Clinical Lead / Dr Lance Saker
Commissioner / Camden CCG
Reporting Mechanism and Frequency / Remotely/variable frequency
Payment Frequency / Quarterly in arrears
Payment Contact /
This Version / 10 Long Term Conditions LCS Spec 2014-2015 v1.2
Date / 21 March 2014
Original Version / long-term-conditions-lcs-specification-2013_14
Service Specification for Long Term Conditions
Locally Commissioned Service 2014/15
- Service aims
- The Long Term Conditions Locally Commissioned Service (LTC LCS) aims to improve diagnosis and management of five long term conditions in people registered at general practices in Camden Clinical Commissioning Group (CCG): Diabetes, Hypertension, Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF).
- Long term conditions (LTCs) are responsible for over a third of all deaths in Camden CCG each year. Alongside cancer, differences in rates of early death from LTCs are the major cause of inequalities in life expectancy in the CCG. Management of LTCs accounts for a very high proportion of health service activity and costs locally: in 2010 it was estimated that the care of people with LTCs was responsible for 70 per cent of the total health and social care spend in England, more than 50 per cent of all GP appointments, 65 per cent of all outpatient appointments and over 70 per cent of all inpatient bed days.
- Evidence suggests that early recognition and high quality clinical and lifestyle management of people with LTCs are the most effective interventions for preventing or delaying onset of the serious complications that are the major causes of early death and disability and inequalities in death and disability from these conditions. As the majority of LTC management takes place in general practice, this setting offers enormous opportunities for improving outcomes including patient experience for people with LTCs. Planned care and integrated service management in primary care can also reduce unscheduled and often costly health and social care episodes in people with LTCs.
- The LTC LCS aims to improve the identification and management of patients with LTCs by:
- Incentivising general practices to commit sufficient resource to undertake additional work required to case-find and to deliver more in depth management of patients with LTCs.
- Promoting best practice reviews of LTCs through provision of locally developed EMIS Web templates that emphasise critical aspects of clinical review for particular conditions.
- Emphasising locality-wide incentives to encourage inter-practice working and sharing of best practice, and to reduce variations in LTC identification and management.
- Linking participation in the LTC LCS with participation in a practice LTC education programme that aims to increase knowledge and skills for identifying and managing LTCs in primary care.
- Directly incentivising improvements in outcomes.
- By integrating the incentives and processes for the delivery of GP practiced-based services for these five LTCs into a single LCS with most data gathered through automated remote extraction of data recorded by practices in specified templates, the LCS aims to streamline reporting processes for participating practices and allow them to focus on maximising outcomes for patients.
- The LTC LCS is meant to operate in conjunction with the Camden NHS Health Checks LCS. Whenever possible, practices should make use of the opportunities offered by the NHS Health Checks LCS when recalling patients for each of the elements of the Long Term Conditions LCS. Please see Appendix 1 for further detail.
- Duration
- The Long-Term Conditions LCS is available for eligible providers from 1st October 2013 until at least 31st March 2015. Continuation of the LES will be subject to any reviews NHS England requires of CCG commissioned locally commissioned services but funding for has been secured to 1st April 2017. The LTC LCS will be reviewed separately by the CCG after 6 months to ensure that CCG strategic objectives are being met.
- Camden CCG reserves the right to amend this LCS from time to time to reflect changes to legislation, national guidance and priorities.
- Eligibility criteria
- Camden general practices can apply to deliver this LCS provided they are able to demonstrate:
- Full compliance with all core contract (GMS, PMS or APMS) and additional services requirements.
- A commitment to ensuring that all patients at the practice will be offered all components specified within the LCS and that the practice will provide validated activity against each component. Practices may demonstrate this by indicating how they will work with another practice or practices in Camden to deliver components of the LCS that they are unable to provide themselves.
- They have a named clinical lead (GP) for the LTC LCS who has attended the LTC LCS Launch Event and is responsible for disseminating LTC LCS related information to relevant practice staff. Practices that have not attended the Launch Event and wish to sign up later must have viewed the associated webinars and satisfied the relevant locality clinical leads they have gained sufficient understanding of all LCS components at a practice visit.
