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Public Health Local Service Agreement - Summary of Changes

Service/ subject Comments/queries Initial Response Action Taken

Contract Will all service specifications be changed and reissued?

We will assess the changes and summarise them as a variation within the end of April timeline. We will then re issue all the service specifications when they have been printed.

This document summarises the changes that will be made to PHLSAs. The current PHLSA agreements have now been extended to the end of May to enable Providers to review the changes.

Data recording system

Need to ensure that data extraction system is fit for purpose and easy to use. Don’t assume that Primis is the best option.

Need to ensure that have input into choosing a system from people who are going to be using it.

Need to make sure that it doesn’t take too much time.

Keith Newman would be happy to discuss the development and provide input to any new system.

We acknowledge the importance of proper engagement with GP Practices and that we build on existing intelligence to identify an appropriate data collection/payment system.

Primis is given as an example of a data recording system and is not being suggested as the solution. Work on the solution is at a very early stage and we have noted the various comments at both meetings around the shortcomings of the Primis system.

To be incorporated in work to take forward data system

Data recording system

There are likely to be lots of errors in reporting when a new system is put in place – will practices be penalised or embarrassed if this happens.

Data extraction will only be as good as the data that’s recorded.

We fully expect that with any new system there will be limitations to the data when we first start using it. We will look to work with practices to address this over time.

Yes, we recognise that any system will need to consider the way that data is recorded and support etc. around this element e.g. existing templates

To be incorporated in work to take forward data system

DBS Concern was raised about DBS checks. Ian Harper, LMC stated that usually those delivering a service should have DBS and other staff should be subject to a risk assessment. Ian would forward the thinking behind this.

To follow when received



DBS GPs are already registered with the GMC. If they are on the GMC any recorded incidents are on public record. All GPs are DBS checked and rechecked when applying for a new job. ESCC DBS checks redundant and bureaucratic.

We are exploring again the DBS requirements with our legal team to ensure that the Local Authority is not exposed to risk whilst trying to find a way that minimises the burden on GP Practices, and to consider how DBS might be applied to groups with particular registration requirements . If this is not possible then we will explore how we might ease the burden of the cost of DBS checks.

Further up date to follow once legal team have finalised their work.

If an extensive programme of DBS registration proves to be essential solely for delivering public health services (I.e. would not otherwise be required for staff member) we will look to fund this

DBS The frequency of three yearly DBS checks is onerous and expensive.

We are exploring the DBS requirements with our legal team to ensure that the Local Authority is not exposed to risk in a way that minimises the burden on GP Practices. If this is not possible then we will explore how we might ease the burden of the cost of DBS checks.



DBS What is meant by delivering ‘part’ of the service?

Are receptionists required to have DBS for your services?

The requirements for DBS vary depending on the type of activity, who is doing it and the frequency. We will supply a summary of where we think DBS may be required for each service.

It is unlikely that a receptionist would be delivering any of our service activity that would be eligible for DBS.





Main contract The terminology of LARC duties carried out by practice nurses has insurance implications for GP Practices because it has been reported that one practice nurse has been deemed to be a nurse practitioner which carries a higher insurance premium where practices insure on an individual basis rather than as a practice

Payment of Sexual health is based on GP unit costs therefore this included indemnity considerations as is a total micro-costed currency and payment. However we will seek to understand whether there are similar implications in other practices where nurses do the service and no other similar activity and link with the LMC on this.

Awaiting further information on insurance requirements.

We understand that where a nurse undertakes surgical or practical procedures not normally undertaken by nurses the MDU recommends that nurses indemnify themselves.

We will review on a case by case basis where practices are proposing to use nurses to provide the service if additional insurance is required to undertake LARC fitting, and work with affected practices wishing to provide a service to address this. This may for example include the potential to cluster provision/fitting services.

Main contract The contract clause on indemnity was raised as an issue as the implications have only just been considered.

The main part of the contract is the same as last year. LMC will review insurance clauses and seek input from practices on their current insurance provision .

We will continue to work with the LMC to understand any insurance implications

Main contract The main contract (4.1, general terms) states that ‘you will employ sufficient staff to cover any sickness absence etc.’ Sick patients are out priority and will take precedence over services such as health checks / smoking cessation.

We will review to see where we may vary the wording.

We will amend wording to:The Provider shall employ sufficient suitably qualified personnel to ensure that the Services are provided in accordance with the Specification including (without limitation) during periods of absence of some members of its personnel due to sickness, maternity leave, holidays, training or otherwise.



