PACT CONTRACT SPECIFICATION
2017/18
Issue date: AUGUST 2017
This is the final PACT service specification for 2017/18 and replaces the interim specification
previously issued. All other versions are to be discarded.
(Final version)
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CONTENTS
A. EXECUTIVE SUMMARY .......................................................................................................5
Please note: .................................................................................................................................5
B. INTRODUCTION ...................................................................................................................6
B.1 Service Aims ..................................................................................................................6
B.2 Achieving the Aims .........................................................................................................6
B.3 Scope.............................................................................................................................6
B.4 Term ..............................................................................................................................6
B.5 Patient Coverage ............................................................................................................7
C. MINIMUM ENTRY CRITERIA ................................................................................................8
C.1 Overview ........................................................................................................................8
C.2 Miscellaneous Entry Requirements .................................................................................8
C.3 Named PACT Contacts...................................................................................................9
D. FINANCIALS – PAYMENT AND ACTIVITY ..........................................................................10
D.1 Minimum Entry Criteria .................................................................................................10
D.2 Administration Payment ................................................................................................10
D.3 Core Payment ..............................................................................................................12
D.4 EMIS Web Coding ........................................................................................................12
D.5 Timing of Payment........................................................................................................12
D.6 Error Notification ...........................................................................................................12
D.7 Budget Cap and over-performance ...............................................................................13
E. REPORTING.......................................................................................................................14
E.1 Activity Reporting..........................................................................................................14
E.2 Rights of Audit ..............................................................................................................14
F. GOVERNANCE AND QUALITY ASSURANCE ....................................................................15
F.1 Governance..................................................................................................................15
F.2 Quality Assurance ........................................................................................................15
G. PACT AND AUA ENHANCED SERVICE …………………………………………………………….16
G.1 Background ………………………………………………………………………………………16
H. ARRANGEMENTS 1ST JULY TO 31ST MARCH ……………………………………………………...17
1. SERVICE REQUIREMENT 1 OBSOLETE ...........................................................................18
2. SERVICE REQUIREMENT 2 ...............................................................................................19
3. SERVICE REQUIREMENT 3: PACT ENHANCED CARE PATHWAY (PACT ECP) MULTI-
DISCIPLINARY CARE PLAN DEVELOPMENT AND REVIEW PROCESS ..................................29
3.1 Summary ............................................................................................................................29
3.2 Rationale and Requirements................................................................................................29
3.3 Identification of PACT ECP patients .....................................................................................30
3.4 Payment..............................................................................................................................30
4. SERVICE REQUIREMENT 4: CARERS..............................................................................32
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4.1 Summary ............................................................................................................................32
4.2 Definition .............................................................................................................................32
4.3 Rationale.............................................................................................................................32
4.4 Care Pathway......................................................................................................................33
4.5 Suggested Best Practice .....................................................................................................33
5. SERVICE REQUIREMENT 5: OBSOLETE .........................................................................36
6. SERVICE REQUIREMENT 6: STABLE HAEMATOLOGY ...................................................37
6.1 Summary ............................................................................................................................37
6.2 Definitions ...........................................................................................................................37
6.3 Rationale.............................................................................................................................38
6.4 Record Keeping ..................................................................................................................38
7. SERVICE REQUIREMENT 7: MENTAL HEALTH DEPOT INJECTIONS .............................41
7.1 Summary ............................................................................................................................41
7.2 Definitions ...........................................................................................................................41
7.3 Rationale.............................................................................................................................41
8. SERVICE REQUIREMENT 8: END OF LIFE CARE ............................................................43
8.1 Summary ............................................................................................................................43
8.2 Definitions ...........................................................................................................................43
8.3 Rationale.............................................................................................................................43
8.4 Good Practice / Resources ..................................................................................................44
9. SERVICE REQUIREMENT 9: PATIENT SELF-MANAGEMENT ..........................................46
9.1 Summary ............................................................................................................................46
9.2 Objective .............................................................................................................................46
9.3 Definitions ...........................................................................................................................47
9.4 Rationale.............................................................................................................................47
10. SERVICE REQUIREMENT 10 (OBSOLETE): ......................................................................49
11. SERVICE REQUIREMENT 11: HOLISTIC CANCER CARE REVIEWS ................................50
11.1Summary ............................................................................................................................50
11.2Definitions ...........................................................................................................................50
11.3Rationale.............................................................................................................................51
11.4Good Practice / Resources ..................................................................................................51
12. SERVICE REQUIREMENT 12: DRUG MONITORING (DMARDS) ......................................53
12.1Summary ............................................................................................................................53
12.2Definitions ...........................................................................................................................53
12.3Rationale.............................................................................................................................53
12.4Standards and Pathway.......................................................................................................53
13. SERVICE REQUIREMENT 13: GP PEER REVIEW ............................................................56
13.1Summary ............................................................................................................................56
13.2Rationale.............................................................................................................................56
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14. SERVICE REQUIREMENT 14: CLINICIAN TRAINING........................................................57
14.1Summary ............................................................................................................................57
14.2Definition .............................................................................................................................57
14.3Rationale.............................................................................................................................57
PLEASE NOTE THAT A RANGE OF SUPPORTING DOCUMENTS RELATING TO THE PACT CONTRACT CAN BE FOUND ON THE LEAD PROVIDER’S WEBSITE USING
THE FOLLOWING LINK:
www.bhcic.co.uk
PLEASE NOTE ALSO THAT THE LISTS OF GP PRACTICES CONTAINED WITHIN THIS
SPECIFICATION MAY CHANGE IN-YEAR.
(BALHAM HILL PRACTICE CLOSED LATE MARCH 2017).
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A. EXECUTIVE SUMMARY
The PACT Service Requirements for 2017/18 are set out in the table below.
Please note:
1. Non-GP refers to Practice Nurses, Nurse Practitioner and Physician's Assistant. Healthcare Assistants are only included where specifically stated within the Service Requirement details.
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B. INTRODUCTION
B.1 SERVICE AIMS
The overall aim of this specification is to contribute to the overarching Wandsworth Clinical Commissioning Group (WCCG) (the “Commissioner”) objectives of:
Better patient experience;
Improved quality of clinical care;
Reduced utilisation of secondary care resources.
B.2 ACHIEVING THE AIMS
This PACT Specification 2017/18 will support the Commissioner in achieving the above aims by funding and encouraging Providers to:
Actively identify and assess the most vulnerable and needy patients, especially those with comorbidities, housebound, resident in Nursing Homes, dementia/stroke patients, those with a primary mental health need, those with a cancer diagnosis and stable haematology patients;
Provide comprehensive care planning for these patients, including participation in Community Services multi-disciplinary/joint care planning processes for some patients;
More time and thought to the needs of carers, including young carers;
Provide depot injections for stable mental health patients referred by secondary care;
Provide more focus on patients that are in the last year of their life (end of life care patients); Provide Holistic Cancer Care Reviews for patients at the end of their acute treatment;
Provide drug monitoring (eg DMARDS) and drug administration for some patients referred by secondary care;
Support and promote patient education and patient self-management;
Improve the quality of GP consultations through GP peer review; Invest in the education and training of primary care healthcare professionals.
B.3 SCOPE
This specification has been designed to cover enhanced aspects of patient care, which are beyond the scope of presently contracted GP services (including the Quality and Outcomes Framework or QOF).
B.4 TERM
This specification will come into force on 1 April 2017 and will be available for delivery by any Provider commissioned by the Lead Provider (Battersea Healthcare CIC/the GP Federation) once both the have signed the agreed Service Agreement Form (provided to the Lead Provider by the CCG). The Lead Provider is commissioned by the CCG to ensure integrated and equitable delivery of this specification to Wandsworth patients. For the purposes of this specification, it is assumed that the Lead Provider will sub-contract the provision of this specification to Wandsworth GP Practices (the Provider). Should that not be the case
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and an alternative Provider commissioned, the Specification administration and service requirements remain unchanged. Rates of pay for non-GPs Practice Providers will be agreed between the Lead Provider and the sub-contractor. This specification shall operate for a 12 month period from 1 April 2017 until 31 March 2018, although may be subject to amendment during the course of that period. There will be a review of this specification by the Commissioner on at least a 6 monthly basis to inform on-going commissioning decision-making.
B.5 PATIENT COVERAGE
The Commissioner wants all patients (and carers) in Wandsworth who are targeted under and will benefit from this service specification to have access to the services that are to be provided. To ensure that this happens, the Lead Provider will select one of the following options:
Sign up a GP Practice as a Provider to provide the services in-house to its patient population;
Where a Practice doesn’t wish to or is, for any reason, unable to provide the required level of care/service to its Practice population, agree with another Practice or Practices to provide the services for that Practice patient population. The Lead Provider will agree and organise any such arrangement;
Nominate another suitable Provider to provide the services to specific patients, subject to agreement with the Commissioner.
Each Provider must complete a Service Agreement Form (see above). If a Provider signs up to the specification themselves but, in the reasonable opinion of the Lead Provider and/or Commissioner, is not subsequently delivering a reasonable and agreed level of activity in respect of all the service requirements under this specification), the following steps will be taken:
1. Where they have concerns, the Commissioner will provide a written notice to the Lead Provider stating their concern over the activity levels being delivered and requesting a written explanation for this;
2. Notwithstanding receipt of concerns as described in 1. above, the Lead Provider will provide a written notice to the Provider stating their concern over the activity levels being delivered and requesting a written explanation for this;
3. The Provider shall respond to this written request in writing within 10 working days and provide the Lead Provider, for discussion and agreement, with a rectification action plan within 4 weeks of the Lead Provider’s concerns being raised. The action plan should include explanation of how the Provider will improve their activity levels and timeframes. The Lead Provider will share this plan with the Commissioner where they have raised specific concerns;
4. If the Provider fails to rectify the situation within the agreed timeframe, the Lead Provider
reserves the right to approach other Practices or Providers to step in and provide the service
requirements under this contract/specification on behalf of the original Provider.
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C. MINIMUM ENTRY CRITERIA
C.1 OVERVIEW
A Provider that wishes to sign up to, and receive any payment under this PACT Specification 2017/18 will first have to comply with the following minimum entry criteria:
Comply with various miscellaneous entry requirements;
Provide a named contact for the various PACT subject areas; Comply with advice and instruction from the Lead Provider and included within this document in
relation to patient registers at 1 April and when subsequent Service Requirement arrangements are issued.
