City Locality PPG Forum Thursday 05 March 2015 Oxfordshire Clinical Commissioning Group Welcome Michael Leech Chair of City Locality PPG Forum Oxfordshire Clinical Commissioning Group Agenda Welcome Michael Leech Co-commissioning Dr Rosie Rowe, Head of Provider Development (Out of Hospital Care), OCCG Refreshment break Review into Mussculoskeletal Services Colin Sullivan, Senior Project Lead, Planned Care, OCCG Changing role of the GP Dr Merlin Dunlop, Deputy Clinical Lead, Oxford City Locality Closing remarks Oxfordshire Clinical Commissioning Group Oxfordshire Clinical Commissioning Group Primary Care Co-Commissioning Update 5 March 2015 Oxfordshire Clinical Commissioning Group Purpose of this briefing What is co-commissioning Potential scope of co-commissioning OCCGs current co-commissioning activity Risks and Benefits 5 Oxfordshire Clinical Commissioning Group What is primary care co-commissioning? Primary Care Co-commissioning is about joining up the commissioning arrangements between NHS England and the CCG in order to: Co-ordinate focused support for primary care Deliver local priorities better Reduce system barriers and inefficiencies Put clinicians at the heart of commissioning primary care Increase the quality of primary care commissioning Improve patient experience 6 Oxfordshire Clinical Commissioning Group Scope of Co-commissioning (Table 1) (excludes decision- making on Pharmacy, eye health and dental commissioning and Medical Performers List) 7 Primary care function Option 1:Greater involvement Option 2: Joint commissioning Option 3: Delegated Commissioning Current Level of Co-commissioning in OCCG General practice commissioning Potential for involvement in discussions but no decision making role Jointly with area teams, including the design of APMS contracts YesYes - Services under Primary Care contract Design and implementation of local incentives schemes NoSubject to joint agreement with the area team - opportunity to amend national DES Yes - opportunity to amend national DES Yes OPCLIS but with no flexibility around national DES Oxfordshire Clinical Commissioning Group Scope of Co-commissioning (Table 2) 8 Primary care function Option 1:Greater involvement Option 2: Joint commissioning Option 3: Delegated Commissioning Current Level of Co-commissioning in OCCG General practice budget management NoJointly with area teams YesNo Contractual GP practice performance management Opportunity for involvement in performance management discussions Jointly with area teams YesNo Oxfordshire Clinical Commissioning Group Benefits Currently undertaking joint commissioning - Option 2 will formalise existing arrangements and provide governance structure for making decisions Greater scope to develop local schemes to deliver primary care strategy (e.g. a local QOF) and to amend national DES. Opportunity to have locally sensitive and place based commissioning rather than target- chasing Improve the quality of primary care commissioning by greater OCCG clinical commissioner engagement Both OCCG and NHSE Area Team are responsible for quality of primary care joint commissioning will avoid duplication and allow alignment of approach to quality Enables CCG to provide system leadership Oxfordshire Clinical Commissioning Group Risks As a membership organisation, performance management of practices may not sit comfortably conversely, greater local understanding and more ability to offer peer support Conflicts of interest will require robust and transparent governance arrangements national guidance to be followed, need to be open and transparent OCCG capacity to undertake work. Resource available: Ginny Hope identified as Area Team primary care lead for OCCG 6 month co-commissioning manager being funded by AT AT will continue to resource administration of contracts, performance management of individuals and practices 1 FTE OCCG senior commissioning manager NHS England will keep under review the ability for CCGs to implement co-commissioning without an increase in running costs in 15/16 Oxfordshire Clinical Commissioning Group Proposed Approach CCG Executive has recommended to member practices that they adopt Option 2 in order to formalise existing co- commissioning activity and provide an effective governance structure for taking decisions. The CCG to continue to undertake joint commissioning functions identified in Table 1 whilst NHS England continues to undertake functions in Table 2 including contracting, payments and administration of primary care. This incremental approach will minimise risk to the organisation. The CCG to review the nature and outcomes of joint commissioning arrangements and to assess its long-term sustainability. 