http://www.kirklees.nhs.uk/fileadmin/documents/publications/PBC_Business_Plan_Oaklands_2008-2009

PRACTICE BASED COMMISSIONING BUSINESS PLAN OAKLANDS HEALTH CENTRE 2008/2009

INTRODUCTION Oaklands Health Centre has a population size of 7000 (as of 1.4.08). It covers a wide geographical area across the Holme Valley, which is predominantly rural in character.

GPs

Dr Shamsee Dr Ward Dr Curgenven Dr Spencer Dr Henry

The Practice offers a full range of Practice based services delivered under a PMS plus contract. Over the years the Practice has successfully developed the role of the Nurse Practitioner to improve patient access and the patient experience and has also introduced GPSI services in neurology and musculoskeletal medicine. The Practice also plays a role in the management of intermediate care at Holme Valley Memorial Hospital and provides a vasectomy service Kirklees PCT. The Practice is currently working towards developing a number of locally based services and indeed has just started providing ENT and rheumatology clinics in addition to Ophthalmology to again provide care closer to home and improve patient access to health services.

As previously mentioned the Practice is based in close proximity to the Holme Valley Memorial Hospital and thereby provides access to step up and step down intermediate care beds which are accessible to all residents across Kirklees. The Practice also provides significant input into the local nursing home (i.e. 35 out of 60 beds) and has established a weekly ward round in the nursing home in an attempt to improve the patient experience for those patients unable to access the surgery conventionally. This is part of the Practice’s strategy towards managing long term chronic conditions in vulnerable patients and has also included the use of a Practice based pharmacist, a consultant outreach clinic and a nurse practitioner adopting the role of a ‘community matron’. The Practice has also extended its opening hours since September ’06 to include early mornings, evenings and Saturday surgeries in order to improve patient access. This was developed as a consequence of feedback from patient surveys which identified the need for better access for commuters and mums with pre-school/school-aged children. The extended hours have also enabled the Practice to implement a Practice based minor injury service which allows patients to benefit from treatment closer to home. This has been of significant benefit to patients since the closure of the minor surgery unit at HVMH. The Health Needs of the Practice Population The population of the Practice principally falls into the Local Area Committee of the Three Valleys. Health needs assessments have been undertaken based on information from health statistics, local community health teams and other local information and views with the identification of key priority areas.

There are substantial areas of deprivation in the area covered by the Practice including the former local authority estates in Cinderhills (Holmfirth), Roundway (Honley) and Holme Close (Holmbridge). In these areas there are substantial challenges for both individuals and groups within the population and this is often heightened by areas of relative wealth surrounding them. Their deprivation is also heightened by a lack of transport infrastructure in the Holme Valley locality which can create access problems to health resources. This is an issue which has been raised by the Practice with both the Primary Care Trust and the Local Parish Council. The issue of rurality is important as the national formula currently used by PCT’s to calculate ‘weighted budgets’ fails to recognise rurality and the distance

decay phenomenon. The Practice actively contributes to a multi-agency group, including the Local Authority and Kirklees PCT’s public health department, aiming to design a series of health awareness road-shows across the Holme Valley. These road-shows will target vulnerable adults and provide social support as well as medical and benefits advice. In addition, the Practice is piloting an outreach mobile surgery, which aims to reduce health inequalities by delivering health care and health promotion to patients living in the more rural areas, who may have difficulty in attending the surgery.

Areas of particular significance within the Practice population are the rising birth rate over the last 18months, and the high rate of chronic kidney disease (almost double the national average). Interestingly, although the Practice is deemed to be above its weighted PBC budget (according to a national formula), it has at least the average national prevalence (if not higher) for all the major chronic diseases. The increased birth rate has coincided with an increased referral to Barnsley FT for ante-natal care. In the main this highlights patient concern over reconfiguration of maternity services at CHT.

