Practice Based Commissioning Incentive Scheme 2010/11 Specification
Introduction
The purpose of this document is to set out the specification for the Practice Based Commissioning (PBC) Incentive Scheme covering 2010/11[1]. The PBC incentive scheme for 2010/11 is aligned with the Quality, Innovation, Productivity and Prevention (QIPP) agenda by improving the quality of referrals to secondary care, promoting compliance with best practice for unplanned care in general practice and aligning prescribing with the Better Care Better Value indicators.
Objectives
This Incentive Scheme has four principal objectives:
1. The PCT recognises GPs are the key gatekeepers to NHS services. A large share of the PCT’s total allocation is spent or committed by primary care clinicians through direct treatment, prescribing or onward referral. The PCT wants practices to be more directly involved in controlling and directing commissioning resources as a means both of improving services and effectively managing budgets;
2. To facilitate greater managerial and clinical involvement by practices in the full range of commissioning processes (referral management, pathway design and refinement, patient involvement etc).
3. To focus practices on management of non-elective admissions to hospital, quality of all referrals to secondary care and offering choice.
4. To facilitate effective prescribing.
What does the Incentive Scheme cover?
The Incentive Scheme will cover the following areas:
1. Referral Quality for all referrals to secondary care (Appendix D – Referral Guidelines)
2. Non elective admissions, A&E frequent attendees and use of Out of Hours (OOH) Appendix E – Audit tool
3. Prescribing
1. Taking Part
Practices wishing to take part in the Incentive Scheme will need to sign and send back the signature sheet (see Appendix A). Signing up to the Incentive Scheme involves:
· Identifying a PBC Lead within the practice who will attend 75% of PBC meetings to demonstrate a commitment to PBC and service re-design by putting forward Business Cases or ‘invest to save’ schemes which align with the locality business plans.
· Meeting bi-monthly with the Locality Development Manager (LDM) & medicines management colleagues to review and monitor activity against the agreed objectives within the PBC incentive scheme.
Payment for this element of the scheme is 30p per patient
PBC Indicative Budgets & Payment by Results (PbR)
In order to gain maximum effect from the Incentive Scheme and from PBC, practices need to know what resources are being used by their patients e.g. hospital activity and prescribing as part of the overall budget of the practice. These are shown as part of the practices PBC budget (Appendix C) and this incentive scheme encourages practices to look at how they currently manage the elements of their budget which they have control over and investigate opportunities for changing how the budget is currently allocated and used.
All charges made to a practice by the hospital for their activity is paid through a tariff called Payment by Results (PbR). To cost activity, a national tool, HRG4 is being used.
2. Referral Quality
This type of care you commission is exactly as it says, planned and usually starts with a referral from the practice into the hospital. In PbR, this is called a first outpatient referral. Each first outpatient referral has a financial value attached to it which is listed in one of two ways:
· Consultant led referral
· Multi professional referral
A consultant led referral costs slightly less than a multi professional referral but all first outpatient referrals will cost somewhere in the region of £121 - £437. If the patient returns to the hospital for a follow up appointment, this costs less than a first outpatient referral and is often in the region of about £63 - £348. Work undertaken during 09/10 has revealed that there is wide variation in the quality of the referrals to secondary care by GP’s. Compliance with the referral template (appendix D) is therefore a central component of the incentive scheme this year to reduce this variation. Practices can adapt the template to suit their clinical systems providing the fields within the template) are used as a minimum dataset within any referrals to secondary care.
Payment for this element of the PBC incentive scheme is as follows:
Participation of a quarterly audit of 50 referral letters in a high volume specialty e.g. plastics, dermatology, orthopaedics. The referral letters will be audited against the fields outlined in the referral template (appendix D). The audit will be led by the locality development managers with support from the clinical governance team and the practice. Any actions arising from the results will be taken forward by the practice.
Payment = 40p per patient on completion of 4 audits and implementation of actions arising from the audit, agreed by the practice and locality development manager/clinical effectiveness facilitator.