C.2 MISCELLANEOUS ENTRY REQUIREMENTS
A Provider that wishes to sign up to this PACT Specification 2017/18 will first have to comply with the following miscellaneous requirements:
Use EMIS Web as their medical record; Have signed up to the Lead Provider’s record sharing and data processing agreements to
enable data access required for the management of PACT programme and the shared care initiatives such as the Urgent Care, Diabetes, or Dermatology Record Sharing Agreements. They are also required to have signed any data processing agreements for Risk Stratification or PACT evaluation with CSU IT or other processors which is necessary to enable the PACT contract work. The Lead Provider will ensure Providers/Practices are notified of any future agreements which are specifically linked to PACT.
Be NHS Information Governance (IG) Toolkit Level 2 compliant and all Provider/Practice staff members have successfully completed the NHS IG Training Tool;
Have installed and been trained on the Sollis Clarity Software (which uses the Johns Hopkins Adjusted Clinical Groups (ACG®) System to identify patients at high risk and forecast future healthcare utilisation1) or other similar tools identified by the Commissioner and agreed with the Lead Provider. Please see web resource pages* for how to access Sollis training and support;
Have a log-in/s for the Coordinate my Care (CMC) web-based software and have undertaken some training in its use. Please see web resources pages* for how to access training and support;
Have completed an agreed level of Diabetes education for key practitioners providing care to patients as part of this specification;
Have completed and returned (if a GP Practice) any Primary Care Healthcare Professional Training Needs Analysis as required by the Lead Provider;
Have viewed the web training that explains how to use the Sickle Cell EMIS Web template (see the web resource pages* for details), prior to providing a Care Plan Consultation with Sickle Cell patients.
*www.bhcic.co.uk
1 See www.acg.jhsph.org for more details.
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C.3 NAMED PACT CONTACTS
In addition, the Provider must confirm (on the Service Agreement Form) names and contact details of the following individuals within their organisation/Practice:
Overall Lead GP (or equivalent) for the PACT contract/specification and Care Planning2
Lead Practice Nurse/HCA (or equivalent) for the PACT contract/specification
Lead GP (or equivalent) for Carers, including Young Carers Lead GP (or equivalent) for Haematology
Lead GP (or equivalent) for End of Life Care
Lead GP (or equivalent) for Cancer (including Holistic Cancer Care Reviews) Lead GP (or equivalent) for Self-Management
Lead GP (or equivalent) for Safeguarding.
2 The overall Lead is responsible for understanding the terms of the Specif ication and available support resources to support
Practice colleagues in delivery of the Specif ication requirements , including good practice Care Planning, as w ell as liaising w ith Battersea Healthcare CIC/GP Federation Locality Leads in the delivery of the Specif ication.
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D. FINANCIALS – PAYMENT AND ACTIVITY
D.1 MINIMUM ENTRY CRITERIA
In order to be eligible to receive any payments under this specification, the Provider must first have complied with the minimum entry criteria described in Section C and completed a Service Agreement Form. Once the Lead Provider is satisfied that the above have been completed, the Provider shall be eligible to receive payments under this specification.
D.2 ADMINISTRATION PAYMENT
A sub-contracted Provider GP Practice will receive their Administration Payment, as set out in Table A below, at the end of the financial year , subject to their participation in and response to a range of requests from the Lead Provider in relation to the implementation/review of the PACT specification within the Practice. This may include, for example, participation in a PACT “Health check” and/or responses to requests for data and will be assessed across 2017/18. “Participation in” and “response to” will be assessed b y the Lead Provider (as well as activity levels) and discussed with the individual Practice to ensure transparency and understanding of expectations, thereby enabling the Practice to respond to any concerns the Lead Provider may have. The Lead Provider reserves the right to pay a proportion (or none) of the Administration Payment to a Practice should they not adequately meet the requirements as set out above and any others agreed with the Lead Provider.
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TABLE A: PAYMENT - ADMINISTRATION PAYMENT
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D.3 CORE PAYMENT
The Provider will receive a Core Payment based on the following hourly rates:
All payment amounts include any associated administrative costs in carrying out a particular service requirement;
Non GP tasks can be performed by a Practice Nurse, Nurse Practitioner or Physician's Assistant. HCAs are only included where specifically stated within the Service Requirement details;
The Core Payment for each Service Requirement is set out in each Section. If a GP (or equivalent) performs a Non-GP task (or vice-versa) they will only be paid at the rate of a Non-GP as specified.
D.4 EMIS WEB CODING
A Provider must ensure patients have been added to the correct patient register using the specified EMIS Web register code as set out within this specification. On completion of a Service Requirement, a Provider must also record the activity completed by entering the correct Read Code in the patient’s (EMIS) notes, as specified in each Section and as required by the Lead Provider. If a Provider fails to add a patient to the correct patient register using the specified EMIS Web Read Codes or fails to report activity using the specified EMIS Web Read Codes then they will not be paid for completing the Service Requirement.
D.5 TIMING OF PAYMENT
As soon as practicable after the month end, the Lead Provider shall extract activity data from EMIS Web, undertaken by each Provider in the previous month. The Core Payment amount for each service requirement (as specified in each Section) will then be added to the extracted activity data to show the total Core Payment amount due to a Provider for the previous month. The Administration Payment and Core Payment amounts due will form the basis of the Monthly Report which will then be sent by the Lead Provider to all Providers. Each Provider will then be paid the amount specified in the Monthly Report (subject to any Error Notification – see Section D.6). No additional invoicing to the Lead Provider will be required (although additional reporting for some Service Requirements is required – see section E1).
D.6 ERROR NOTIFICATION
If a Provider believes the Monthly Report is incorrect they shall notify the Lead Provider as soon as possible, clearly specifying the errors in the Monthly Report. The Provider and the Lead Provider will endeavour to work together to agree the Monthly Report and correct any errors. Any amounts due as a result of errors in the Monthly Report shall be paid in the next reconciliation.
NonGP GP
ClinicalTasks £25 £80
Non-ClinicalTasks £18 £70
CorePayment(Hourlyrates)
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D.7 BUDGET CAP AND OVER-PERFORMANCE
The sub-contracted and Lead Providers should note that there is a financial budget cap in respect of the total amount the Commissioner has available to spend on this PACT Specification. This financial budget cap is in place because it is not possible to accurately predict the exact numbers of patients that may be treated under this specification (e.g. the number of registered carers in Wandsworth is far lower than the actual likely number of carers etc). If the financial budget cap is reached the Commissioner reserves the right to suspend this PACT Specification and not thereafter be responsible for making any further payments to the Lead and/or subcontracted Provider. If the Commissioner does suspend this PACT Specification/contract, it will endeavour to give as much notice as is reasonably possible to the Providers. Whilst the Lead Provider and Commissioner will review activity levels on a regular basis, it is important that sub-contracted Providers do not over-perform on designated target patient numbers without express and advance permission from/arrangement with the Lead Provider on behalf of the Commissioner. Failure to do so may result in non-payment for activity beyond target numbers. In order to promote equity of service provision (and therefore available resources) across all Providers, the Lead Provider, on behalf of the Commissioner, may introduce “controls” on activity levels for some Requirements that don’t include a pre-allocation of patient numbers/activity. This will be communicated to Practices in advance.
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E. REPORTING
E.1 ACTIVITY REPORTING
For the majority of Service Requirements set out in each Section, the Provider shall not have to submit activity data to the Lead Provider, as activity will be extracted centrally from EMIS Web by the Lead Provider. This means it is very important that the Provider correctly records all activity with the correct Read Codes in the patient’s notes. There are a small number of Service Requirements, as set out in the relevant Section, which do require additional reporting by the Provider:
Service Requirement 8B (see Section 8 End of Life Care): email the Lead Provider with the number of reflective MDT meetings held;
Service Requirement 14A and 14B (see Section 14 Clinician Training): complete a training schedule (available on the resources website).
Please note that activity in respect of Service Requirement 9 (see Section 9 Patient Self-Management) will be reported to the Commissioner by the Wandsworth Self-Management Service. Providers should note the detail set out with Service Requirement 9 to ensure payment.
E.2 RIGHTS OF AUDIT
The Commissioner (and Lead Provider on their behalf) reserves the right to fully audit any aspect of the information provided by the Provider in respect of this specification. The Commissioner (and Lead Provider on their behalf) also reserves the right to take a random sample of patients who have received a Care Plan Consultation and do a full audit of the investigations, advice, assessments and consultations provided. The random sample will be collated using EMIS Web functionality to import random patients using a specified search. Patient Care Plans will be audited by the Commissioner/Lead Provider for quality of content.
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F. GOVERNANCE AND QUALITY ASSURANCE
F.1 GOVERNANCE
Governance is a mechanism to provide accountability for the way an organisation manages itself. Clinical Governance (CG) is a system through which healthcare organisations are accountable for continuously improving the quality of their services and safe-guarding high standards of care, by creating an environment in which clinical excellence will flourish. CG should be integrated into the organisation’s whole governance arrangements. The Provider is responsible for ensuring that it has appropriate CG in place that ensures the following is carried out:
Clinical records and safety netting systems are developed and maintained;
Effective and appropriate patient feedback is regularly sought through surveys and other means;
An effective patient complaints procedure is in operation;
Critical incidents are reported to the Commissioner (Significant Events/Serious Untoward Incidents).
F.2 QUALITY ASSURANCE
The Provider is responsible for ensuring adequate internal quality controls exist to ensure day -to-day consistency in the delivery of the service requirements under this PACT Specification. This includes ensuring there are adequate records and reporting systems and selection and appropriate training of staff. The external quality controls will be provided by the Commissioner (and/or Lead Provider on their behalf) monitoring this PACT Specification. Further external quality controls will be delivered through the GP Peer Review processes.
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G. PACT AND AUA ENHANCED SERVICE
G.1 BACKGROUND
The Avoiding Unplanned Admissions DES ceased on 31 March 2017. As the Frailty guidance was not available at that time interim arrangements were put in place for the period April to June. This specification has now been amended in light of the new Frailty guidance
The work that practices are expected to do in order to fulfil the requirements of the Frailty Pathway do not replicate any of the PACT requirements. Therefore, in light of this, the patient cohorts have been amended and all patients will be seen as “Full Service
Service Requirement 1 “Top-up” is now obsolete.
