathway through the agreed LiverpoolModel. Implement strategies to reduce complication rates. Reduce gap between expectedand actual prevalence rates, increase percentage of patients with HbA1c at or below 7%.Continue to achieve the offered and screened targets for retinal screening. Reduce thevariability in practice provision and agree the model of care for more complex patients.

7.9 Paediatric Asthma

The paediatric asthma pathway was developed several years ago but was never successfully implemented; North PBC will implement this pathway during 2010/11.

Implementation will involve:

o Review of admission data by practice

o Educational events for GPs and practice nurses

o PDSA cycles that encourage practices to review their own systems and processes

o Regular feedback of activity and cost data

8. Neighbourhood Health Improvement Model

The clear and unequivocal intent of Liverpool PCT is to address health inequalities andsecure meaningful health improvements for our communities. The need to work with localgovernment, the third sector and independent sector has never been greater, if we are toraise our ambitions, and meet the challenges of addressing health inequalities, andpromote health and well-being in local communities. Health inequality in Liverpool is

significantly based on postcode and the neighbourhood you live in. It is thereforenecessary to develop an approach to tackle health inequalities and secure healthimprovement that has a neighbourhood focus. Ellergreen Neighbourhood has launchedthe Health Improvement Model with a disease prevention focus around Health Homes,Health Trainers and Social Prescribing.

9. Medicines Management

Medicines use is one of the most important tools for a GP and accounts for substantialproportion of the Consortium’s expenditure.

Cost reduction

Better care, better value indicators

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Statins – statins have been part of the better care, better value indicators and thereforePBC targets for several years and, although there are still savings to be made, there is alack of enthusiasm for further switches to low cost statins in existing patients. Instead, thework of the MM service will focus on appropriate statins for newly prescribed patients.

It is well documented that many patients do not take medication as intended by the GPand there is evidence that this is a particular problem with drugs for asymptomaticdiseases like hypercolesterolaemia and hypertension. The MM service will identify andreview patients who are not achieving cholesterol targets due to poor compliance. In theshort term this will avoid the need for more expensive drugs of higher potency and, in thelong term, reduce hospital admissions.

Low cost statins

High cost statins still high cost area although less growth. Atorvastatin top spend drugaccounting for 6.2% of total drug spend, patent to expire mid 2011 although likely to have

at least 6mth extension (recent paed research completed which can grant 6mthextension), so probably will be mid 2012 before prices significantly drop. Consortium isbelow PCT average. There are still some gains from considering switching patients onatorvastatin 20mg/rouvastatin 5mg, 10mg and reviewing patients on atovastatin 80mg3mths post ACS

Clopidogrel

Accounts for 2.2% of spend, 5th top spend drug. Now off patent, price reducing.Consortium above PCT average with potential gains to ensure all new patients reviewedafter 12mths

PPIs

Esomeprazole , while reducing, still accounts for 0.9% of spend (10th top spend drug).Pantoprazole now off patent so with 3 low cost PPIs further potential to reduce use of highcost options (esomeprazole and rabeprazole).

Low cost statins Clopidogrel Low cost PPI

Consortium at 3rd

qtr 2008-960.1% 445.5 85.4%

Target for 2009-10 Min of 60% aimfor 63%

421 Min 85% aim for 88%

ConsortiumCurrent position at3rd qtr 2009-10

61.7% 403.5 87.4%

PCT currentposition at 3rd qtr 2009-10

63.6% 357 87.6%

North PBCTarget 2010-11

64% 375 90%

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10. Financial Management

Finance – North LiverpoolDuring the financial year 20009/10 the Consortia services provided were done so at thecost below

0910 Budget 0910 Cost 0910 Variance 10/11 Plan884321 - Executive Annual Costs (North) 119,318 119,611 293 125,449

884324 - PBC Incentive Scheme (North) 30,824 311,129 280,305 321,657

First Payment 102063 107,219

Second Payment 101615 107,219

Third Payment 107451 107,219

884325 - Innovation Fund (North) 8,949 2,000 - 6,949 -

884334 - Practice Nurse (North) 149,148 154,021 4,873 154,021

884336 - COPD Community Matron (North) - 39,173 39,173 -

Total 308,239 625,934 317,695 601,127

During 0910 an additional GP was added into the Executive Annual Costs. The plan for 2010/11 has been increased to account for this addition. It is currently unclear as towhether the COPD Community nurse will incur any more costs in 2010/11. The incentiveschemes for 09/10 were not paid at 100% on the first and second payments and there hasalso been an adjustment on the population to change the plan for 2010/11.

Service Change PlansTargets: Target Actual Variance

1st OP attendances as a result of GP referral 1,575,589 1,779,221 203,632

Emergency Admissions for ACS Conditions 4,509,391 4,389,004 -120,387

Unplanned Care 3,681,531 3,669,428 -12,102Prescribing Targets 3,693,240 3,490,124 -203,116

Total 13,459,751 13,327,777 - 131,974

*these figures are based on M10 reconciled data forecast to year end

1st Outpatients – the consortia has achieved 3 of the GP referred 1st outpatient targets thisyear on T&O, Urology and ENT. There are considerable gaps between the targets andactual on the other areas. The most significant of these are Gastroenterology with an over performance of 57%, Vascular Surgery with an over performance of 47% andOphthalmology over performing by 38%.ACS Conditions – the consortia appear to be meeting their targets on ACS conditions

overall however this is caused by a large saving being created on COPD and Angina. Theconsortia still need to target areas such as Diabetes which is over performing by 31% tomaximise its savings.Prescribing targets – the consortia is currently meeting its target on all areas

11. Incentive Scheme

North Consortium’s incentive scheme will operate as per Liverpool Incentive SchemeModel.