- Have a named clinical (GP or nurse) lead for each domain within this LCS. An individual clinician can be a lead for multiple domains.
- A commitment to routinely using all specified EMIS Web templates, searches and other resources related to the LTC LCS provided by Camden CCG’s GPIT Team.
- Compliance with all additional requirements outlined in section 7, “Quality and Safety”, below.
- To participate fully in the Camden LTC education and training programme, which will include:
- Individual practice visits by LTC GP clinical leads and relevant consultants Joint practice peer review meetings to discuss LTC case management
- Attendance at specified LTC education events (likely to be 4 sessions in first year).
- Service to be provided
Diabetes
Component 1- Targeted case finding of people with undiagnosed diabetes
Aim
4.1.To identify patients with diabetes or pre-diabetes not already on practice registers by:
A.Reviewing practice records to identify people with diabetes or pre-diabetes based on previous test results but not coded, and people with IGT, IFG and pre-diabetes not recently tested.
B.Undertaking HbA1c testing on people at high risk of diabetes as identified through theQDiabetes Score (QDS) risk assessment tool.
4.2.Practices will only qualify for payments for B if they complete A.
Process
A. Review of practice records to identify people who may have diabetes or pre-diabetes
4.3.Practices should:
4.3.1.Run and view the following searches created by Camden CCG GP IT Team within EMIS Web system as explained below.
- From EMIS Home → Reporting → Population Reporting → Camden PCT InformationTeam → 2013-2014 LTC Target Searches → Likely Diabetes
i)Patients likely to be Diabetic Based on last Blood Sugar Level/HbA1c
ii)Patients who might be Diabetic Based on last Blood Sugar Level/HbA1c
iii)Patients who might be Diabetic Based on last HbA1c
iv)Patients who might be Pre-Diabetes Based on last HbA1c
v)Patients with Pre-diabetes, IGT or IFG and no glucose / HbA1c in past 12m vi)
vi)Patients with Diabetes but not Coded as Type 1 or 2
4.3.2.These searches will identify those patients:
i)With recent HbA1c and glucose results that meet or may meet diagnostic criteria for diabetes or pre-diabetes not on practice Diabetes, IFG, IGT or pre-diabetes registers.
ii)On IFG, IGT or pre-diabetes registers and not had HbA1c check in the past 12 months.
4.3.3.Review the relevant records and where appropriate:
i)For i), ii), iii), and iv) code patients as having diabetes or pre-diabetes or arrange repeat testing (see WHO diagnostic criteria)
i)For v), arrange an Hba1c check
ii)For vi), code diabetes diagnosis using Read code C10E or C10F
4.3.4.Using the designated spreadsheet report (LTC LES Diabetes Records Review) submit a report on this activity which includes:
a)The outcome for each patient in groups i), ii), iii), and iv) (i.e., diagnosed diabetes, pre-diabetes, or no new diagnosis as well their latest Hba1c result).
b)Numbers of new diabetes and pre-diabetes diagnoses.
c)Key learning points and observations on the records review.
B. HbA1c testing based on QDiabetes Score (QDS)
4.4.Practices should:
4.4.1.Record the basic demographic, clinical and lifestyle data on which the QDS is based.[1] Failure to record certain criteria e.g. family history will lead to an underestimation of QDS.
4.4.2.Run the QDS tool quarterly to identify all patients aged 25-74 years old with QDS ≥ 20 and QDS10-19.9, who are not already on the diabetes, IFG, IGT or Pre-diabetes registers.
4.4.3.For people ≥ 75 years, calculated QDS using the recommended Web QDS tool (as QDS is not yet available on EMIS Web for people ≥75).
4.4.4.Confirm whether patients have had an HbA1c test within the previous 12 months. For tests done prior to 1st October 2013, a fasting glucose, Glucose Tolerance Test (GTT) or HbA1c result 12 months prior to a Read coded QDS will be counted.
4.4.5.Arrange an HbA1c test to look for diabetes for those who have not been tested.