11 Oxfordshire Clinical Commissioning Group Next Steps 12 Approval to be requested of Governing Body with appropriate change to OCCG constitution. Formal governance arrangements to be established by April 2015 currently designing supporting meeting group Integrating Oxfordshire Musculoskeletal Services Dr Rob Russ (Clinical Lead) Colin Sullivan (Senior Project Lead) Ceris Challenger (Project Support) Oxfordshire Clinical Commissioning Group What standard of service do you currently have? PALS Patient complaints CCG Patient complaints Patient Complaints Data/ Financial Analysis GP Feedback Qualitative Analysis Current State Analysis Patient Advisory Group Clinical Advisory Group What constitutes a good service? Identify areas of service for change Information Sources: Activity data Financial information Datix PALS and CCG complaints Contracts/ service specification Articles/ Journals Patients, GPs, Providers, Academics and Commissioners National context Bench-marking Local context Opportunities Follow up GP Referral YES Triage Assessment (face to face) Treatment This is what it looks like on paper!! Paper triage Referral accepted? Referral rejected Paper triage outcome recorded GP Admin modifies/ resubmits rejected referral or adds info to patient record Administrator processes: 1. to GP 2.Letter to patient NO Referral to appropriate MSK clinician (booked by ) Referral to Podiatry (CAB & fax) Referral to secondary care and letter to pt. Pt. phones to book Secondary Care Consultant/ therapist Surgery/ procedure HUB Podiatrist (off shelf) Secondary Care Consultant Delays between decision that pt. needs 2 ndry care, MRI or face to face appt (paper triage) to appt being processed. Pt. factors e.g. holidays GPs not using C&B use separate system InfoFlex. Licence expiring - will need to record numbers in Excel. Difficult to monitor Patient not treated due to inappropriate referral - returned to GP. Patient may be re-referred to OMAS by GP and repeat pathway again. HUB Physio (NOC) Diagnostics HUB Patient Other Provider GP Practice KEY ! ! ISSUES Direct referral Orthotist Re-assessment by comm. podiatrist for bespoke foot orthotics (as service not included in OMAS contract) Primary Care Physio Physical Disability Service (OHFT) Neurosurgical spinal unit (back pain) Physio triage/ Consultant Spinal Unit Direct referrals to Neurosurgical Spinal Unit. Patients triaged, followed by consultant review and surgery if required Pt. attends A&E Patients attending A&E receive follow-up appointments in secondary care Rheumatology Direct referrals to Rheumatology consultants into out of area Acutes Appt OMAS Physio/ podiatrist Appt Community Podiatrist Appt. OMAS visiting Consultant GP Many patients referred to Direct access physiotherapy are sent back to GP for referral to MSK HUB for further assessment and treatment. Drain on GP resources Additional steps in patient pathway Many patients referred to Direct access physiotherapy are sent back to GP for referral to MSK HUB for further assessment and treatment. Drain on GP resources Additional steps in patient pathway Referral & Screening What needs to change? Problems identified and defined Areas requiring change identified (five cross-cutting and one pathway): 1.Primary & Secondary prevention required 2.Referral processes to be more efficient with improved access 3.Patients to be fully informed on treatment options/ involved in decision-making 4.Effective Communication required between clinicians and with patients 5.Focus on whole patient with meaningful Outcomes 6.Redesign Spinal pathway (significant delays and inefficiencies) Patient and clinical advisory groups proposed initial solutions for exploration: 1.Self-referral (patient) and direct-referral (clinician to clinician) 2.Develop prevention (public health & voluntary sector) 3.Shared decision-making tools 4.Patient centred outcomes 5.Information technology for cross-boundary communications 6.Review spinal pathway } Patient-Centred Approach How do we decide what service improvements to make? 25th November: MSK all stakeholders workshop process solutions 13th January: MSK all stakeholders improving patient experience SpinalShared decision-making tools CommunicationsPreventionReferralsOutcomes Experience Based Co-Design Patient Survey Strategic Outline Business Case approved 23 rd Sept Five year Strategy and Plan Current state analysis Case for Change 3rd February: MSK all stakeholders workshop modelling Focus groups develop options Patient/ Clinician task and finish group develops new service model Focus groups develop options Stake holders event 25th November process changes Defined proposed solutions/ new processes explored potential benefits/ threats and agreed options to be developed Commenced development of options Stake holders event 13th January improving patient experience Film and experience map viewed to test estimated impact of emerging development options on patient experience, inform further developments and identify gaps. Introduced personalisation as a solution to facilitate integration prevention shared decision-making patient centred outcomes Communications/ information