First £1 for participation – This will be paid on completion of an action plan (by 30 June2010) outlining the areas the practice will need to focus on in order to achieve the agreed“green line” targets. In addition, 75% attendance will be required at monthly

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Neighbourhood and quarterly Congress meetings by a general practitioner. Practicesmanagers and practice nurses are of course welcome to attend, however the content of the meeting will essentially have a clinical focus and will therefore require the input of clinicians. Practice managers will be expected to attend bi-monthly practice manager meetings and where possible, practice nurses to attend quarterly North PBC nurse forums.

Second £1 for achievement – This will be paid on achievement of a 50% move towardsthe “green line” target.

Third £1 for consortium achievement of the green line (see Appendix A)

Baseline PositionConsortium and practice achievement against the ‘green line’ target in each of these areasis charted below. In each case the red line is the Consortium baseline spend (2009). Thegreen line is the consortium target spend.

North A&E Attendance

6 2 . 8

3

5 8 . 8

5

5 4 . 6

9

5 2 . 2

2

4 7 . 5

2

4 7 . 3

7

4 5 . 2

6

4 4 . 0

4

4 3 . 7

8

4 0 . 8

2

4 0 . 2

2

3 8 . 2

2

3 7 . 5

7

3 7 . 4

3

3 7 . 3

2

3 5 . 1

8

3 3 . 5

1

3 3 . 0

2

3 2 . 4

2

3 0 . 1

5

3 0 . 0

6

2 8 . 6

3

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

R A Z V I S A H

G E R G R K

R A S T O G I T K

N D E G E Y A C

C H I L V E R S

M C R A E

S Y E D O A

E L - S A Y E D

F E H A

P A T E L N M

H A R M A N A

S R

O ' H A R A D P

S H A H D K

L O C K J D T

O O D S I M M

E D M O N D S J

K A S W A D I A

A R H

L E X A N D E R

W H I T E

B A J A J V

G H O S E S L

U B B E R T C M

C H I V E R S

M C R A E

O B E R T S J W

L U C K S E

2009 Actual Rate 2009 Consortium Baseline 2010-11Target

Red line = £299,248.00 Green line = £228,927.45

North ACS

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

R A Z V I S A H

I V E R S M C R A E

U K A S W A D I A

A R H

P A T E L N M

L U C K S E

L O C K J D T

W O O D S I M M

S H A H D K

- S A Y E D F E H A

B A J A J V

S Y E D O A

R E D M O N D S J

R O B E R T S J W

O ' H A R A D P

R A S T O G I T K

A R M A N A S R

A L E X A N D E R

W H I T E

E N D E G E Y A C

H U B B E R T C M

C H I L V E R S

M C R A E

G H O S E S L

G E R G R K


£4,454,

£4,099,

Red line = £4,454,863.97 Green line = £4,099,671.23

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North OP

1 4 5 . 2 5

1 3 9

. 0 6

1 2 2

. 6 6

1 2 2

. 4 8

1 1 3 . 9 4

1 0 6 . 7 7

9 9

. 3 9

9 3 . 5 8

9 2

. 6 4

9 2

. 4 9

8 8 . 9 3

8 8 . 5

1

8 8 . 4 3

8 2 . 9 1

8 1

. 9 8

7 8 . 8

0

7 8 . 2

4

7 3 . 1 1

7 1 . 1 1

6 7

. 1 7

6 4 . 1

4

5 8 . 0 5

0

20

40

60

80

100

120

140

160

180

200

G E R G R K

H U B B E R T C M

L O C K J D T

A L E X A N D E R

W H I T E

L U C K S E

- S A Y E D F E H A

E N D E G E Y A C

O O D S I M M

R E D M O N D S J

O ' H A R A D P

C H I L V E R S

M C R A E

R A Z V I S A H

B A J A J V

S H A H D K

S Y E D O A

R O B E R T S J W

R A S T O G I T K

V E R S M C R A E

P A T E L N M

G H O S E S L

A R M A N A S R

U K A S W A D I A

A R H


Red line = £2,491,536.71 Green line = £2,482,086.34

North Prescribing targets 2010-11(target saving =£1.376m)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

R E D M

O N D S

J

P A T E

L N M

G O D D A R D M

L

L U C K S E

C H I L V E R S M

C R A E

H U B B E R T C

M

S H A H

D K

R O B E R T S J W

L O C K

J D T

E L - S A Y E

D F E H A

R A S T O

G I T K

O ' H A R A D

P

B A J A J

V

W O O D

S I M M

C H I L V E R S M

C R A E

G E R G

R K

G H O S E S L

K U K A S W A

D I A A R H

D H A R M A

N A S R

R A Z V

I S A H

S E N D E G E Y A

C

S Y E

c o s t p e r 1 0 0 0 w e i g h t e d p o p u l a t i o n

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