NHS Health Check

Are liquid reagents costs paid separately? Yes. Last year it was a fixed fee. We are working with manufacturers to identify efficiencies in the price that practices are charged for reagent (for the brand that the majority of practices are using) because of the volume purchased across East Sussex. Practices will be asked to indicate the actual price paid and we will refund up to the current price

We will add this to the claim form

Payment section updated on p.14 with reagent payment. This will also be added to the quarterly claim form for reimbursement.

NHS Health Check

Are practices required to invite each patient 3 times? £2 per invitation does not cover the postage cost, or the work to code this on practice systems each time. Other services e.g. text which were free now have to be paid for by the practice.

Extraction at the end of the year should show invites 1, 2 and 3 so this will require coding. It is a national expectation that we invite twice. Subsequent contacts can be a reminder via some other method.

We will review the time/cost element for this component of the check

The practice requirement to invite patients has been reduced to 2 times, one invitation plus one reminder (letter, text, phone, face to face) for non-responders. However practices can choose to invite further if they would like to encourage more patients to have their Health Check. Changes made on p.7.

The price for invitation will increase by 50p to £2.50 (nb not all patients will require a second invitation so this is not a payment for 2nd invitation but a single payment for 1 or 2 invitations)

NHS Health Check

Are there additional blood tests for example the serum creatinine tests for those with high blood pressure?

The blood pressure assessment is part of the commissioned NHS Health Check. Assessing for chronic kidney disease is best practice with adults who have a high blood pressure, and this is would be part of further clinical investigations and routine care. The NHS Health Check pathway in Appendix C presents the risk assessment and further follow up.

No further action



NHS Health Check

Are we able to use a tool to determine the eligible population?

There is a free Primis search tool – the link is available in the service specification. If Practices are having difficulty please contact Hayley Martin in Public Health for assistance.

Contact details for Hayley Martin will be circulated.

NHS Health Check

Concern was raised at the amount of data to be collected.

The vast majority of data is already collected as part of health check . The change is reporting this to commissioner (anonymised). Additional data reporting is only required once a system is in place to extract data

Clarification that additional Health Check data will only be collected once a data extraction system has been agreed and is in place is updated on p 15-18.

NHS Health Check

Do we need to complete the annual audit for Health Checks that has been sent to practices recently?

Yes the annual audit form relates to last year, and therefore must be collected. Future data for the 15/16 service will be collected only when a new data extraction system is in place.

No further action

NHS Health Check

Even if targets are aspirational practices do not wish to receive emails reminding them of their repeated failure to reach the aspirations. It would be acceptable to provide a summary of progress

We will look at the way that we feed back to practices

Public Health will send quarterly summary of progress to each practice, showing their practice progress, and the progress of their CCG, for information.

NHS Health Check

How do practices ensure that their staff meet the competencies in Appendix E

This is usually through checking staff have attended the training.

We will develop a supplementary sheet for health checks detailing in a straightforward way the actions that practices could take

A supplementary sheet will be distributed to all practices.

NHS Health Check

Inclusion of patient survey in existing leaflet is fine, but patients are not likely to return the survey. Are there any penalties for not achieving 20% self- return rate

No this is an aspiration we will monitor this to see how can encourage patients to return their surveys. We will re word the specification to make this clearer.

Wording has been changed on page 14.



NHS Health Check

It is quite likely that some of the data extracted will be flawed, as data extraction is dependent on the quality of data going into the system.

We understand that the data extraction is dependent on the quality of the data being coded into the system and this is why we have specified the read codes that should be used in local templates. Those using national clinical system templates like EMIS WEB will be based on these nationally specified. We have realistic expectations and anticipate that early extractions will highlight gaps in data quality and we will work with practices to improve this moving forward.

Further work will be undertaken with practices in 2015

NHS Health Check

Practices are happy to report data through an extraction system or through a data facilitator coming into practice as long as it is not extra work for the practice.

No further action

NHS Health Check

Some of the practice representatives who attended the meeting had not seen the East Sussex patient results leaflets.

Starter packs of the patient results leaflets were sent to all GP Practices, with details on how to order more from the Health Promotion Resource Centre. The new print run including the patient survey would soon be printed & sent to all practices.

All practices will be sent copies of the new patient results leaflet including patient survey in May.

NHS Health Check

There is a limit to the amount of information/completed surveys that patients will provide.

We will ensure that our expectations are realistic.