4.4.6.For eligible patients consider offering this test as part of a full NHS Health Check.
4.4.7.Appropriately code all people with an HbA1c result that meets diagnostic criteria for diabetes or pre-diabetes.
4.4.8.Recheck HbA1c every year in people who meet criteria for pre-diabetes and every three yearsfor those with HbA1c < 42.
Payment
Payment per activity
A. Review of practice records to identify people who may have diabetes or pre-diabetes
4.5.Practices will be paid 10 pence per practice population for undertaking the records review as per A. and submitting a report in the designated form.
B. HbA1c testing based on QDiabetes Score (QDS)
4.6.Practices will be paid for a Read coded HbA1c result performed within one year of the QD Score entry in the patient record on all patients who are not on the practice Diabetes, Pre-Diabetes, Impaired Glucose Tolerance (IGT) or Impaired Fasting Glycaemia (IFG) registers on 1st October
4.7.2013 depending on QDS risk assessment score as follows:
- QDS ≥ 20£20 per test
- QDS 10-19.9£7.50 per test
- Practices will only receive one payment every three years for any individual patient not on thepractice’s Diabetes, or Pre-diabetes, IGT or IFG registers with a QDS>10.
- In recognition of practices’ efforts to undertake QDS-based diabetes case finding since the QDS tool became available on transition of Camden practice systems to EMIS web circa end 2012, a patient with a QDS ≥ 20 recorded between 1st January 2013 and 1st October 2013 with a valid glucose, GTT or HbA1c result in the 12 months before or after the QDS will also attract a payment of £25. From 1st October 2013, practices will be expected to have used HbA1c to test for new diagnoses of diabetes except in specific circumstances (see Appendix 1).
- Practices will be paid an additional £25 for delivering an NHS Health Check to eligible patients, as part of the NHS Health Checks LCS.
Practice target
4.11.There is no practice target. This is because absolute numbers are likely to be small and therefore subject to chance variation. Increased diagnoses are already incentivised through the greater valueof QOF points to practices with larger numbers of people on their diabetes registers. However,numbers of new diagnoses of diabetes and pre-diabetes at the practice will be monitored.
Locality target
4.12.Localities will be paid 10p, 20p and 40p per combined practice population if they achieve improvements in prevalence of diabetes set at three thresholds of improvement, to be determined after establishment of accurate baseline prevalence during the first 3 months of the LCS.
Monitoring of achievement
4.13.Data will be extracted electronically from practice record to identify numbers of patients meeting the criteria above. Numbers will be included on practice scorecards.
Component 2 – Audit of patients with HbA1c>75
Aim
4.14.To review the current clinical metrics, treatment, service use and lifestyle and social circumstances of Camden patients with diabetes (type 1 and type 2) who have poorly controlled blood glucose to:
A. Analyse the main reason/s for the raised HbA1c level in order to develop an appropriate plan for improving diabetes control in each patient.
B. Obtain data to identify gaps or inadequacies in current services for patients with poorlycontrolled diabetes to improve service capacity and configuration in Camden.
Process
4.15.Practices should:
4.15.1.Identify all patients on their diabetes register with HbA1c>75. If the number of patients at the practice who have HbA1c>75 is less than 20 per cent of all patients on the practice diabetes register, practices should also include patients with thenext highest levels of HbA1c lower than 75 such that 20 per cent of the total practice population of patients aged 17 years and over with diabetes are included in the audit.
4.15.2.Follow the instructions for using the LTC LES DM Audit Template and Spreadsheet.
4.15.3.Complete a clinical case review for each eligible patient using these tools.
4.15.4.Remove identifiable data and submit the completed LTC LES DM Spreadsheet to the CCG.
4.15.5.Produce a short practice report and action plan based on the case reviews, to include observations, findings and recommendations, and submit this to the locality diabetes lead.
4.15.6.Review the population of patients with HbA1c>75 every quarter to identify additional patients who should be audited in the same manner. Add these audits to the existing LTC LES DM Spreadsheet and resubmit quarterly if there are new cases.
