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‘Super-enhanced service’ puts the local back into primary care commissioning
9 March 2016
Bolton’s £3.4m “super-enhanced service”, which aims to divert care from hospitals to GP practices and to help manage demand, is facing its first major test.
Recognising the need to reduce A&E attendances and improve the effectiveness of primary care, NHS Bolton Clinical Commissioning Group (CCG) developed the Bolton Quality Contract. The contract is also intended to address inequalities in healthcare and improve outcomes.
At its heart is a set of 19 standards, each with key performance indicators (KPIs), that practices have signed up to and receive graduated payments for meeting. The standards, which are designed to balance local focus on population health, value for money and best care, include:
- Minimising referrals for certain conditions or treatments
- End of life care
- Best care for a series of long term conditions
- Transfer of care
- Patient experience.
Kathryn Oddi, the CCG’s primary care performance and support lead, explains: “We wanted to bring every practice to a certain level of income and we developed specifications that would level out inequalities of provision. We spent time working with practices to agree what is best care and told them we would invest additional money so they could deliver that.
“Practice funding has developed in such a sporadic way over the last 15 years with PMS, GMS and APMS. There was such diversity in funding and in provision.”
The quality contract boosts practice income to around £95 per patient – a significant increase for most. The average per capita income was around £73.50 plus £5 from local enhanced service payments.
Oddi says: “This is like one big enhanced service and we worked with NHS England because we needed to know where practices were starting from – what they were paying and what NHS England was getting for that. We needed to swap the KPIs in their contract to reflect ours.”
With practices suddenly seeing an income spike of up to £200,000, the CCG understandably asked each to produce an action plan showing their plans for additional staff and how they would meet the new KPIs.
“We expected them to spend 50-60% (of the additional funding) on new staff but we recognise they are up against it and we did not expect them to commit all the new funding at once,” she says.
The access standard not only requires practices to provide ten bookable sessions each week but specifies minimum opening hours (8am-6.30pm Monday to Friday) and requires at least 75 contacts per 1,000 registered patients each week. The contacts can be by a GP or nurse practitioner and either face-to-face or by telephone.
The set hours can help educate the public to seek help from their GP rather than A&E, Oddi says. During the winter the CCG is running a ‘Think your GP, not A&E’ campaign. Practices are also expected to have capacity to see patients deflected by A&E staff.
Oddi says: “Having the same opening hours and no lunchtime closures helps to reinforce the message to people that they should be looking to their GP first rather than A&E.”
She and her colleagues invested an “unbelievable” amount of time in working with practices and the local medical committee. They also discussed issues such as financial incentives for GPs with the General Medical Council (GMC).
Oddi says: “We felt very strongly that we had to take practices with us. We worked hard with the local medical committee and all the practices with regular engagement events. We showed them the suggested standards and KPIs and asked if we had missed anything or anything was too onerous.
“The GMC felt very strongly that no doctor should feel compromised on demand management and prescribing but the evidence shows there’s a 30% waste in prescribing and we are only seeking a 1% reduction in referrals. The GMC looked at the specifications and of course they were cautious but they said that as long as were emphasising waste and talked about inappropriate referrals and we educated and supported practices then that would be fine.”
She believes that the CCG’s move is an important step towards returning primary care commissioning to its local roots.
“As a CCG we are coming full circle because you need to understand the diversity of your primary care providers and know them and the circumstances they are working in. We have got all 50 practices signed up and that is a feather in our cap.
“The only way to tackle the NHS’s cash problems is to do more in primary care.”
Oddi says that data for the first six months of the year suggests “good progress has been made” but firm conclusions won’t be available for another few months. The prescribing standard, for example, sets practices a target of reducing spending by £59,000. Halfway through the year practices were averaging savings of £28,000 – just short of the target.
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