KPI wording amended to reflect that return rate is an aspiration



NHS Health Check

What are the implications for practices not achieving KPIs in the service specification?

Are there any financial penalties?

KPIs are included as an indication of quality in the health check and are based on national requirements e.g. all eligible people offered a health check every 5 years. The only KPIs to be reported prior to having a data extraction system are: Number of people offered a check, number of people receiving a check (this is reported nationally and also enables payment to practices). There is no claw back for not achieving KPIs. Practices are paid for each health check given.

Practices who signed up to the POCT grant scheme did so on the basis that they would take all reasonable steps to ensure that they offer tests to 20% of their eligible population during 2014/15. The grant scheme contains the potential for ESCC to reclaim grant funding should the Practice have not made not made satisfactory progress towards inviting those 20%. The vast majority of practices offered 20% in 14/15 and based on current performance we expect all practices who choose to continue to offer health checks to achieve 20% 15/16. We will contact any Practices who have fallen significantly short, to discuss whether the shortfall can be addressed and how to best achieve the desired outcome.

We will change language in service specification to ‘aspiration’ for all KPIs other than 20% invited (because this is part of the mandated service we are required to have in place).

Wording has been changed on p‘s 15-18 to reflect aspiration and working towards indicators.



NHS Health Check

What are we actually expected to do – it looks far more onerous? The time needed to undertake the checks must be longer and is unrealistic. For example, dementia awareness is new.

The NHS Health Check and assessments included have not changed, the Health Check is the same so we don’t anticipate that the time to deliver the check will change. Nationally it is expected the check would take 20-30 minutes. The dementia awareness element was introduced in last year’s service specification and forms part of the national mandated service. It is an intervention for those aged 65-74 having a Health Check to raise awareness of the signs & symptoms of dementia and signpost to their GP if they believe they have these symptoms for consideration for memory assessment. A short 20 minute online learning module is available (in Appendix E) on dementia awareness in the Health Check and a free leaflet that can be given to patients (p.11 in service spec).

No further changes

NHS Health Check

When exploring new data systems, please would you also include and collaborate with those that will actually use it.

Yes we will keep you updated on this development as it progresses and include practices in this process to ensure the solution proposed is fit for purpose for all practices and clinical systems.

We will work with practices in 2015

NHS Health Check

Where is information made available on resources and training etc? DXS is not used everywhere.

We will ensure this is on ESCC website, DXS and Map of Medicine or any other practice information system

ESCC website to be updated and we will liaise with CCG on appropriate practice systems to include information



NHS Health Check

Will we be penalised if we offer a health check to one of our patients and we find they have had a health check elsewhere e.g. at work in another county e.g. because we are sent their results

When identifying and inviting eligible patients for a check, all patients who have had a health check in the last 5 years should be excluded. Therefore if the patient has had a health check by another provider and the results have been sent to the practice, they should be recorded in the patient record and therefore they are not eligible for a check by the practice. However if the practice provided the check first and was subsequently repeated by another provider then the practice would be paid for undertaking the health check on their patient so wouldn’t be penalised for this.

No further action

Review process It would be easier if the LA worked with the CCGs to use the same process that the CCGs use for their locally commissioned services.

Our approach has been based on needing to meet the councils Procurement and Contract standing orders. We are aware that the approach this year hasn’t worked as well as we’d hoped. However, we will look and see how we can do this differently in future including if there is any scope for aligning with processes that CCGs are using

We will work on our processes during 2015/16

Review process It’s not enough to hold the Provider Forum or other meetings solely in Eastbourne/Lewes.

Provider Forums are meetings for all providers of PH services and are usually held in Eastbourne . The working group to review PHLSAs were held in Lewes. We will ensure that meetings are rotated around the county.

No further working group meetings are planned at this point



Review process Please could nurses and Practice Managers be included in the review process as well as GPs?

Please can you note that August, December and January are not good times for GPs

Our invitations were sent to the Practices and not to GPs direct.

We will review our process including when meetings are held for future years


Review process Who represented GPs in the working groups?

All practices sere invited by only 2 practice staff attended. The LMC attended but LMC have said that it would be beneficial to have more engagement from GP Practices. Public Health have acknowledged that despite best efforts the process did not work well this year and will reconsider the review process.


Sexual Health How often is the STIF training offered? Every year if there are enough attendees to warrant continued funding. We will raise the profile of available training further. Please email Tony [email protected] direct if training availability is unclear. In addition there will be an annual free contraception and sexual health update day run by local sexual health services, and free training for IUCD and SDCI is available via the local specialist services and Meridian practice.