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H. ARRANGEMENTS 1 JULY TO 31 MARCH
It has been agreed that the least complicated way forward is to recognise all PACT patients as “Full
Service” for 2017/18. Whilst the combined 2016/17 Top Up and Full Service activity budgets are
available for 2017/18, this change impacts on the total number of patients who can receive a Full
Service consultation due to all patients being funded at the higher Full Service level.
HELP AND SUPPORT
If you have any questions or need support with these arrangements, please do not hesitate to contac t
the PACT Support Team as follows:
Email: [email protected]
Phone: 020 7228 6654
Web: www.bhcic.co.uk
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1. SERVICE REQUIREMENT 1: PACT “AUA TOP UP” PATIENTS NOW OBSOLETE
THIS SERVICE REQUIREMENT IS NOW OBSOLETE.
THE NUMBERING OF SUBSEQUENT SERVICE REQUIREMENTS HAS BEEN MAINTAINED TO PROVIDE CONSISTENCY/FAMILIARITY FOR PRACTICES/PROVIDERS.
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2. SERVICE REQUIREMENT 2: PACT “FULL SERVICE” PATIENTS 2.1 Summary
Service Requirement 2 (A to I) is summarised in the table below:
Non-GP refers to Practice Nurses, Nurse Practitioner and Physician's Assistant. Healthcare Assistants
are only included where specifically stated within the Service Requirement details.
2.2 Patient Numbers
Using risk stratification software, allocation of the “Full Service” patient group is based on the number of patients in the high and very high Resource Utilisation Bands (RUB) in each Practice. The CCG have had the RUB reports re-run, identifying the maximum number of patients affordable within the available activity budget. This amounts to 5,800 Full Service patients. These patients were allocated to their registered Practices. This method of allocation ensures that the patient numbers allocated to Practices are those patients across Wandsworth with the highest need.
As the patient allocations for 2017/18 vary from those of 2016/17 the CCG has looked at the actual income Practices earnt through PACT in 2016/17. These figures have then been mapped against their potential income from their 2017/18 Full Service allocation plus their increased ECP 800 MDT allocation. As the PACT budget is fixed and the CCG does not want to destabilise Practices by significantly reducing their PACT earning potential IN 2017/18, Clinical Leads have agreed that any potential losses
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should be capped at 4% of last year’s actual PACT income. This applies to 11 Practices who will be given an additional allocation of Full Service patient numbers to enable them to mitigate any loss of earnings by seeing more patients, up to the 4% loss cap. The CCG will work with the Federation on the appropriate way to fund in 2018/19. In order “free up” these additional patients for Practices who have lost potential income, the remaining 29 Practices will have their “Full Service” allocations capped at 95% of their total. The CCG and GP Federation will monitor and review the total Full Service activity across all Practices during the ye ar and it is anticipated that some or all of the remaining 5% patient allocations may be released at the end of the calendar year. It is expected that this additional released allocation would be seen by Practices in the period January to March 2018. Practices have been notified individually of their “Full Service” activity figure for the year 2017/18. The practice should review their existing Full and Top Up registers to identify those patients who will continue to be a part of PACT. The practice should decide if all Top Up patients are moved to the Full Service register for review or review each register independently. Patients included within the PACT “Full Service” patient cohort may also be included within the PACT Enhanced Care Pathway (ECP) cohort (benefitting from additional multi-disciplinary care planning) as described in Service Requirement 3. The Practice must ensure that their Full Service register includes all PACT patients including their ECP cohort.
2.3 Care Plan Interventions
The PACT “Full Service” patients will receive the care planning interventions set out in the diagram below and described in more detail on the following page:
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2.1.1 Initial Care
2.3.1.1 Patient Notes Review The objective of this service requirement is to allow a GP (preferably the patient’s named and accountable GP) to spend time reviewing the patient notes of each patient selected for care planning interventions prior to their Initial Patient Consultation. The Patient Notes Review is expected to take, on average, 15 minutes per patient. A Practice can claim for payment for one “Patient Notes Review” per PACT “Full Service” patient per annum.
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2.3.1.2 Initial Pre-Consultation Assessment The objective of this service requirement is for the Practice to ensure they have all the information they need to maximise the effectiveness of the care planning process for the patient.
Patients should be invited in to the Practice for their Initial Pre-Consultation Assessment. An example invite letter is available. When contacting patients for the first time, Practices will be required to inform relevant patients that they have been included on the PACT patient register, what it is they can expect from being included and who their named and accountable GP is. The Initial Pre-Consultation Assessment can be carried out by any suitably qualified Practice staff member (e.g. Healthcare Assistant) and should preferably be a face-to-face assessment.
The Initial Pre-Consultation Assessment is expected to take, on average, 15 minutes per patient. A Practice can claim for payment for one “Initial Pre-Consultation Assessment” per PACT “Full Service” patient per annum. The Practice should use their discretion to decide if a patient requires an Initial Pre -Consultation Assessment or not prior to the Initial Patient Consultation. For example, it may not be appropriate for a Sickle Cell or dementia patient. A template which can be used for the Initial Pre-Consultation Assessment is available in an electronic format on EMIS Web. This template is only intended as a guide/aide memoire as to the information to be discussed and recorded and Practices should use their clinical judgement and discretion here. Patients should receive their Initial Pre-Consultation Assessment results in an easy to understand format along with a short leaflet explaining the whole care planning process and also asking patients to write down some key concern discussion areas and to bring them to the Initial Patient Consultation. Templates are available in an electronic format on EMIS Web which can be used / altered at the discretion of Practices. The patient will ideally book the Initial Patient Consultation for a date not (normally) earlier than 2 weeks after they patient has received their Initial Pre-Consultation Assessment results. This allows time for the patient to reflect on their condition and to generate ideas about what would be important for them to cover in the Initial Patient Consultation (especially in respect of goal setting and action planning). However Practices should use their discretion to book patients in for the Initial Patient Consultation directly after the Initial Pre-Consultation Assessment if this is more convenient and practical for a patient.
2.3.1.3 Initial Patient Consultation The objective of this service requirement is about creating a personalised care plan with, and for, the patient. The Initial Patient Consultation may be carried out by a GP (preferably the patient’s named and accountable GP) or a Non-GP (Nurse Practitioner, Physician’s Assistant or a Practice Nurse). The Consultation should be a face-to-face assessment (either at the patient’s own home or at the Practice). The Initial Patient Consultation is expected to take, on average, 30 minutes per patient. A Practice can claim for payment for one “Initial Patient Consultation” per PACT “Full Service” patient per annum.
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An electronic template is available on EMIS Web3. This template is only intended as a guide/aide memoire as to the information to be discussed and recorded during the Initial Patient Consultation and Practices should use their clinical judgement and discretion here. The Care Plan document template, available on EMIS Web, must be used to record the patient’s Care Plan. Once completed, it is designed to be shared with the pat ient and, as appropriate, other health and social care practitioners. Every patient within Practice’s “Full Service” patient group should have a personalised Care Plan completed as part of their annual PACT consultation process. This includes the “PACT ECP” patient group (see Service Requirement 3). All patient Care Plans should be regularly updated as their needs change. A range of education resources will be available to Providers/GP Practices to support the development of quality Care Plans. Patient Care Plans will be audited by the Commissioner/Lead Provider for quality of content. The Commissioner reserves the right to “claw back” commensurate payments where the quality of a Care Plan is considered to be below the required standard and is not improved on request within a reasonable timescale. GPs should include a discussion with patients around their medication and medicines optimisation. Further information and advice is available on the PACT resources website at http://www.bhcic.co.uk.
Patient Experience:
At the end of Initial Patient Consultation, the GP/Provider shall encourage patients to participate in
a confidential feedback process. GPs/Providers will be advised of the nature and process for confidential feedback to be obtained from patients by the Lead Provider;
If and when the patient’s (informed) consent to participate in the feedback process is obtained, the
GP/Provider will ensure this is indicated within the patien t’s record via the PACT template;
Patients should understand that in giving consent, their contact details will be passed to the
organisation commissioned to undertake the confidential feedback process to enable them to be contacted directly.
2.3.1.4 Plan / Organise / Coordinate Patient Care (Care Plan) The objective of this service requirement is to allow a GP (preferably the patient’s named and accountable GP) to spend time after the Initial Patient Consultation planning, organising and coordinating the on-going care needed for the patient as part of the care planning process. See also requirements around development of a Care Plan as described in 2.3.1.3 above.
For all patients who are considered to require one, this should include the completion of a Special Patient Note (SPN) for OOH/111/LAS to provide up-to-date information about a patient to assist in providing care and potentially avoiding inappropriate hospital admission. Wherever possible, Practices should use direct access to urgent care provider systems (eg 111/OOH GP Adastra system) to upload appropriate patient information. Where this isn’t possible, an SPN form is available on the resources webpage (at http://www.bhcic.co.uk) and should be sent by email (details on the form). Patient consent is required to share information contained in the SPN which should be updated as patient needs/care plans change and reviewed at least every 3 months. (SPNs should not be used for identified End of Life Care patients who should, subject to consent, have a Coordinate My Care record set up to communicate their care needs, wishes and preferences. See Service Requirement 8). GPs can make a referral to a dedicated Social Worker/Social Care Officer via an Access Officer based in the CAHS Access and Coordination Locality Hub. This service ensures a timely response to
3 GPs must use the bespoke Sickle Cell EMIS Web template when seeing Sickle Cell patients.
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review a patient’s social care needs and, where appropriate, commence appropriate packages of care to assist and support the most vulnerable patients and avoid unnecessary admissions due to social care breakdown. Further information is available on the PACT resources website at http://www.bhcic.co.uk. Please note this service is not available for patients living outside of the Borough boundary. Service Requirement 3 PACT Enhanced Care Pathway MDT Care Plan Development and Review Process describes an additional intervention for a limited cohort of the most complex and vulnerable patients on a joint CAHS/PACT caseload (who may also be “Full Service” patients). It is recognised, however, that there may be patients who are not included within the PACT Enhanced Care Pathway cohort who would benefit from a Community Geriatrician assessment to provide GPs with additional support in how best to care for them. Further details will made be available on the resources website at www.bhcic.co.uk. Planning / Organising / Coordinating Patient Care is expected to take, on average, 30 minutes per patient. A GP may decide to combine the time for this service requirement with the time allocated to the Initial Patient Consultation so they have a total of 60 minutes to spend on a patient in one go. A Practice can claim for payment for one “Planning / Organising / Coordinating Patient Care” PACT “Full Service” patient per annum.