MALE %

FEMALE % 90 to 94

90 to 94

75 to 79

75 to 79

60 to 64

60 to 64

45 to 49

45 to 49

30 to 34

30 to 34

15 to 19

15 to 19 0 to 4

0 to 4 0.00

2.00

Age Band 95+ 90 to 94 85 to 89 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 40 to 44 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4 Grand Total

4.00

6.00

Males 1 14 30 48 83 122 146 290 279 245 283 277 273 182 156 176 229 251 206 185 3476

CHD Heart Failure CVA Hypertension Diabetes Mellitus COPD Epilepsy Cancer Mental Health Dementia Asthma Chronic Kidney Disease AF Smoking Depression

8.00

10.00

% Males 0.03 0.40 0.86 1.38 2.39 3.51 4.20 8.34 8.03 7.05 8.14 7.97 7.85 5.24 4.49 5.06 6.59 7.22 5.93 5.32 100

Females 10 24 61 74 86 117 167 277 264 280 294 295 272 191 164 147 231 220 182 165 3521

0.00

2.00

4.00

% Females 0.28 0.68 1.73 2.10 2.44 3.32 4.74 7.87 7.50 7.95 8.35 8.38 7.73 5.42 4.66 4.17 6.56 6.25 5.17 4.69 100

No of Patients

Practice %

252 47 127 888 213 106 34 63 36 29 431 210 97 1508 984

3.7 0.7 1.8 12.8 3.0 1.6 0.5 0.9 0.6 0.4 6.2 3 1.5 21.6 14.1

6.00

Total 11 38 91 122 169 239 313 567 543 525 577 572 545 373 320 323 460 471 388 350 6997

8.00

% Total 0.16 0.54 1.30 1.74 2.42 3.42 4.47 8.10 7.76 7.50 8.25 8.17 7.79 5.33 4.57 4.62 6.57 6.73 5.55 5.00 100.00

National Prevalence 3.7 N/K 1.6 12 3.5 1.4 0.6 0.7 0.6 N/K 5.8 N/K N/K N/K

10.00

The key areas of focus are:A) Long term Conditions - e.g.

• Cardio vascular conditions (heart disease, hypertension, strokes, heart failure and primary prevention) • Diabetes – The Practice manages 98% of its diabetics in house with no reference to services provided at HRI or else where. This again heightens transport issues in getting patients to and from the surgery.

• Respiratory Conditions – The Practice has developed an innovative and well reviewed local pulmonary rehabilitation service to under pin its management of respiratory diseases. The Practice has above average prevalence’s for both chronic obstructive airways disease and asthma.

• Chronic Renal Disease – The Practice has a significantly higher % of patients with CKD than the national average and is currently able to manage the majority of patients with CKD4 and better, in house including the management of associated anaemia.

Cancer Care/Palliative Care – The Practice has above the national prevalence and incidence of diagnosis of cancer and this has a significant impact on primary care work load, prescribing and referral costs. In particular the Practice will aim to place far greater emphasis on the management of end stage conditions within primary care to include COPD and heart failure as well as end stage cancer.

Orthopaedic Services – The Practice is exploring a business case to provide an orthopaedic clinic at the Practice which would improve the access, patient experience and clinical out comes for patients with musculoskeletal diseases beyond the scope of the clinicians at the Practice and Moorfields.

Mental Health – The Practice has noted 4 mental health sections in the past 12 months and an increasing part of our work load is the management of patients with dementia. The Practice is therefore keen to look at the introduction of a mental health case management system similar to that provided for physical illness which should help to improve the management of patients with long term mental health problems in primary care. We intend to target under-spends from PBC on pump-priming such a service.

Obesity Management – Over the past 12 months the Practice has initiated an “exercise on prescription” scheme and has introduced “Counter Weight” weight management in an effort to help patients reduce BMI. The Practice also intends to use freed up resources from 06/07 to screen patients with metabolic syndrome who are at a higher risk of diabetes, strokes and heart disease.

Gynaecological Conditions and Sexual Health – Both of these conditions are managed to a greater extent in house as a consequence of training provided by local consultants.

Given the government’s target of 100% “48 hour” access to sexual health services by 2008, the Practice would hope to improve upon the services already provided to again enhance the patient experience and ensure that these patients can receive care closer to home.