Information on training will be circulated by the sexual health commissioner

Sexual Health How quickly can someone be re-accredited?

Can fitting requirement be averaged over number of years?

If already accredited then need to be observed fitting. New guidance is set out in the links from the service specification to FSRH guidance.

It is a FSRH requirement that GPs/Nurse fit 12 coils/6 implants per year. There is no ability to average out fittings over 3 years.

No additional action (see also training response below)

mailto:[email protected]



Sexual Health Concern was raised regarding the cost effectiveness for practices who fit very few IUD or SDI’s because of training time etc

Some areas have chosen to cluster these services in one practice.

No further action

Sexual health Is sign up to sexual health PHLSA dependent on sign up to C-Card? This would prevent some practices signing up to the sexual health PHLSA’s.

Yes it was included as an expectation. This was to enable practices to receive free condoms for distribution. We will clarify that this is not a requirement and practices are free to choose to sign up or not. .

Requirement to sign up to C-Card will be removed from the specification



Sexual Health Follow up payment has been removed from the PHLSA in EHS and HWLH. Patients come back to practice for follow up appointments for a range of reasons. It was suggested that around 25% of patients come back in one surgery.

New DRAFT guidance also removes need for follow up appointments. However we will include in the specification a follow up payment at the 14/15 payment rate until such time as the DRAFT guidance is issued

We will explore the rate and reasons for returns further. Currently our understanding is that patients come back for range of reasons, many of which may be covered by theAdditional services element of the GMS contract e.g. where alternative contraception is sought or wherepatients using Mirena for bleeding disorders (not covered by PHLSA ) they are more likely to returnPatients should be informed of self -check methods to limit returnsAnnual checks and thread checks have been removed from the current guidance.

We will revise specification to re-instate follow up appointment in HWLH and ESH and also include in H&R (this was not included previously in this area).

Follow up payment of £21.63 has been re-instated in HWLH and EHS and will be offered in H&R until new guidance is published.

Sexual Health The Commissioner reported that some practice managers had reported the annual audits are onerous and difficult to understand because although they had always been in the specification practices had not been completing them

We will improve the wording and template so that requirements are clearer.

New templates will be issued



Sexual healthC-Card

There is no payment for registering, why not as this is the most onerous part and is required to deliver the service as specified?

Registration is not an essential part of the service. Section 4.1 of the service specification states that providers may choose to offer:• registration and distribution, or;• distribution only.There are a sufficient number of locations where registration services are on offer to young people e.g. through a range of services in youth and community settings. The services currently providing registration to young people are not paid to offer this. It is hoped that General Practices offering distribution services will increase the reach and availability of C-Card products. General Practices participating in C-Card may wish to offer registration in order to drive throughput of distribution services. We will update the wording to emphasise that offering C-Card registration is optional.

No further action

Sexual Health / IUCD

Coils and implants can be difficult to remove

Complex IUD removals and none palpable or deep implant should be referred to specialist sexual health who have received nationally recognised training to deal with these complications (Do not refer to gynaecology). GPs are still able to claim for failed attempted simple removals even if the patient subsequently ends up being referred to specialist sexual health.

No further action




IUCDs require two 20 minute appointments – 1st appointment for STI screen and 2nd to fit. How are STI screen appointments funded?

There was a suggestion by one practice that STI screen is funded through STI PHLSA (this is a problem for practices who are not signed up to this).

Chlamydia self -test not used for STI screen because GPs don’t get the results and results wouldn’t be back in time or patient may not use self-test but return for fitting appointment without a screen being done

Our understanding is that this is covered as part of the contraceptive assessment under Additional Services in GMS contract, as set out below. We are checking this. The contraceptive services commissioned by NHS England area teams are an “additional service” defined in the standard GP contract (clause 9.3.1) as follows:1. The giving of advice about the full range of contraceptive methods Including advice regarding IUD and SDI as they are part of the whole range2. Where appropriate, the medical examination of patients seeking such adviceThis would cover the assessment and taking of swabs, The local authority is responsible for the fitting of the IUCD and removal

No further action. Checking with other commissioners indicates that payment for pre coil swabs is not routinely included in Local Authority coil/implant service specifications as we understand that payment for first appointment is covered in Additional services. If Chlamydia self-test is used for 15 to 24 year olds by practices signed up to the chlamydia PHLSA payment will continue to be available for this




PHLSA price for IUCDs is priced at lowest benchmark. This is disappointing.