2.3.2 Follow Up Care
2.3.2.1 Urgent Patient Calls The objective of this service requirement is to provide the patient with a same day telephone consultation number for future urgent care enquiries that can be used to avoid a crisis situation arising. This same day telephone consultation service will be with the most appropriate healthcare professional in the Practice. This service requirement allows the Practice time to handle these telephone calls as part of the care planning process and is expected to take, on average, 15 minutes per patient4. If a Practice receives one urgent care enquiry from a patient they should make a claim for payment using the appropriate Read Code, irrespective of the healthcare professional that dealt with the enquiry. A Practice can claim for payment for one “Urgent Patient Call” per PACT “Full Service” patient per annum.
2.3.2.2 Care Plan Review The objective of this service requirement is to allow a GP (preferably the patient’s named and accountable GP) to review the patient’s care and personalised care plan at agreed regular intervals with them, and, if applicable, their Carer. The Practice should look at the patient’s personalised care plan to ensure that it is accurate and is being implemented, making any changes as appropriate and agreeing these with the patient and where appropriate, the Carer.
A Care Plan Review is expected to take, on average, 15 minutes per patient. A Practice can claim for payment for one “Care Plan Review” per PACT “Full Service” patient per annum.
2.3.2.3 Review Consultation The objective of this service requirement is about providing a patient with a follow-up review consultation to discuss and update the patient’s care plan. The Review Consultation may be carried
4 NB This service requirement is paid at the “GP Clinical Task” rate so it equates to longer than 15 minutes on average if dealt w ith by Non GPs.
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out by a GP (preferably the patient’s named and accountable GP) or a Non -GP (Nurse Practitioner, Physician’s Assistant or a Practice Nurse) and can be either done face -to-face (either at the patient’s own home or at the Practice) or by telephone. A Review Consultation is expected to take, on average, 30 minutes per patient. A Practice can claim for payment for one “Review Consultation” per PACT “Full Service” patient per annum.
2.3.3 Crisis Care
2.3.3.1 Patient Contact Post Crisis The objective of this service requirement is to ensure that when a patient is discharged from hospital following an unplanned, crisis admission (ie discharged from A&E or after being admitted to hospital from A&E), attempts are made to contact them by an appropriate member of the Practice in a timely manner to ensure co-ordination and delivery of care. This would normally be with in 24 hours of the discharge notification being received, excluding weekends and bank holidays, unless there is a reasonable reason for the Practice not meeting this time target (e.g. the patient has been discharged to an address outside the Practice area or is staying temporarily at a different address unknown to the Practice). Once a Practice has attempted to make contact with the patient a Practice should make a claim for payment using the specified EMIS Web Read Code. Patient Contact Post Crisis is expected to take, on average, 15 minutes per patient. A Practice can only claim for payment for one “Patient Contact Post Crisis” per PACT “Full Service” patient per annum.
2.3.3.2 Crisis Follow Up Care The aim of this service requirement is to promote the role of the GP (preferably the patient’s named and accountable GP) as the co-ordinator for post hospital discharge care and to provide a standard approach for reviewing and effectively “actioning” discharge letters for vulnerable patients. Crisis Follow Up Care can include any care administered by the Practice as a result of the crisis episode. This must include reviewing and “actioning” all tasks listed in a patient’s hospital discharge letter. All urgent actions should be identified and completed by the next working day after receipt of the discharge letter in the Practice. All other actions listed should be started within a reasonable period of time. Once a Practice has initiated all tasks identified in the hospital discharge letter a Practice should make a claim for payment using the specified EMIS Web Read Code. Crisis Follow Up Care is expected to take, on average, 30 minutes per patient. A Practice can only claim for payment for one “Crisis Follow Up Care” PACT “Full Service” patient per annum.
2.4 Payments
Practices will be paid for the time taken in carrying out each of the PACT Specification “Full Service” care planning interventions, as set out in the diagram in Section 0, for each of the PACT “Full Service” patients. The average time taken and payment to be received for each of the “full service” care planning interventions is set out in the table below.
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As can be seen from the table above, the total “Full Service” payment under the PACT Specification is £193 per patient per annum (if relevant Requirements are undertaken by a GP and not a non -GP in which case the total figure will be reduced accordingly). There is another additional payment of £46 per patient per annum for those vulnerable patients who also have a “crisis” episode during the year. Practices will receive the above payments for these “Full Service” care planning interventions from the Commissioner by following the instructions set out in this PACT Specification. Payment for MDT care plan development and review for any patients included within the PACT ECP patient cohort (see Service Requirement 3) is in addition to the above.
2.5 Selection of Patients and Patient Registers
2.5.1 Patient Selection
A Practice should select vulnerable older people, high risk patients and patients who are at risk of an unplanned admission to hospital for their PACT “Full Service” patient group.
All patients selected must be adults (i.e. aged 18 years or over) or children (aged 17 and under) with complex physical or mental health and care needs, who require proactive case management.
Practices must include the following groups of patients within their PACT “PACT “Full Service” patient register:
Housebound patients (see definition below);
Nursing Home Residents (see definition below);
End of Life Care (EOLC) patients (see definition below);
Patients with Learning Disabilities;
Dementia patients; and
Sickle Cell patients.
A “housebound patient” means someone who finds:
Leaving home is a major effort; and
Is normally unable to leave home unassisted; and
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When leaving home, it is only to get medical care, or for short, infrequent non-medical reasons
such as a trip to get a haircut, or to attend religious services or adult day care. Ultimately, a GP must use clinical judgement to decide if a patient’s particular circumstances mean that they would benefit from being classified as “housebound” in the context of this specification.
A “Nursing Home resident” means someone that:
Lives in a Nursing Home (i.e. a home where meals and personal care (such as help with
washing and eating) are provided and also nursing care is provided for more complex health
needs); and
Receives nursing care within the Nursing Home.
An “End of Life Care Patient” means:
Someone that has an advanced incurable illness and who, whilst acknowledging that making a
prognosis is difficult and imperfect, is likely to die within the next 12 months;
This includes patients with cancer and non-malignant conditions such as severe heart failure,
COPD, long-term neurological conditions, severe frailty and dementia;
These patients should also be included within the Practice’s Supportive Care Register;
Practices are encouraged to also consider including appropriate patients from the following groups
Patients within 5 Years of a Cancer Diagnosis (excluding non-melanoma skin cancers);
Patients with a Social Care “critical” or “substantial” need5;
Patients with a primary mental health need;
Patients living in Residential Care Homes;
Patients that have had a stroke;
Patients with a physical disability.
If a Practice still has “slots” to fill after considering all the above groups of patients then these slots should be filled with vulnerable older people or high risk patients (not included in the above categories) who the Practice considers to be at a high risk of unplanned admission to hospital and most in need of care planning support. Practices should use "risk stratification" software or clinical judgement / local patient knowledge or analysis of their recent unplanned admissions and A&E attendances to help identify which patients to include. However, it is important to emphasize that GPs are able to use their discretion to identify and select any patient that they feel would benefit from a set of care planning interventions. Practices should also use their discretion to remove patients identified through "risk stratification" software searches who are not deemed to require care planning interventions under this specification. Practices are required to inform relevant patients that they have been included on the patient register and what it is they can expect from being included. As part of this communication, patients added to the patient register will be informed of their named accountable GP.
5 The ability of the Practice being able to include these patients is subject to the relevant social care information being mad e available by Wandsworth Borough Council.
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2.5.2 Patient Registers
The Lead Provider will work with Practices to ensure the relevant searches are available on Practice systems to develop their patient registers. Patient Registers should be updated and reviewed regularly. Practices must ensure all patients for each registers have the correct register code.
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3. SERVICE REQUIREMENT 3: PACT ENHANCED CARE PATHWAY (PACT ECP) MULTI-DISCIPLINARY CARE PLAN DEVELOPMENT AND REVIEW PROCESS
3.1 Summary
This Requirement provides additional multi-disciplinary care planning for approximately 800 of the most complex patients on a joint CAHS/PACT caseload. Service Requirement 3 is summarised in the table below:
3.2 Rationale and Requirements
Commissioners have worked with community services (CAHS) to develop an Enhanced Care Pathway (ECP) for any frail patient who requires a range of integrated, planned care between Primary Care and Community Services. The PACT Enhanced Care Pathway (“PACT ECP”) patient group will have been identified as the 800 most vulnerable and complex patients on a Practice’s PACT care plan consultation patient registers. For 2017/18 and as part of that Enhanced Care Pathway, the named GP and the Health and Social Care Coordinator for the PACT ECP identified patients will again be required to participate, following the patient’s PACT Consultation, in a multi-disciplinary care planning and review process, either “virtually“ (ie via conference call or Skype) or in person. The Multi-Disciplinary Team (MDT) meeting comprises a of range healthcare professionals such as CAHS GPs, consultant geriatrician, district and specialist nurses, social services, end of life, and other health professionals. This enab les a comprehensive review of the patient’s care through discussion and agreement to the most appropriate care pathway. A Care Plan will have been developed for these PACT ECP patients by their GP as part of their PACT consultation process. For this PACT ECP patient group, GPs are required to share this Care Plan with a wider MDT, as part of this additional MDT Care Plan Development and Review process. This will ensure a clear and informed medical perspective is included within the MDT approach to develo ping and reviewing care plans for this specific group of patients. The MDT process will be led by the ECP Provider/CAHS. CAHS will have EMIS access to view and update the PACT ECP patient’s Care Plan held on EMIS. The PACT ECP patient list has been “capped” at 800 patients to ensure affordability of payments to the GP Practices required to participate in this MDT care planning and review process described above. It is, however, recognised that some patients may no longer require MDT care planning in-year (eg
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should they die or no longer require such high levels of care) and more patients may be identified as meeting the agreed clinical criteria for an MDT care planning process. As such, a limited number (up to 100 maximum) of additional patients will be held on a “reserve list” and may be added to the PACT ECP cohort during the year, based on individual patient need and as agreed between the PACT Lead Provider and the ECP Provider. This will ensure that c800 patients remain within the PACT ECP patient cohort during 2017/18.