Payment
Payment per activity
4.16.Practices will be paid £40 per clinical case review completed upon submission of the spreadsheet summary and short report on findings, observations and planned actions. If further patients withHbA1c>75 are identified through the year, practices will need to submit an updated spreadsheetwhich includes the details of the new patients’ case review findings.
Practice target
4.17.There is no practice target.
Locality target
4.18.If >80 per cent of all patients with HbA1c>75 in the relevant locality have a clinical case review completed practices will be paid 10 pence per patient on relevant practice lists in the locality.
Monitoring of achievement
4.19.This will be via spreadsheet submissions of data on completed audits.
Component 3 – Diabetes review and year of care plan approach to people with HbA1c>75
Aim
4.20.Delivery of diabetes review and implementation of care planning using a Year of Care (YOC)approach for patients with HbA1c>75 in order to:
4.20.1.Reduce the numbers of people with very poorly controlled glucose in Camden.
4.20.2.Improve secondary prevention management of diabetes in high risk patients.
4.20.3.Embed a care planning / YOC approach to managing people with diabetes in Camden, starting with those who have poorly controlled glucose.
Process
4.21.Practices should invite patients with HbA1c>75 for review according to the following protocol:
4.21.1.Arrange blood and urine testing (to include HbA1c, lipids, renal function and ACR) in advance of the diabetes review.
4.21.2.Write to patients in advance of the review with copies of recent blood tests and otherresults (e.g. BMI) that are relevant to care planning.
4.21.3.Ask patients in advance to set the agenda for their diabetes review
4.21.4.Conduct at least one full face to face review annually using the Camden LTC LCSdiabetes review EMIS web template
4.21.5.Promote delivery of the Diabetes UK Nine Care Processes to all patients (see below)
4.21.6.Develop a care plan in conjunction with the patients that includes:
i)Specific goals for improving glucose, blood pressure, lipid and lifestyle management with timelines for achievement.
ii)Agreed methods for follow-up, these may be telephone, letter or face to face follow-up (ideally all may be used as appropriate).
4.21.7.Practices should follow up with further consultations face to face or telephone to monitor progress to achieving care plan goals, to include (but not necessarily be limited to) a reduction in HbA1c level.
4.22.If the number of patients at the practice who have HbA1c>75 is less than 20 per cent of all patients on the practice diabetes register, practices should include patients with the next highest levels of HbA1c lower than 75 such that 20 per cent of the total practice population of patients with diabetes aged 17 years and over are invited for review.
4.23.Table 3: The nine care processes defined by Diabetes UK
- Blood glucose level measurement
- Blood pressure measurement
- Cholesterol level measurement
- Retinopathy screening
- Foot and leg check
- Kidney function testing (urine)
- Kidney function testing (blood)
- Weight check
- Smoking status check
Payment
Payment per activity
4.24.Practices will be paid £100 for every diabetic patient with HbA1c>75 who receives a completed review using the designated EMIS Web template, an agreed care plan that includes specific goals, and monitoring and support to achieve these goals over the next 6–12 months. The date of the case review will be counted as the day on which the care plan is entered. Although payment will be triggered by electronic completion of the template, it is expected that practices will conduct a full year of care approach in following up through the year progress to achieving the care plan goals. This will be reviewed at practice visits.
4.25.Claims may only be made if the template records all of the nine care processes specified by Diabetes UK excepting diabetic retinopathy screening (DRS). Care processes will only be counted as completed if recorded on the designated EMIS Web template (relevant fields are marked “LES”). The concession for diabetic retinopathy screening recognises that since attendance for DRS requires attendance at an external clinic and there will be instances where practices complete a full review but are unable to persuade a patient to attend DRS at the approved local NHS screening service. However, practices will be rewarded through the practice target payment described below according to how successful they are in persuading patients to attend DRS at the local NHS screening service.
4.26.For practices with <20 per cent patients with diabetes with HbA1c>75 payments will be made according to the same criteria above for reviews conducted on patients with the 20 per cent highest HbA1c levels.