This will undoubtedly be facilitated by our extended opening hours.

Diagnostic and Therapy Services – The Practice has introduced schemes to improve access and testing closer to home. The significant problem to date is the lack of access of diagnostic imaging (x-rays, ultrasound and MRI scans) which of course is worsened since the closure of the x-ray unit at St Lukes Hospital.

VISION / MISSION STATEMENT The Practice intends to commission high quality services for its patients, which will be provided closer to home either on a Practice specific basis or on a locality basis, which will be sensitive to the needs of the patients as identified by direct consultation with the patients’ forum and which will be relevant to the Vital Signs Operating Framework and the JSNA document. The Practice will use all its available resources to ensure that this engagement not only identifies key health priorities, but also reduces health inequalities.

COMMISSIONING PRIORITIES & TARGETS 1.

Further develop the Practice’s performance monitoring systems by introducing IQ Manager software

Aims 1. Data validation 2. Enables accurate real time assessment of PBC costs 3. Cost and activity can be measured for each speciality for referrals by each clinician 4. It allows the Practice to analyse referrals weekly to identify hotspots of activity 5. We will then be able to identify open spells activity, which will identify patients suitable for transfer to Holme Valley Memorial Hospital, thus reducing length of stay at HRI Issues / Difficulties The software is new to the Practice and is relatively labour intensive but of course without accurate data input, data analysis is meaningless. It is highly likely that the first quarter of 08/09 will be devoted simply to data input and ensuring that the systems work correctly.

Once properly up and running the software will come into its own with regard to data analysis as it is more intuitive and easier to use than the PCT’s web browser. The software itself costs roughly 30p per registered patient and the Practice intends to use some of its PBC management allowance to pay for this. The Practice is also more than happy to demonstrate the software and its applications to the PCT. Current Position / Proposal Currently the Practice uses the PCT’s web browser which clearly provides data several weeks after episodes of care have happened. The advantage of the IQ Manager software is that patient activity is loaded on to the system at the point of referral or hospital admission, so that clinicians are immediately aware of inappropriate hospital admissions or referrals, which could, subject to patient choice, be diverted to Holme Valley Memorial Hospital or to in-house patient clinics.

Expected Outcomes / Performance Indicators The Practice believes that this proposal links well to the NHS operating framework (Vital Signs) in terms of reducing the number of emergency bed days per head of weight of population and reducing rates of hospital admissions for ambulatory care and sensitive conditions per 100,000 of population. Clearly better data analysis and, therefore, better management of our patient population should lead to more effective use of NHS resources, which clearly links back to the financial balance of the PCT and the Practice’s PBC budget. It is, therefore, hoped that use of this software will enable the Practice to better manage its resources as well as helping us to produce business cases in the future, which accurately reflect patients’ clinical needs. The software will also add more value to the process of regular peer review of referrals, as it will also be immediately obvious which clinician is referring to which speciality and at what volume. This should also save clinical time and make peer review much more effective.

2.

The Practice intends to introduce a business case to develop an Orthopaedic clinic in the Practice

Aims 1. To initiate an Orthopaedic business case which is consultant led in house, which integrates with the Practice’s in house physiotherapy / GPSI musculoskeletal and consultant led rheumatology service.

2. To enable the practice to better manage pain due to arthritis, which is clearly identified as a priority area in the JSNA. 3. By improving the integration of musculoskeletal services, the Practice believes it can better manage NHS resources by reducing referrals and therefore improving value for money.

Issues / Difficulties The business case has already been submitted to the business case clinic in April 2008 and we are awaiting clarification from the PCT as to whether or not the Practice is able to proceed with its business case at the reduced tariff cost. The Practice believes that its proposal provides patient care, which is sufficiently different from that traditionally provided by consultants in secondary care to warrant a local tariff being applied. The Practice is also taking on additional clinical / admin responsibility and consequently we feel we have unpicked significant elements of the tariff further supporting our notion that the proposed case is significantly different from the service provided in secondary care.

A key risk is that the PCT does not share our view, in which case there would be little value to the Practice in taking on additional responsibilities and this would effectively make service redesign much more difficult.