3.3 Identification of PACT ECP patients
Each GP Practice will initially be provided with a nominal allocation of the 800 ECP patient cohort. Each Practice will then select patients who are likely to gain the most benefit of the Enhanced Care Pathway. This will be a combination of Practice clinical discussions and SOLLIS to help identify the most appropriate patients meeting the agreed selection criteria. The Practice must review their final list against SOLLIS as a minimum. The final agreed number of ECP patients per Practice will not (normally) be greater than the initial nominal allocation, unless agreed with the Lead Provider. The agreed ECP patient group within a Practice may be agreed to be less than the nominal allocation, based on patient need. The Named GP for each identified patient on a Practice’s allocated list will be required to participate in the MDT Care Plan Development and Review Process for that PACT ECP patient. An appropriate GP substitute may attend for the Named GP where unavoidable.
3.4 Payment
Payment for this new requirement is up to £300 per identified PACT ECP patient (per patient per year). Payments will be made to Providers in 2 qualifying stages:
An initial payment of £150 for each patient on the Practice’s register included within the PACT ECP cohort on 1 April 2017 (or added from the reserve list described above up to 30 September). This will be paid in October;
A second payment of £150 for each patient identified above, subject to the patient continuing to be included within the PACT ECP cohort beyond 1 October 2017 (or added from the reserve list described above after 1 October). This will be paid at year end.
Payment will be made retrospectively on receipt of confirmation from the ECP Provider/CAHS (who will lead the process) that a jointly-developed care plan for the identified PACT ECP patient is in place and that the GP is participating in the MDT care planning discussions in relation to that patient. Payment will be included as part of the wider PACT Specification monthly payment.
For clarity, no payment will be made for ECP MDT attendance should a patient die (or be removed from the ECP for another reason) before a GP has attended an MDT Care Plan Development an d Review meeting.
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PACT ENHANCED CARE PATHWAY JOINT CARE PLANNING DEVELOPMENT AND REVIEW PROCESS
This joint care planning process w ill apply to approximately 800 of the most complex patients on a joint CAHS/PACT caseload.
GP undertakes a PACT
Consultation w ith an identif ied
PACT ECP patient and develops a Care Plan using the EMIS
template. The patient must be
provided w ith a hard copy of the
Care Plan.
The Named GP (or appropriate
GP substitute w here unavoidable)
attends the CAHS MDT meetings
to discuss the patient and
contribute to the joint care
planning process. Attendance in person is preferable.
How ever, participation via conference call
may be appropriate if it is impractical to
attend.
CAHS w ill continue to develop and update the integrated care plan
w ith the patient and/or carer (if
appropriate), the patient’s Named
GP and the community services
MDT.
CAHS w ill advise the Lead Provider of the
GP’s activity/participation in the
development and review process.
GP Practice to use EMIS to code
their participation in the MDT care
planning and review process.
Payment of up to £300 per
identif ied patient per annum.
Named GPs are required to
continue to liaise w ith the CAHS
GP or patient’s key w orker at least
fortnightly to discuss and agree
changes to the patient’s joint care plan accordingly. The Care Plan
w ill be held centrally on EMIS.
The GP w ill have already developed a Care
Plan w ith the patient as part of Service
Requirements 1 or 2. This can be shared w ith the Community MDT via EMIS to assist
in the development of the integrated Care
Plan.
GP Practice is provided w ith an
allocation of their patients
included w ithin the PACT ECP
patient group
NB: It is imperative that the patient’s consent
is obtained to share their Care Plan w ith the
MDT.
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4. SERVICE REQUIREMENT 4: CARERS
4.1 Summary
Service Requirement 4 is summarised in the table below:
4.2 Definition
For the purposes of this service specification, a carer is someone who regularly provides unpaid support to a partner, child, relative, friend or neighbour, who could not manage without their help due to a physical or mental health condition, physical or learning disability, frailty or substance misuse problems. This includes young carers (people between the ages of 6 and 18). The carer must be registered with a Wandsworth Practice in order to be eligible for the services provided within this specification. This is still the case even if the patient being cared for is registered with a Practice outside of the borough.
4.3 Rationale
Carers currently save the UK economy £119 billion each year6 through the care they provide. Without the support of carers NHS services would be unable to meet the demands of those who need care. Unfortunately caring for someone commonly leads to carers neglecting their own health and wellbeing needs in order to meet the needs of those they care for, and as a result many become isolated, ill or injured, impairing their ability to continue caring as they would like to.
The GP patient survey in 2013 highlighted the impact of caring on carer health; 51% of non -carers were found to have a long-standing health condition which rose to 60% of all carers and 70% of carers caring for 50 or more hours per week. 83% of carers stated that caring had a negative impact on their physical health while 87% stated that caring affected their mental health. Similarly, young carers often report feeling tired or under pressure.
In 2013 research by Carers Trust and the University of Nottingham found that almost a third of young carers surveyed (29%), reported their own physical health was ‘just OK’, and 38% reported having a mental health problem.
Young carers providing between 20 and 49 hours per week are over 3 times more likely to report their health as not good compared to children without caring responsibilities (Office of National Statistics, 2011).
6 Statistics and Facts about Carers, Carers UK. Available at: http://w w w .carersuk.org/new sroom/stats-and-facts
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There are known to be in excess of 19,000 carers in Wandsworth7, many of whom remain unidentified by health and social care professionals, and suffer in silence as they are unaware of available support.
GP practices are often the first, and sometimes only, point of contact that carers have with health services. To ensure they remain well and healthy enough to continue caring for as long as they wish to do so GP practices need to adopt processes for identifying and supporting their carers properly.
4.4 Care Pathway
The Carer support pathway is shown on the following page .
Under the terms of this specification, GP Practices will do the following:
Appoint a Carers Lead in each Practice. Identify carers at registration to the practice
Keep an up to date carers register: All carers identified in the Practice should be coded using Read Code 918G “Is a carer”; Once a Practice identifies that someone has ceased caring the carer’s status needs to be updated by inputting Read Code 918f (“Is no longe r a carer”);
Call in Carers on the register for an annual health check.
Perform a 30-minute consultation with each carer identified by the practice (a consultation checklist is available at www.bhcic.co.uk);
Identify whether there are any young people that help to care for the cared–for person Ensure appropriate follow-up referrals are made;
Book next consultation.
4.5 Suggested Best Practice
1. Accurately record Carer details. See requirements above; 2. Patients that have a carer who is registered to the Practice should be coded using Read Code
918F (“Has a carer”); 3. Nominate an administrative Carers’ Lead (e.g. to facilitate patient registration process to
ensure necessary information about carers and young carers is captured ; ensure information for carers in the Practice is current and visible in Practice waiting areas; update the carers register; actively identify carers in Practice waiting areas; coordinate referrals to the local carer support service; code newly identified patients as carers; promote carer awareness to all Practice staff);
4. Capture Carer/Cared-for persons status on new patient registration forms ; 5. Embed a Carer Alert into Carer’s Patient Records (i.e. so that when a carer calls to book an
appointment the alert will be activated and the Carer can be prioritised); 6. Provision of Clear Information and advice on how to maintain/improve their health and
wellbeing 7. Carer awareness training for all staff in the Practice ; 8. Promoting the carer agenda within the Practice ; 9. Encouraging other staff members to actively identify carers (e.g. by asking patients if they
regularly help or support anyone); 10. To improve identification of carers all GPs should ask ALL patients with a long term
condition whether they are being supported by any family members or friends due to their condition;
11. Referring carers and young carers to local carer support services ; 12. Refer Carers to Carers Partnership Wandsworth to access the appropriate support
7 Based on 2011 Census.
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Page 35 of 58
CarersRegister(918G“isacarer”)
AnalerttobeplacedontheEMISpatientrecord
Informationaboutthecaringrole
Ø Relationshiptothecaredforperson
Ø Detailsofcaringduties
Ø Specificconcernsaboutcaringduties
30M
inutecarerconsultation
Carerhealthcheck
Ø Investigations(asappropriate)
Ø Measures(asappropriate)
Ø Complicationscreens(asappropriate)
Physical&emotionalwellbeingassessment
Ø Physicalactivity
Ø Drinking/smoking
Ø Sleeppatterns
Ø Lifestyle
CaregiverStrainIndex
OnwardReferra
lsWandsw
orth
CarersC
entreFo
otstep
stoHealth
yLivingC
ompreh
ensiveSelf-M
anagem
entP
rogram
me
CarerInformationPack
ConsultationinviteletterCarershouldbeaskedtothinkaboutanyparticularissuestheymaywanttoraisewiththeGP
Booknextconsultation
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5. SERVICE REQUIREMENT 5: OBSOLETE
THIS SERVICE REQUIREMENT IS NOW OBSOLETE.
THE NUMBERING OF SUBSEQUENT SERVICE REQUIREMENTS HAS BEEN MAINTAINED TO PROVIDE CONSISTENCY/FAMILIARITY FOR PRACTICES/PROVIDERS.
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6. SERVICE REQUIREMENT 6: STABLE HAEMATOLOGY
6.1 Summary
Service Requirement 6 (A to C) is summarised in the table below. The named GP Lead for Haematology must have completed the training in respect of Stable Haematology Patients (ie have watched the Haematology educational video available on the PACT resources website www.bhcic.co.uk before completing Service Requirements 6A, 6B and 6C.
6.2 Definitions
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Monoclonal Gammopathy of Undetermined Significance (MGUS) is a common condition, which increases its likelihood with age. About one in 30 people aged 50 years or older will have the condition, this rises to one in 20 people aged over 70 years, and nearly one in 10 people aged over 85 years. It is about 1.5 times more common in men than in women. The disorder also appears to be nearly twice as common in patients of African descent as in Caucasians. This disorder may progress to Myeloma in 1-2% of patients per annum and therefore requires regular monitoring.