3. Non elective admissions, A&E frequent attendees and use of OOH
Activity is unplanned because it is, in general, not activity that has necessarily been requested but it has happened because of an accident, trauma, inability to access other services or just an emergency. The locality teams will be able to provide each practice with information illustrating variation in admissions compared with other practices locally, nationally and with other practices of similar populations. This will enable practices to agree realistic objectives for their own practice population as part of the incentive scheme.
Costs incurred in this area are high (09/10 tariff). Some examples of costs are:
· A&E [walk in centre activity is excluded]
o Minor no investigation £59
o Standard with low investigation £87
o High including high cost investigation £117
· COPD length of stay one day or less £475
· Any emergency admission for less than one day circa £500+
Some of the challenges we face in unplanned care may be summarised as follows:
· How do we stop minors attending A&E unnecessarily? What additional services could we put in the community as an alternative?
· Can we avoid patients being admitted for a day or less [often admitted because waiting for results and likely to breach the four hour wait or just for watchful waiting or diagnostics]?
· Do practices know and recognise those patients in the practice who are high cost because they continually present at A&E [often elderly or patients with long term conditions]?
· Do practices understand the variation between each other in managing patients unplanned care and what lessons can be learned from others?
· Are practice based commissioners using the skills of other health professionals to best effect at practice level and particularly to avoid unnecessary hospital admissions?
Practices will be required, with support from the PCT, to carry out an audit to check compliance with the relevant national guidance[2] and agree delivery plan with the locality team for actions resulting from the audit. The audit tool is illustrated in appendix E.
Payment = 40p per patient on implementation of agreed actions resulting from audit.
The estimated total cost of these 3 elements described is £315.000 city wide.
Prescribing Incentives 2010/2011
The following table outlines the areas within the prescribing element of the incentive scheme. The target areas for prescribing are:
1,2,3 – All current Better Care, Better Value indicators – measured by SHA and DoH
4 – In line with NICE guidance CG23
5 – To reduce unnecessary prescribing of sip feeds/enteral products – nourishment, malnutrition state and BMI needs to be assessed
6 - To reduce unnecessary testing of blood glucose levels, mainstay of control is HbA1C, monitored by patients care provider
7 – In line with NICE guidance, for short term, non repeatable courses
8 – To reduce unnecessary prescribing of antibacterial agents, potentially reduce incidence of C.diff and other HCAI’s
Target / Incentive scheme requirement / Incentive Payment1. Low cost statin prescribing / At least 80% of all statin prescribing to be for Simvastatin or Pravastatin.
Higher reward for achieving 85% / For achieving 80% = 0.75 point
For achieving 85%= 1.5 points
2. Angiotensin (ACE and ARB prescribing) / At least 80% of total Angiotensin prescribing should be for ACE inhibitors
Higher reward for achieving 85% / For achieving 80% = 0.5 point
For achieving 85%= 1
point
3. Proton Pump Inhibitors / At least 89% of all PPI’s to be prescribed as omeprazole or lansoprazole capsules
Higher reward for achieving 92% / For achieving 89% = 0.75 point
For achieving 92%= 1.5 points
4. Antidepressant prescribing / At least 70% of all prescriptions for antidepressants to be written as fluoxetine, citalopram or sertraline
Higher reward for achieving 75% / For achieving 70% = 0.5 point
For achieving 75%= 1
point
5. Sip feed/enteral nutrition prescribing / Total practice spend on sip feeds and other enteral products (excluding PEG) to be reduced by 20%
Higher reward for achieving 30% / For achieving 20% = 0.5 point
For achieving 30%= 1
point
6. Blood glucose testing apparatus (SMBG) / Total practice spend on SMBG should be reduced by 20%
Higher reward for achieving 30% / For achieving 20% = 0.75 point
For achieving 30%= 1.5 points
7. ‘Z’ drugs
(zopiclone, zaleplon and zolpidem) / Practices should aim to reduce their prescribing frequency of Z drugs to below the current PCT average (ADQs per 1000 ASTRO-PU). / For achieving compliance = 0.5 point
8. Antibacterial prescribing / Practices should prescribe less than the national average items per 1000 sub-STAR-PU / For achieving compliance = 1 point
Total maximum points available per practice = 9
Practices will be rewarded based on cost-based ASTRO-PU’s[3]
(Total number of points / 9) x number ASTRO PU’s x 15p
Estimated cost of prescribing element of the PBC incentive scheme citywide is £230k.