Current Position / Proposal See above Expected Outcomes / Performance Indicators Within the business case there are a series of expected outcomes, which includes patient satisfaction surveys, monitoring of the volume of new referrals and the new to follow up ratio, the surgical conversion rate and validation of the cost savings, which will become apparent if the service is run at a local tariff.

3.

The Practice wishes to develop an in house pain clinic using specialist GP input, pharmacist medication reviews, acupuncture and the use of TeNS machines

Aims 1. The management of pain was identified as a key priority by the JNSA. An appropriate “low-tech” pain clinic would extend the range of pain management service available in primary care, which could potentially reduce referrals into secondary care.

2. To move work closer to home.

3. The pain clinic should integrate with the clinics in house rheumatology service, GPSI and physio service. It is also hoped that the in house pain clinic would integrate well with the orthopaedic service if approved and would enable the Practice to provide an holistic and comprehensive assessment of the patient’s functional and physiological needs.

Issues / Difficulties The implementation of the business case requires little additional training or support for the practice, as we already have a GP experienced in the management of neuropathic pain and we currently provide an ad hoc acupuncture service for patients with chronic pain, which has had particularly good effect in the management of back pain, migraine and fibromyalgia. The practice would require a small amount of capital expenditure on acupuncture needles and TeNS machines and it is likely that this would be in the region

of a few hundred pounds only and the practice would seek to use the balance of its unspent 06/07 PBC under spend to fund this business case.

Current Position / Proposal It is anticipated that the business case will be submitted to the PCT in August/September 2008 for consideration at the appropriate business clinic. The Practice would therefore hope to have the service up and running by 1st January 2009 and would hope to pilot the service over a two to three year period of time.

Expected Outcomes / Performance Indicators The business case itself will have a number of outcome measures including patient satisfaction surveys, measurement of reduced referrals to secondary care, assessment of potential prescribing costs saved by the appropriate management of neuropathic pain, measurement of the number of patients whose pain can be managed without recourse to facet joint injections / lumbar epidurals.

4.

Redesign Provision of Alcohol Support Services within Primary Care Aims The aim is to develop a business case for alcohol screening and treatment within the Practice, which has direct links to the JSNA and Vital Signs Operating Framework.

Issues / Difficulties Discussion with clinicians within the Practice reveals that patients are reluctant to use central Lifeline services for fear of being stigmatised, which consequently leads to a low uptake of services and the reluctance to identify health issues related to alcohol consumption. Clearly this cultural barrier is a significant risk / issue which needs to be rectified. Other issues will include the critical mass of patients needed to produce a bespoke service and it is possible that the Practice will need to liaise with other commissioners in the Holme Valley to produce a locality based service.

Current Position / Proposal Currently data on alcohol consumption is collected at new patient checks, antenatal booking appointments and when patients present directly with alcohol related problems.

The Practice proposes to add alcohol intake measurement for all metabolic disease checks e.g. hypertension, CHD/CVD and diabetic reviews in order to develop an embryonic register of those patients with greatest need. This would allow the Practice to identify those patients with greatest health risks e.g. obesity, smoking and alcohol intake so that holistic advice can be given, which promote healthy living rather stigmatising patients. The Practice also intends to liaise with Lifeline and other local commissioners to provide a locality based drop in clinic, which could accept direct patient referrals from clinicians as well as self-referral from patients. As part of this process, the Practice would intend to up-skill its own clinicians, e.g. using the AUDIT screening tool, so that a significant element of the service could be provided in-house to support patients, their families and carers. The Practice also intends to link in with social services to ensure that patients and their families receive benefits assessment and support their wider holistic needs.

Expected Outcomes / Performance Indicators Achievement of the target will be demonstrated by examining the percentage of patient notes with a record of alcohol intake in the past fifteen months, as well as looking at the percentage of patients offered referral for support.

5.

The Practice wishes to improve management of long term conditions Aims 1. Improvement of management of long term conditions, particularly the promotion of self education / self management.