Chronic Lymphocytic Leukaemia (CLL)
Chronic Lymphocytic Leukaemia (CLL) is the most common form of leukaemia in the Western World and is often diagnosed by chance following a routine full blood count (FBC). Stage A is the very earliest stage of the disease. Patients are often elderly and trial evidence supports no need for active treatment of early stage disease. The majority of such patients have an extremely good prognosis with slowly progressive disease over many years. Consequently they are ideal patients to be followed up in primary care. Patients with CLL can be more prone to infection and may develop autoimmune haemolytic anaemia and/or immune thrombocytopenic purpura (ITP).
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6.3 Rationale
This element of the specification aims to facilitate the management of appropriate patients with Monoclonal Gammopathy of Undetermined Significance (MGUS) and/or Stage A Chronic Lymphocytic Leukaemia (CLL) within primary care, if their disease is stable or does not require active treatment. This will result in:
Reduced number of inappropriate referrals to secondary care services;
Improved access and shorter waiting times for patients requiring specialist input; Care closer to home for stable haematological patients.
6.4 Record Keeping
It will be the responsibility of the Practice to:
Contact the patient by telephone to book their first appointments with the nurse and GP for ongoing primary care management. It will be at the patient ’s first appointment with the GP that the patient will be advised as to when to book future appointments;
Ensure that failsafe and safety netting processes are in place;
Maintain a register of all patients referred into the service that is routinely checked by Practice staff. This information will be available to the Commissioner at all times.
The Practice should record the following information for every stable haematology patient:
NHS number of discharged patient;
Date of discharge; Disease: Stable Stage A CLL or low risk MGUS;
Referring Consultant and Trust;
Number of face-to-face review consultations agreed with the consultant per year;
Number of face-to-face review consultations offered over the reporting period; Number of face-to-face review consultations attended over reporting per iod;
Patient continuing in Primary Care (Y or N);
Number of referrals back to secondary care over the reporting period;
Reason for referral back to secondary care (where applicable); Patient offered referral to Wandsworth Self-Management Service (Y or N).
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STABLE HAEMATOLOGY – STAGE A CLL PATIENT PATHWAY
Stage A Chronic Lymphocytic Leukaemia (CLL) Patient Pathway:
Discharge from Secondary Care Secondary care providers will:
Identify appropriate patients with Stage A CLL for
management within primary care;
Carry out a discharge consultation with patient ensuring that
the following checks are in place:
Patient understands and accepts the new follow-
up arrangements;
Check with the patient that their GP details are
correct;
Provide a copy of the patient information leaflet
(which includes the hand-held monitoring book);
Send a discharge letter to the patient’s GP (a copy will also
be given to the patient at the discharge consultation).
New referral received from Secondary Care Patient added to the MGUS register and patient recall
system;
Practice to set up recall system;
Patient added to flu vaccination list;
Practice will contact patient by telephone to book their first
appointment with the GP for ongoing primary care
management.
Tests Every 3-6 months (as prescribed in the patient’s discharge
letter), GP practice to arrange full blood count (FBC) tests.
GP appointment (30 minutes) Once test results have been received, patient attends a GP
appointment to review test results and examine for
lymphadenopathy/splenomegaly;
Log test results in patient’s hand-held monitoring book;
GP should remind patients that if they are concerned
about a change in their symptoms to book an urgent
appointment with their GP;
GP to check whether the flu vaccine has been given to the
patient this season;
If patient is to continue being managed in primary care,
GP advises patient to book a GP appointment in 3-6
months (as prescribed in the patient’s discharge letter);
GP to set a diary date for review.
Continue primary care management
If patient does not attend (DNA) appointment,
Practice to contact the patient to rebook a
follow-up appointment.
Refer patient back to secondary care
If there is evidence of disease progression, refer
patient back to relevant haematology secondary care
provider using the agreed proforma.
To note: Warning Symptoms
Blood Tests
Haemoglobin concentration: Less than 105g/l
White cell count: Greater than 50x10^9/l
Platelets: Less than 100x10^9/l
Lymphocyte count: Doubling time of less than 12
months
Patients should be referred back to secondary care
in the following instances:
Falling Hb <105g/l or platelets <100;
Development of bulky lymph
nodes/splenomegaly or “B” symptoms –
unintentional weight loss, night sweats
and/or unexplained fevers;
Doubling of lymphocyte count within a period
of 12 months or less.
Advice and Support
For patients who have been discharged from St
George’s NHS Healthcare Trust:
Contact the Haematology Department using
Kinesis for advice and support regarding test
results and/or advice on whether a referral
back to secondary care is necessary.
For patients who have been discharged from
Coydon Health Services NHS Trust and Epsom and
St Helier University NHS Trust:
Contact the Haematology Department using
the dedicated email for advice and support
regarding test results and/or advice on
whether a referral back to secondary care is
necessary.
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STABLE HAEMATOLOGY –MGUS PATIENT PATHWAY
Monoclonal Gammopathy of Unknown Significance (MGUS) Patient Pathway:
Discharge from Secondary Care Secondary care providers will:
Identify appropriate patients with low risk MGUS for management
within primary care;
Carry out a discharge consultation with patient ensuring that the
following checks are in place:
Patient understands and accepts the new follow-up
arrangements;
Check with the patient that their GP details are correct;
Provide a copy of the patient information leaflet (which
includes the hand-held monitoring book);
Send a discharge letter to the patient’s GP (a copy will also be given to
the patient at the discharge consultation).
New referral received from Secondary Care Patient added to the MGUS register and patient recall system;
Practice to set up recall system;
Patient added to flu vaccination list;
Practice will contact patient by telephone to book their first
appointment with the nurse and GP for ongoing primary care
management.
Nurse appointment (20 minutes) Every 3-6 months (frequency as prescribed in the patient’s discharge
letter), nurse should request the following tests from the pathology
laboratory:
Full Blood Count (FBC)
Urea and Electrolytes (U&E);
Calcium;
Paraprotein levels;
Urinary Bence Jones protein OR Serum Freelite Chain
estimation for patients with significant Serum Freelite
Chain component.
Nurse to ehcek whether patient has received flu vaccine
for this season
GP appointment (20 minutes) Once test results have been received, patient attends a GP
appointment to discuss their test results and how they are feeling as
well as being examined;
Log test results in patient’s hand-held monitoring book;
GP should remind patients that if they are concerned about a change
in their symptoms to book an urgent appointment with their GP;
GP to check whether the flu vaccine has been given to the patient this
season;
If patient is to continue being managed in primary care, GP advises
patient to book a nurse and GP appointment in 3-6 months
(frequency as prescribed in the patient’s discharge letter);
GP to set a diary date for review.
Continue primary care management
If patient does not attend (DNA) appointment, Practice to contact the patient to
rebook a follow-up appointment.
Refer patient back to secondary care
If there is evidence of disease progression, refer
patient back to relevant haematology secondary care
provider using the agreed proforma.
To note: Warning Symptoms
Blood Tests
Haemoglobin concentration: Less than 100g/l
Hypercalcaemia: Abnormal/deterioration
Creatinine and/or urea: Abnormal/deterioration
Paraprotein: If the concentration of the M-protein
increases by more than 25% (a minimum absolute
increase of 5 g/l)
Serum Freelite Chain (can be undertaken instead
of Bence Jones): Increases by more than 25% in
either light chain.
Urine Tests
Bence Jones: Increases by more than 25%
Advice and Support
For patients who have been discharged from St
George’s NHS Healthcare Trust:
Contact the Haematology Department using
Kinesis for advice and support regarding test
results and/or advice on whether a referral
back to secondary care is necessary.
For patients who have been discharged from
Coydon Health Services NHS Trust and Epsom and
St Helier University NHS Trust:
Contact the Haematology Department using
the dedicated email for advice and support
regarding test results and/or advice on
whether a referral back to secondary care is
necessary.
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7. SERVICE REQUIREMENT 7: MENTAL HEALTH DEPOT INJECTIONS
7.1 Summary
Service Requirement 7 (A to B) is summarised in the table below.
7.2 Definitions
There are a number of Wandsworth patients that are currently treated within secondary specialist mental health treatment services who, after a period of treatment have become very stable, and whose needs, specifically around administration of depot injections, can be met within primary care.
7.3 Rationale
This specification aims to facilitate the care management by Practices of patients with Serious Mental Illness who are stable and have been discharged from the care of the Community Mental Health Team. This aims to support and enhance the patient’s recovery by allowing them to access ongoing “depot injections” in a primary care setting, rather than a specialist secondary setting.
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MENTAL HEALTH DEPOT INJECTIONS – PATIENT PATHWAY
Covered by
PACT contract
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8. SERVICE REQUIREMENT 8: END OF LIFE CARE
8.1 Summary
Service Requirement 8 (A to B) is summarised in the table below:
8.2 Definitions
An “end of life care” (EOLC) patient means someone that has an advanced incurable illness and who, whilst acknowledging that making a prognosis is difficult and imperfect, is likely to die within the next 12 months.
8.3 Rationale
It is recognised that, at a national level, over 60% of those who expressed a preference, chose home as their preferred place of death. Many initiatives across the Wandsworth EOLC system are supporting patients to achieve their preferred place of care and death and GPs play a vital role in this.
Co-ordinate my Care (CMC) was launched in Wandsworth in late November 2012 and, whilst there is still room for further development, Wandsworth GPs are continuing to expand its use for the benefit of their patients. Where CMC has been implemented across London, its benefits have been recognised, specifically with 70-80% of all patients with a CMC record having achieved their preferred place of death, where a preference was expressed.
This specification encourages both the use of CMC, with the aim of increasing the number of patients dying in their preferred place of death, and a GP-led MDT review of patient care to support learning and improvements in End of Life Care (EOLC).
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This part of the specification aims to:
Improve identification of patients thought to be in their last year of life, whatever their diagnosis. This includes patients with cancer and those with non-malignant conditions such as severe heart failure, COPD, long-term neurological conditions, severe frailty and dementia;
To increase the number of people with end of life care needs achieving care and ultimately dying in their preferred place of care by improving communication between services;
To improve End of Life Care by entering patients onto Co-ordinate my Care (CMC), enabling care plans to be shared with providers including Wandsworth End of Life Care Coordination Service, community services, hospices, out-of-hours services, London Ambulance Service, secondary care and 111.