Calculation of PBC Indicative Budgets
All practices will hold an indicative budget although the PCT remains ultimately accountable for this. These budgets may be pooled with other practices on a consortia basis, locality or individual basis at the discretion of the participating practices
This year your PBC budget has been calculated in accordance with DH guidance using a methodology which incorporates both historic activity and a move to fair shares. Fair shares reflect the move towards ensuring that practices receive a fair share of the total budget so that their apportioned budget is more accurately reflective of their practice population. This is important because:
· It is a more accurate assessment of your business budget and so it helps you to consider how your practice may need to be developed over the next three to four years
· It puts the responsibility for spending the allocated funding back into the hands of the decision makers such as the GPs. Prior to PBC, activity was identified and auctioned with little or no knowledge of cost. Now through PBC a judgement can be made about the most appropriate option for your patient with a related knowledge of cost to help you gain best value for you and for your patient in terms of outcomes
New Toolkit Highlights
· Toolkit is largely the same with changes in assumptions as follows:
· Person Based Resource allocation to allow calculation of budget by individual and specific categories and trends in population to be reflected, e.g. students in generally deprived area.
· Acute – HES / Nuffield approach looking at individuals and age / gender / diagnosis. This is based on 2007/8 HES data at individual level and predicted using ICD-10 diagnoses combined with age, gender and geographic area information and mapped to the practice patients were registered with at April 2008.
· Mental Health based on Plymouth University methodology to model individual needs based on individual person types rather than historic utilisation.
· No minimum pace of change subject to local agreement. If fair share and historic activity differ by more than 10%, a minimum movement of 1% will occur.
· Subject to local agreement can operate Pace of Change relative to previous year’s budget rather than historic expenditure.
· Pace of Change can be operated at consortia level.
PBC Savings (FURs)
Practices will have access to up to 70% of any agreed savings for investment in patient services through the submission of business cases. They must be utilised within the following financial year after they are made, although there is provision to carry forward 30% of the savings into one subsequent financial year.
Any freed up resources must be used for reinvestment in patient services and in line with the national PBC guidance. They should also align to the PCT World Class Commissioning Strategy, reflect the needs of their practice population and aspirations/needs of local people. Proposals for longer term invest to save schemes will be considered on an individual basis.
Business Cases
Formal business case submissions, as outlined in the PCT business case template, are required in order to access any savings made through the Incentive Scheme. A sub group of the Locality Board will receive the Business Cases and has the authority to approve those under £50K. For those over this amount, they will be submitted to the PCT Commissioning Board. These approval processes are in accordance with PCT standing financial instructions.
Summary of Maximum Payment within 2010/2011 incentive scheme
Audits of referral quality and implementation of actions / 40p per patient
Audit of practice against national standards for urgent care in general practice and implementation of actions / 40p per patient
Prescribing: total maximum payment (9 points per practice) / 15p per patient
APPENDIX A
NHS Hull
PBC Incentive Scheme 2010/11 practice signature sheet
Name of Practice: ………………………………………………………………………..
Name of Clinical PBC lead………………………………………………………………
This Practice wishes to participate in the PBC Incentive Scheme from 1 April 2010 to 31 March 2011.
Submitted by:……………………………………………….
Date:…………………………………………………………
*If the practice intends to participate as a member of a commissioning group or consortium please identify the other members of the consortium in the box below:
APPENDIX B
NHS Hull
PBC INCENTIVE SCHEME 2010/11: DEDUCTION OF MONIES