2. Identification of those patients who are at risk of developing long term conditions.

3. Provision of appropriate information on healthy living / healthy lifestyles to reduce the risk of developing long term conditions Issues / Difficulties The practice has identified this as a significant priority area and has submitted a business case to the PCT in April 2008. We propose to use underspends from our 06/07 PBC budget to fund a 0.44 full time equivalent GP on a three year pilot basis to provide the practice with enough capacity to identify, screen and treat patient who are either at risk of developing long term conditions or currently have long term conditions where their management could be improved.

Although the JSNA identifies that “The Valleys” area has the lowest rates of premature deaths from the major killers of cancer and heart disease, it also identifies that 20% of adults smoke on a daily and that 10% of adults are obese. The JSNA also identifies that two in three adults were not physically active enough to benefit their health and up to one third of people locally binge drink. The Practice believes that these are significant risk factors for the development of long term conditions e.g. respiratory illness, renal disease, heart disease and liver disease, which in time will become a major health burden and could potentially increase the rate of premature death from cancer and heart disease.

The Practice also believes that this business case has very clear links to the operating framework (Vital Signs) e.g. via the proportion of people with long terms conditions supported to be independent and in control of their condition, the rates of hospital admissions for ambulatory care and sensitive conditions per 100,000 population, less than 75 year old CVD mortality rate amongst many others.

Current Position/Proposal As identified above, the Practice as submitted a business case, which has received approval for funding and the Practice will be in a position to implement this business case from May 2008.

Expected Outcomes / Performance Indicators The business case itself contains a number of expected performance measures, which includes analysis of saved referrals costs, saved prescribing costs, saved hospital admissions and hopefully also reduce length of stay on the back of better management of long term conditions 6.

Mental Health Case Manager Aims • To improve the capacity of the primary care metal health team.

• Provide support to carers and patients with dementia.

• Identify physical and/or mental health deterioration at an early stage to reduce unnecessary hospital admissions.

• Liaise with Social Services to provide holistic assessments and ensure patients and carers receive appropriate benefits.

Issues Although there is no tariff for mental health, the practice would seek to prioritise this scheme from within residual 06/07 underspends or potential 07/08 underspends.

The practice would seek to pilot such a scheme over two to three years and would need to identify £36,000 to £50,000 to fund this scheme. Clearly failure to secure this underspend will jeopardise the scheme!

Expected outcomes • Improved integration of care for patients with dementia.

• Reduced hospital admissions and decreased length of stay.

• Improved medicines management (Compliance and Concordance) with reduced risk of iatrogenic illness and drug wastage.

IMPLEMENTATION TIMETABLE Please see the table on the next page

Brief outline of rationale for choosing target

Detailed action required to achieve target

1

Further develop the Practice’s performance monitoring systems by introducing IQ Manager software

• Desire to monitor activity and budgets in real time • More accurate data validation • Improves resource management

Software installed and practice now recording and analysing data in real time

2

The Practice intends to introduce a business case to develop and Orthopaedic clinic in the Practice

• Reduce variation in care • Integrate with in-house rheumatology and physio and GPsi to provide holistic service • Meets 18 week target • Improve value for money • Moves care closer to home

Business case

The Practice wishes to develop an in house pain clinic using specialist GP input, pharmacist medication reviews, acupuncture and the use of TeNS machines

4

5

3

Completion Date

Target No.

Description

Installation April 08 Data collection and analysis ongoing April 08

Outline approval received

April 08

Implementation phase

By QTR2 (08/09)

• Identified priority by JSNA • Integrates with above priorities • In-house skills to deliver service • Opportunity to review prescribing

Data collection and outline business case

By start QTR3 08/09

Implementation plan if approved

By start QTR4 08/09

Redesign Provision of Alcohol Support Services within Primary Care

JNSA identified higher than average health problems secondary to alcohol

• Data entry to be improved • Discuss AUDIT scheme with Lifeline • Up-skill clinicians • Develop locality service

The Practice wishes to improve management of long term conditions

• Need to improve health promotion and prevention of metabolic illnesses by lifestyle intervention • Links to numerous targets in Vital Signs and JSNA. • Better resource management • Self-empowerment and selfmanagement

Business plan produced in April 2008.