Wandsworth EOLC Coordination Service.
Where appropriate, please remember to refer your patients (with their consent) to the Wandsworth EOLC Coordination Service. This service provides a “one-stop shop” to support patients, their family/carers, GPs and other health professionals caring for them.
Telephone: 0300 3000 116
Email: [email protected]
Fax: 0207 787 2005
8.4 Good Practice / Resources
Please see the PACT resources webpage (www.bhcic.co.uk) and DSX for the following resources:
Copy of the ADA form
Information about Coordinate my Care
EOLC referral options
“Care Plan Consultation for EOLC patients” guidance document/checklist “Thinking Ahead” document for patients
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EOLC - PATIENT PATHWAY
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9. SERVICE REQUIREMENT 9: PATIENT SELF-MANAGEMENT
9.1 Summary
Service Requirement 9 is summarised in the table below:
9.2 Objective
This specification aims to promote patient self-management by encouraging GPs to directly refer appropriate patients on to the Wandsworth Self-Management Service and promote self-management during the Care Plan Consultations, Carer Consultations and Consultations for those living with a Mental Health Condition. Funding and payment is made on the basis that it is:
To support the admin behind identifying an appropriate patient, through a PACT consultation or otherwise and;
To recognise the skill of the HCPs and Practices in selecting motivated and “ready” patients for appropriate referral to the Self-Management Service. This will, in turn, increase the benefits for patients;
Referral is via the Lead Provider searches.
Referral to the Self-Management Service requires the following:
That the patient is living with a mental or physical long term condition or caring for someone who does;
The GP has discussed the benefits of self-management and together agreed with the patient that it would be helpful for them to attend a self-management course;
The GP has given the patient relevant materials about the Wandsworth Self -Management Service courses and made a referral to the service via the online referral form.
Payment for this activity only requires a referral to the Service as the team will make contact with the patient and manage the rest of the pathway. Results from the searches should be sent to the Self–Management team at [email protected] every month. The referral is only complete once the list
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has been sent to the Self-Management team and they confirm to the Federation that they have received the patient information. Payment can then be made.
Patients are also able to self-refer to the Self Management Service via the self-referral form available at www.wandsworthccg.nhs.uk/localservices/Self-Care/Pages/self-management-referral-form.aspx. GPs will not receive a payment for self-referrals.
9.3 Definitions
Person-centred care (2013)1, describes self-management as moving away from patients as passive recipients of care to a collaborative relationship where patients are active partners in their own health. Self-management is not designed to replace a service but it can reduce a patient’s dependence on regular visits to their General Practitioner (GP) or hospital.
9.4 Rationale
Self-Management skills are not exclusive to people with existing long terms conditions but also for carers who may need support in caring for their loved ones. People are encouraged to find out more about their condition, learn new skills and in the process find themselves in better control of their own healthcare (self-management UK, 2013). To do this, patients need to develop their knowledge, skills and confidence to make informed decisions and adapt their health-related behaviours.
The 2008 final report for the Year of Care8 states “that effective care planning consultations rely on three elements working together in the local healthcare system: an engaged, empowered patient working with healthcare professionals (HCPs) committed to a partnership approach, supported by appropriate/robust organizational systems.” It goes on to emphasize the need for each element to be strong; missing or weak elements reduced the potential benefits to little or no benefits.
The Expert Patients Programme (EPP) is a nationally recognised and evidenced peer -led self-care support programme for people living with any long term condition, their carer and families. A Department of Health letter to all NHS Chief Executives dated 23rd July 2009 stated: “EPP is an important strand of our policy to improve the health and wellbeing of people with long term conditions……..You will recall that “Our health, our care, our say: a new direction for community services” made a commitment to increase EPP capacity from 12,000 course places a year to 100,000 course places by 2012. Data from approximately 1,000 EPP course questionnaires (Jan 2003 – Jan 2005)9 showed that, four to six months after completing the course:
GP consultations decreased by 7%
Outpatient visits decreased by 10%
A&E attendances decreased by 16% Pharmacy visits increased by 18%
A review of self-care interventions commissioned by the Department of Health found that effective interventions, such as self-management courses, can reduce GP visits by as much as 69%, hospital admissions by as much as 50% and the number of bed days by up to 80%.
8 Year of Care. (2011). Report of findings from the pilot programme. 9 EPP Internal Monitoring Results – Expert Patients Programme, 2005.
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This would achieve cost savings of 10-15%.10 In particular, an evaluation of EPP courses have demonstrated cost savings of £800 per patient on average 11.
Wandsworth has a strong history of providing self-management programmes since 2003, almost exclusively delivered through the Expert Patients Programmes (EPP) and its derivative Looking After Me (LAM) for carers and New Beginnings (NB) for those living with a mental health condition. The EPP is a peer-led self-care support programme for people living with any long term condition, their carer and families. The programme, delivered by volunteer tutors, runs over six weeks and offers support, advice, information and training.
Please also refer to the PACT resources webpage for further self-management information and resources at www.bhcic.co.uk
10 Department of Health (2007), Research evidence on the effectiveness of self -care support. 11 Bunt, L. and Harris, M (2009), The human factor, Nesta.
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10. SERVICE REQUIREMENT 10 (OBSOLETE):
THIS SERVICE REQUIREMENT IS NOW OBSOLETE.
THE NUMBERING OF SUBSEQUENT SERVICE REQUIREMENTS HAS BEEN MAINTAINED TO PROVIDE CONSISTENCY/FAMILIARITY FOR PRACTICES/PROVIDERS.
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11. SERVICE REQUIREMENT 11: HOLISTIC CANCER CARE REVIEWS
11.1 Summary
Service Requirement 11 is summarised in the table below:
11.2 Definitions
Patients should be offered a Holistic Cancer Care Review (HCCR) at the end of acute treatment, 9 - 12 months from initial diagnosis. Some patients may be discharged back into the community whilst some will be maintained in follow up in secondary care. Pat ients should be contacted initially by letter to state that they are due for their Holistic Cancer Care Review, allowing the patient to consider what they wish to discuss.
The appointment may be carried out over the phone, or the patient invited in to discuss face to face. This can be carried out by a GP or suitably trained Practice Nurse (training provided by Macmillan). Payment is made for carrying out an HCCR (not offering). The new and specific Holistic Cancer Care Review template should be completed. The patient should be requested to complete the specific HCCR patient experience/evaluation form. The purpose of a HCCR is to support self-management and ensure an individual’s holistic needs are addressed in the post-treatment phase of the pathway. It is recommended that the HCCR provides tailored information (for example prescription exemptions, possible late effects of the disease and treatment including physical and psycho-social needs) and signposting and onward referrals to relevant local services. The person may benefit from annual follow up in primary care as part of a holistic, multi-morbidity review - particularly as 47% of people with cancer have at least one other long term condition.
Please note:
The HCCR should be carried out 9-12 months from initial diagnosis; The HCCR is independent of any other care plan consultation/review undertaken as part
of PACT;
It is also separate and additional to any QOF Cancer Review undertaken with the patient.
0
Read Code
11
Patients with a
cancer
diagnosis:
Holistic
Cancer Care
Reviews
9OUZ
(Clinic C
monitoring
admin.NOS)
Carry out a Holistic Cancer Care
Review at the end of acute
treatment, 9 to 12 months
following diagnosis
8CL2
(Cancer diagnosis
discussed with patient)
GP/Practice
Nurse£20 20 mins 1
Srve
Req.
No.
Patient
GroupsPatient Register Intervention Required
Reporting
Amount Unit
No. of Paid
Inter-
ventions per
patient
p.a
Who?Core
Payment
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11.3 Rationale
There are two million people living with or beyond cancer England. This figure is estimated to rise to four million by 2030. When we talk about people living with and beyond cancer (LWBC), this is from the point of someone receiving a cancer diagnosis, through their active treatment phase and then either completing treatment or requiring ongoing treatment. Their cancer may be cured or they may be living with terminal cancer but not yet requiring palliative care. The number of people is increasing due to:
an aging population and higher rates of diagnosis in older people
better treatment, which means people are living for longer the fact that fewer people are dying of cancer
This changing picture in cancer survival presents new challenges for health professionals who have an increasingly important role to support individuals with cancer to manage the long term impacts of the disease or treatments. In addition, with the increased focus on personalising and stratifying follow-up, more elements of care and rehabilitation will be provided in the community.
Cancer treatment is often invasive and can have both short and longer term consequences, some of which may arise years after treatment was administered. The consequences of treatment include physical and psychological effects, such as chronic fatigue, sexual difficulties, mental health problems, pain, urinary and gastrointestinal dysfunction and lymphoedema. Failure to identify and manage these significant late effects can compromise survival, recovery and quality of life for the person with cancer and their carers.
The holistic CCR enables patients to actively manage their cancer care through treatment and recovery. It supports GP Practices to deliver the right service for the patient based on individual need.
This Service Requirement within PACT complements the new Primary Care Checklist – which promotes best practice in providing cancer care in primary care; which be encouraged to be used alongside the holistic needs assessment.
11.4 Good Practice / Resources
Resources in relation to this Service Requirement are available on the PACT resources website at http://bhcic.co.uk/library/cancer/
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HOLISTIC CANCER CARE REVIEW PATHWAY
Practice is aware that Patient’s main course of treatment has finished and/or Treatment Summary is received.
Patient is contacted by GP Practice and offered a Holistic Cancer Care Review with
GP or suitably trained Practice Nurse
£20 payment made per completed Holistic Cancer Care Review, subject to
verification via EMIS coding.
Holistic Cancer Care Review takes place
(Over the phone or the Patient is invited in to the Practice to discuss face to face).
Specific PACT template completed in EMIS
Template letter available
Specific resources available at bhcic.co.uk/library/cancer
PATIENT DECLINES = NO PAYMENT
Patient asked to complete HCCR evaluation/patient
experience form
9 - 12 MONTHS POST-
DIAGNOSIS
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12. SERVICE REQUIREMENT 12: DRUG MONITORING (DMARDS)
12.1 Summary
Service Requirement 12 is summarised in the table below:
12.2 Definitions
This Service Requirement is aimed at monitoring shared-care patients only and so this element of the specification should be read in conjunction with the latest shared -care drug monitoring arrangements for DMARDS.