appropriate times and types managed approach Stake holders event 3rd February developing the service model Emerging model scrutinised Risks and benefits Areas for further development Task and finish groups Groups developed proposals for redesign between events and final model Liaison with other CCGs voluntary organisations and County Council e.g. Coastal West Sussex and Sheffield CCGs, e.g. Arthritis Research UK e.g. National Rheumatoid Arthritis Society e.g. Oxfordshire Sports Partnership Public Health How do we decide what service improvements to make? Follow up GP Referral YES Triage Assessment (face to face) Treatment Remember this? Paper triage Referral accepted? Referral rejected Paper triage outcome recorded GP Admin modifies/ resubmits rejected referral or adds info to patient record Administrator processes: 1. to GP 2.Letter to patient NO Referral to appropriate MSK clinician (booked by ) Referral to Podiatry (CAB & fax) Referral to secondary care and letter to pt. Pt. phones to book Secondary Care Consultant/ therapist Surgery/ procedure HUB Podiatrist (off shelf) Secondary Care Consultant Delays between decision that pt. needs 2 ndry care, MRI or face to face appt (paper triage) to appt being processed. Pt. factors e.g. holidays GPs not using C&B use separate system InfoFlex. Licence expiring - will need to record numbers in Excel. Difficult to monitor Patient not treated due to inappropriate referral - returned to GP. Patient may be re-referred to OMAS by GP and repeat pathway again. HUB Physio (NOC) Diagnostics HUB Patient Other Provider GP Practice KEY ! ! ISSUES Direct referral Orthotist Re-assessment by comm. podiatrist for bespoke foot orthotics (as service not included in OMAS contract) Primary Care Physio Physical Disability Service (OHFT) Neurosurgical spinal unit (back pain) Physio triage/ Consultant Spinal Unit Direct referrals to Neurosurgical Spinal Unit. Patients triaged, followed by consultant review and surgery if required Pt. attends A&E Patients attending A&E receive follow-up appointments in secondary care Rheumatology Direct referrals to Rheumatology consultants into out of area Acutes Appt OMAS Physio/ podiatrist Appt Community Podiatrist Appt. OMAS visiting Consultant GP Many patients referred to Direct access physiotherapy are sent back to GP for referral to MSK HUB for further assessment and treatment. Drain on GP resources Additional steps in patient pathway Many patients referred to Direct access physiotherapy are sent back to GP for referral to MSK HUB for further assessment and treatment. Drain on GP resources Additional steps in patient pathway Referral & Screening Follow up Sign posting & Booking Triage & Assessment Treatment Referral & Screening Referral: Patient (self) General Practitioner, Trauma, Urgent Care, Emergency Dept Referral completed by referrer and resent Administrator processes: Patient contacted, appointment booked and communications sent to GP & Patient Surgery/ procedure Post-surgical follow-ups Delays between decision that pt. needs 2 ndry care, MRI or face to face appt (paper triage) to appt being processed. Pt. factors e.g. holidays MRI / CT scan Patient Other Provider Primary Care KEY ! ! ISSUES Secondary Care It now looks like this! Administration checks referral for completeness Community based One Stop Shop with same day access to diagnostics (except MRI and CT scans) provide triage, assessment treatment and follow-ups (including Trauma, Urgent Care and Post-surgical from Secondary Care) Available clinicians: Podiatrists, Physiotherapists, Extended Scope Practitioners, Clinical Pharmacist, Rheumatologist, or delegated team members. Primary Care Physiotherapists in alternative community settings provide extension to the MATT service Primary Care/ Secondary Care interface meetings Single Point of Access YES NO Referral complete? Secondary Care Administrator processes: Patient contacts Centre to book appointment MSK Assess, Triage and Treat Service (MATT) Third sector organisations; Oxfordshire County Council; Ancillary Health Services Onward referrals Referrals MSK Referral Access Point (RAP) Clinical paper triage Patient Choice & Booking MSK Referral Access Point (RAP) Clinical paper triage Patient Choice & Booking MSK Assessment Triage & Treat (MATT): Same day diagnostics Person-Centred Care Primary Care Physio & Podiatry Treatment Non-resolving MSK problems (orthopaedic medicine) Medicines advice MSK Assessment Triage & Treat (MATT): Same day diagnostics Person-Centred Care Primary Care Physio & Podiatry Treatment Non-resolving MSK problems (orthopaedic medicine) Medicines advice Urgent secondary care opinion Follow-ups Secondary Care Treatment (Surgery and Paediatrics) Voluntary Organisations Oxfordshire County Council Prevention Peer support Advice & guidance Voluntary Organisations Oxfordshire County Council Prevention Peer support Advice & guidance MRI & CT Scans Library (response time