Identifies resourcing from 06/07 underspends to fund three year pilot.

Case approved.

End Qtr1 08/09

Submitted to PCT April 08

Implementation by May 2008

Nominated lead

Key links

Anticipated freed up resources as applicable

YS/DC at practice

Not applicable

Not known Resource management will be improved

Dr Shamsee

• PBC locality manager • Barnsley FT • BMI Hospital • CHFT

≈ £22k p.a. on out-patient costs

Dr Shamsee

PBC locality manager

Not known

GPs

• Lifeline • Other commissioners in Colne Valley • PBC locality managers

N/K

Dr Shamsee

• PBC locality manager • Public Health (James Williams)

≈ £30k p.a.

PERFORMANCE MONITORING In general, the Practice intends to implement the following measures to ensure that adequate performance monitoring is in place to monitor its PBC budgets and activity.

• Provide protected clinical time for clinicians to peer review each other’s referrals and share learning. This should help to encourage in-house referrals and up-skill clinicians in general with the aim of reducing unnecessary hospital referrals.

• The Practice uses IQ software to analyse its PBC activity on a ‘live’ basis, which allows us to check on our clinical and financial performance in real time. In addition, we are the only Practice in the PCTY to use Scriptswitch software, which provides clinicians with up to date prescribing advice on cost effective / safer prescribing alternatives as well as monitoring / safety alerts.

• The Practice will regularly review data on the PCT’s web browser to identify referral patterns or trends. Analysis of the data will also allow the Practice to identify patients who frequently attend hospital / are frequently admitted and who otherwise could be supported by the case management business case. Analysis of referral trends will also allow the Practice to monitor its financial performance as well as identify clinical areas, which might require training and development of clinicians or the production of business cases. The Practice will also similarly monitor its prescribing data and has regular input from the PCT’s prescribing team to ensure that the prescribing budget remains on track.

• The Practice will meet regularly with the PCT’s locality managers for commissioning and finance in order to monitor its financial and clinical performance and also will regularly attend the PCT’s commissioning forum to understand the wider context and implication of PBC across the PCT as a whole.

• The Practice will also collect data specific to each of its business cases, if approved, to support the evaluation of the business cases and/or to refine their service delivery.

PATIENT AND PUBLIC INVOLVEMENT The Practice is committed to ensuring that patient and public involvement is central to developing and monitoring business cases and service redesign. Without appropriate critical feedback it would be impossible to know whether proposed services and changes actually meet patient need.

Aims 1. Ensure that the Practice thoroughly explains Practice Based Commissioning to both patients and the public.

2. To ensure that the Practice receives appropriate feedback from patients and the public to ensure that service redesign delivers appropriate health gains.

Issues 1. The Practice reintroduced its patients’ forum in 2007, which meets bi-monthly.

2. The anticipated pace of change within the Practice may not allow for adequate patient and public engagement.

3. There will be a differential pace of development in understanding Practice Based Commissioning between clinicians at the Practice and patients, which could generate tensions if not appropriately managed.

Proposals As well as introducing the Practice’s patient forum, it is anticipated that the Practice would seek a nominated lead patient to act as a critical friend in developing PBC business plans, who can also feedback to the wider patient forum. The Practice would also seek the support of the Primary Care Trust and its own patient forum to help develop

appropriate patient / public involvement in Practice Based Commissioning. It may also be appropriate for the nominated patient lead to attend some of the Practice’s monthly meetings with the PCT’s locality managers.

Expected Outcomes 1. The Practice will develop and distribute a leaflet explaining PBC to its patients.

2. The Practice will propose a nominated lead patient with whom to discuss PBC issues and will map current PPI arrangements / future work streams.

3. The Practice intends to develop a regular newsletter to patients to explain changes / improvements in services which will clearly include PBC initiatives.

TRAINING AND DEVELOPMENT • • • • •

•

The key issue has been the development of closer team working within the Practice particularly around the integration of the nurse practitioner / case manager regarding the management of complex tier 3 patients.