The decision to start the drug/s to be monitored within primary care should be made by a Secondary Care Consultant or PwSI. The subsequent monitoring of the effects of the drug treatment, both in the desired effects and potential side-effects, is covered by this specification. The Practice is to arrange for blood monitoring via the phlebotomy and results service and then act on those results.
12.3 Rationale
The treatment of several diseases within the fields of medicine, particularly in rheumatology, is increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This is due to the potentially serious side-effects that these drugs can occasionally cause. It has been shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out in a well-organised way, close to the patient’s home.
The near patient testing service is designed to be one in which: (i) therapy should only be started for recognised indicat ions; (ii) maintenance of patients first stabilised in the secondary care setting are properly controlled; (iii) the service to the patient is convenient; (iv) the need for continuation of therapy is reviewed regularly (within secondary care); (v) the therapy is discontinued when appropriate; (vi) the use of resources by the National Health Service is efficient.
12.4 Standards and Pathway
Payment is per monitoring blood test (see below). A suggested DMARD rheumatology pathway is included within this Section 12 but please also ensure you seek monitoring advice from the prescribing secondary care specialist eg Dermatology.
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Please refer to the latest relevant shared-care guidelines and relevant NICE guidance. The following standards must be met:
Practices should maintain an up-to-date register of all shared care drug monitoring service patients, indicating patient name, date of birth and the indication and duratio n of treatment and last hospital appointment;
Have appropriate “call and recall” systems in place to ensure that systematic call and recall of patients on this register is taking place;
Ensure that all patients (and/or their carers and support staff when appropriate) are informed of how to access appropriate and relevant information;
Ensure that the patient has an individual management plan provided by their Secondary Care Provider prior to their transfer in to Primary Care., which gives the reason for treatment, the planned duration, the monitoring timetable and, if appropriate, the therapeutic range to be obtained;
Ensure that any health professionals involved in providing any aspect of care under this scheme have the necessary training and skills to do so;
Referral Policies: Where appropriate to refer patients promptly to other necessary services and to the relevant support agencies using locally agreed guidelines where these exist;
To maintain adequate records of the service provided, incorporating all known information relating to any significant events e.g. hospital admissions, death of which the practice has been notified;
Repeat prescriptions should be generated by a clinician; The Provider is obliged to report related untoward events;
All practices involved in the scheme should perform an annual review.
Practices must establish who will be responsible for audit arrangements and how and where the information will be stored. Practices are required to adhere to prescribed audit and safety indicators.
NB: It is possible to manage this cohort of patients through use of the Cohort Management tab in the PACT Template. Patients can be added to the register and removed using the correct code (eg 9Kn7 for DMARDS monitored in secondary care). Practices shou ld seek advice from the Lead Provider if required.
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START METHOTREXATE,
LEFLUNOMIDE,
SULPHSALAZINE,
MYCOPHENOLATE
AZATHIOPRINE
FBC, U&E, LFT
Every 2 weeks for first 6 weeks
then continue every 6 – 8 weeks
Neutrophils >2.5
Platelets > 150
ALT < 50
Neutrophils 1.6-2.5
Platelets 100-150
ALT 50-100
TEXT
Neutrophils 1.0-1.5
Platelets 50-99
ALT 101-150
Neutrophils < 1.0
Platelets < 50
ALT >150
Hb
Involve Secondary
care if falling or
<10g/dl
Result remains abnormal in this range:
Neutrophils 1.6-2.5 Platelets 100-150
ALT 50-100
But stable after 2x cycles of 2 weekly monitoring,
then revert to 6-8 weekly with no dose change
No dose change
Monitor abnormal value
every 2 weeks
Reduce dose
Monitor abnormal value
every 2 weeks
INVOLVE SECONDARY
CARE
Stop Drug
INVOLVE SECONDARY
CARE
Note some patients have a constitutional low Neutrophil count,
often < 1.5. If baseline, pre treatment, values are in this range
then involve secondary care if drops below 1.0, as drug may not
need to be stopped
Suggested Rheumatology pathway/algorithm for DMARD
monitoring in primary care
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13. SERVICE REQUIREMENT 13: GP PEER REVIEW
13.1 Summary
Service Requirement 13 is summarised in the table below:
13.2 Rationale
The objective of the GP Peer Review Meeting is to improve the quality of clinical care provided in primary care through peer feedback and sharing of ideas.
The Lead Provider, in discussion and agreement with the Commissioner, may provide a more flexible approach to the GP Peer Review process during 2017/18. This may include the offer of a range of shorter meetings across the year to facilitate the attendance of GPs. Practices will be required to ensure a GP from the Practice attends the requisite amount of Review time and disseminates their learning to other GPs/HCPs in the Practice.
The specific topics to be covered in the GP Peer Review Meetings will be flexible but could include:
General views on the PACT Contract Specification and suggestions for improvement; Care planning process;
Effectiveness and suggested ways to improve the care planning interventions;
Effectiveness and suggested ways to improve the Carer Consultation;
Effectiveness and suggested ways to improve other elements of the specification; Patient Experience feedback.
A PACT User Group will be developed for Practice Administration Team members involved with PACT. There will be no payment for attendance at these User Group meetings, although some allocation of funding is included within each Practices’ Administration payment.
0
Read Code
13
GP Peer
Review
Meeting
n/a
Ensure at least 1 GP within the
Practice attends GP Peer Review
Meetings as required by the Lead
Provider and disseminates their
learning to other Health Care
Professionals (HCPs) in the
Practice. One claim per Practice
regardless of number of GPs
attending.
GP (non-
clinical time)£70
Up to 6
hours
Srve
Req.
No.
Patient
GroupsPatient Register Intervention Required
Reporting
Amount Unit
No. of Paid
Inter-
ventions per
patient
p.a
Who?Core
Payment
None from Practice.
Attendance at meetings
will be recorded by the
Lead Provider
per hour
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14. SERVICE REQUIREMENT 14: CLINICIAN TRAINING
14.1 Summary
Service Requirement 14 is summarised in the table below.
14.2 Definition
For the purposes of this specification, relevant education and training refers to accredited events, courses and other formal methods of education that are relevant to caring for patients with long-term conditions as described within this Specification. The Lead Provider, on behalf of the Commissioner, is responsible for validating and agreeing payment of a Practice’s application for funding under the terms of this Requirement and reserves the right to ask a Practice for proof of relevance to validate (or otherwise) the claim.
14.3 Rationale
The Provider is responsible for ensuring that all staff involved in any aspect of care under this specification have the necessary training, education and skills to do so. Any gaps in competence must be addressed through training to ensure that all staff may undertake their duties safely. The Provider will need to ensure that all staff providing the service are appropriately trained and certified to carry out the service requirements of this specification.
Further details are also available on the PACT resources webpage www.bhcic.co.uk
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HEALTHCARE PROFESSIONAL TRAINING
The following table sets out the number of training hours available to each Practice under this specification. This does not in any way change the legal training responsibility of staff working within Practices.
Every Practice in Wandsw orth receives the same number of Basic training hours.
Practices receive Extra training hours in proportion to their Registered Practice List size.
WandsworthDistribution-4kbyRUB(Patients18+,HighandVeryHighRUB)Code Practice Name
Code Practice Name BASIC EXTRA TOTAL BASIC EXTRA TOTAL
H85001 Wandsworth Medical Centre 4 19 23 4 14 18H85002 Falcon Road Medical Centre 4 11 15 4 8 12H85003 Queenstown Road Surgery 4 10 14 4 7 11H85005 Trinity Medical Centre 4 14 18 4 10 14H85006 Mayfield Surgery 4 7 11 4 5 9H85007 Southfields Group Practice 4 15 19 4 11 15H85008 The Roehampton Lane Surgery 4 7 11 4 5 9H85009 Bedford Hill Family Practice 4 14 18 4 11 15H85011 The Greyswood Practice 4 10 14 4 8 12H85012 Putneymead Medical Centre 4 30 34 4 22 26H85041 Earlsfield Practice 4 14 18 4 10 14H85045 Bridge Lane Group Practice 4 17 21 4 13 17H85047 Chatfield Medical Centre 4 13 17 4 9 13H85048 Brocklebank Group Practice 4 21 25 4 15 19H85049 Battersea Rise Group Practice 4 9 13 4 7 11H85052 Streatham Park Surgery 4 6 10 4 4 8H85056 Balham Hill Medical Practice 4 2 6 4 2 6H85057 Elborough Street Practice 4 7 11 4 5 9H85061 Heathbridge Practice 4 19 23 4 14 18H85065 The Alton Practice 4 5 9 4 4 8H85066 Balham Park Surgery 4 20 24 4 15 19H85067 Danebury Avenue Surgery 4 4 8 4 3 7H85069 Lavender Hill Group Practice 4 15 19 4 11 15H85075 Haider Practice 4 4 8 4 3 7H85077 The Bolingbroke Medical Centre (formerly Heritage) 4 7 11 4 5 9H85082 Triangle Surgery 4 6 10 4 4 8H85087 Open Door Surgery 4 11 15 4 8 12H85088 Clapham Junction Medical Practice 4 4 8 4 3 7H85100 St Pauls Cottage Surgery 4 8 12 4 6 10H85111 Battersea Fields Practice 4 12 16 4 9 13H85114 Thurleigh Road Practice 4 15 19 4 11 15H85637 Balham Health Centre 4 2 6 4 2 6H85643 Inner Park Road Surgery 4 3 7 4 2 6H85659 Dr Begg/ St John's Practice 4 5 9 4 4 8H85664 Tooting Bec Surgery 4 3 7 4 2 6H85680 Tooting South Medical Centre 4 12 16 4 9 13H85682 Tudor Lodge Health Centre 4 8 12 4 6 10H85691 Nightingale Practice 4 0 4 4 0 4H85695 Furzedown Primary Care Centre 4 4 8 4 3 7Y01132 Chartfield Surgery 4 15 19 4 11 15Y02423 Grafton Medical Partners 4 43 47 4 31 35Y02946 The Junction Health Centre 4 9 13 4 6 10
GP TRAINING HOURS NON-GP CLINICIAN TRAINING HOURS