It is anticipated that several clinicians within the Practice will need training and development in terms of data analysis and the process of writing business cases.

It is anticipated that this support will be provided in-house.

It is also likely that the Deputy Practice Manager and key admin staff will need training in the use of the web browser and it extraction of data from the browser to populate real time analysis of referral data and open spells admission data.

The Practice is also supporting Dr Edara with his aim of becoming a GPwSI in ENT, which would support the provision of a Practice based ENT clinic with support from ENT surgeons at Barnsley.

The further significant challenge / development need will be in introducing systems to allow clinicians to peer review each others clinical referrals and hospital admissions using a support of, no blame culture to facilitate clinical learning and engagement.

A significant development need will be the education of the patients / members of the public on the Practice’s patient forum and the Practice would seek the PCT’s support in facilitating this.

RISK MANAGEMENT STRATEGY A lack of clinical engagement Given that the Practice has ensured that clinicians have regular weekly protected time to discuss significant events, referral patterns and peer review of referrals it is not anticipated that there will be a lack of clinical engagement. Clinicians with the Practice will also be encouraged to attend the Kirklees Commissioning Forum as well as contribute to HIT meetings where appropriate. Protected time has also been provided for the Practice nurse and the GP at the surgery to review current clinical governance procedures and policies with the aim of improving the standard of clinical care and reducing unnecessary hospital referrals.

No efficiency gain generated The Practice will ensure that it adopts best Practice in terms of performance monitoring arrangements and will meet regularly (monthly) with the PCT’s locality commissioning and finance managers to ensure that clinical activity and associated PBR costs are kept on target and any adverse variation can be identified promptly and fully investigated.

Failure to engage patients / members of the public in the PBC process The introduction of the patient forum and the selection of a “lead patient” to liaise with the Practice on Practice Based Commissioning should ensure that there is appropriate dialogue and engagement to ensure that proposed service changes truly reflect patient need. In addition, the Practice will regularly update PBC information which will be

displayed in the Practice via posters, in the Practice newsletter and on the Practice’s website which is currently under development.

Oaklands business cases not approved by the PCT The Practice has discussed at length the potential to develop an Orthopaedic clinic inhouse in order to redesign this speciality to reduce service variation and move care closer to home. This case is crucial in engaging both patients and clinicians and failure to implement this case will slow this process down dramatically. It would also significantly affect the Practice’s ability to manage its overall PBC budget.

BEST PRACTICE By attending the Kirklees Commissioning Forum and having regular meetings with the PCT’s locality managers, it is anticipated that the Practice will be able to benchmark its performance against that of local consortia and other stand alone Practices. The Practice will be able to benchmark directly against Slaithwaite Health Centre in terms of referral rates, hospital admissions and prescribing costs. The Practice will also regularly review business cases proposed by alone stand alone Practices / consortia via their individual websites or via the PCT. The Practice will also regularly review clinical performance in light of new guidelines e.g. NICE updates, NSF’s and clinical research. The Practice also has regular input from the PCT’s prescribing team, thus ensuring that clinicians are kept up to date with best prescribing Practice and clinicians at the Practice will be encouraged to keep up to date via medical journal and the PCT’s prescribing newsletter. A number of other GP publications regularly contain examples of best Practice across the country and the Practice will continually review its performance in light of these articles.

USE OF FREED UP RESOURCES Should the Practice free up resources during 2008/2009 it is proposed that debate would occur between the clinicians and the patient forum as to what clinical priorities would be most deserving. Very early discussions with the clinicians have demonstrated concerns regarding the provision of primary care based mental health services in general and specifically with regards to provision of services for patients with mental health illnesses e.g. dementia and those illnesses exacerbated by alcohol / drug abuse. The Practice would therefore prioritise freed up resources to target this area.

Given the Practices higher than average incidence of respiratory illnesses, freed up resources would also be targeted at ensuring that patient with asthma and COPD are properly stratified into those patients whose would benefit from self help / self management and those patients who require more intensive case management.

Resources would therefore be prioritised into developing these two areas, which could also include a locality based expert patient programme.