The price was derived from benchmarking and costing time to undertake using PSHRU unit costs, using GP Unit costing (GP prices used rather than nurse). Unit cost price was lower so we proposed to continue with existing price. Many benchmarked services are being reviewed as based on old practises and GPs undertaking tasks (nurses can now do this). Time to fit has been raised separately (see above) so we will look at the time factor again.

As above. We have also re-checked benchmarked prices. The latest information we have received to date indicates that prices now range

IUCD insertion IUCD removal

highest

85.00 but this includes any removal and follow up as an episodic payment

65.00

lowest 65.00 including removal

0.00

Service priced at PSSRU GP unit costs including qualifications which include all practice costs (and direct staffing costs, not just GP).


PHLSA says that removal and fitting in one appointment just paid as a fitting. More time is required for fitting and removal.

We will look to remove this line and retain separate fitting and removal price

We will amend the PHLSA to pay separately for removal and fitting

Removal and fitting amended to separate payment


Routine clinical practice in GP practice is to have 2 people present for coil fitting . HCA’s aren’t always available and nurse may have to be used – this adds extra cost.

Guidance indicates that 2nd person only required because of potential for cervical shock not as chaperones.

However, if this is routine practice in primary care we will look at the implications of this and check the PSSRU Unit costs.

Service priced at PSSRU GP unit costs (‘including qualifications’ rate) which include all practice costs (and direct staffing costs, not just GP)




Training and CPD requirement for IUCD is onerous

Improvements have been made to availability of training e.g. nurses can train doctors and sessions can be arranged to cover required number of fits quickly. Training requirements are based on Faculty guidance and are a national requirement

We have sought further advice and clarification on training requirements from the FSRH. They have indicated that practitioners fitting coils and implants should assure themselves that they are competent to do so. The best way of doing this is to complete the FSRH training. We will continue to require providers to have completed the FSRH training. However we have added transitional arrangements into the service specification to enable practitioners who have completed equivalent training to continue to provide the service and either transfer their training to FSRH (in the case of RCN certification) or to undertake FSRH training in the course of the year.FSRH accredited training (full course or to support re-certification) will be provided by the Specialist Sexual Health Service and /or Meridian Practice accredited trainers).

Information on training courses will be available through the links/contacts included in the service specification.



Smoking Cessation

How much are Quit 51 paid per quit? The specialist service is paid a single price for all of the activity they undertake. This includes face to face, web and telephone stop smoking services, training and support to other providers, provision of equipment to other providers, marketing and promotion of services, direct supply of NRT to patients, provision of Quit Manager data base, specialist smoking advice to partners etc.

No further action

Smoking cessation

In addition to the time seeing patients there is a lot of additional work undertaken following up patients who do not attend their appointments.

The historical price for smoking cessation was too low because it didn’t take account of this extra time.

Where services are run as clinic sessions there are fixed costs of nurse/HCA time if patients don’t attend. This is less of a problem for patients seen in treatment room time

The additional resources for 4 week quitters (£95 compared with £45) was intended to off- set costs of non- quitters).

We will review the balance between outcome based payment and time to chase up DNA patients and look to understand better issue of DNA in primary care services

Payment of £20 for patients receiving full intervention but not quitting has been amended to payment of £20 for all patients setting a quit date.

We will keep quit rates under review to ensure that the balance between quitters/non quitters is within the expected thresholds in line with DH exception reporting ( 35-70% quit rate) and add a review process to the specification were rates fall below threshold

Smoking cessation

Moving to outcome based payment is too big a risk for practices because there is concern that practices may not be able to cover their costs, especially with high DNA rates. Patients who DNA may not appear as lost to follow up in smoking data because practice staff chase them up and re-book their appointment.

We will review the balance between outcome based payment and time to chase up DNA patients and look to understand better issue of DNA in primary care services

As above



Smoking cessation

Practices are experiencing difficulty logging on to quit manager to check their data and reconcile with payment received

We will follow this up with Quit 51. In general Quit Manager log on difficulties can be referred to [email protected]

We will ask Quit 51 to email all practices/pharmacies to check if they have issues with Quit Manager

Smoking cessation

Practices see a lot of people who are harder to help stop smoking such as people with mental health problems.

Specialist service is commissioned to focus on patients who are harder to treat such as MH, pregnant women. It may be that we need to review pathways to make sure that people are supported into the right service.

We will develop and circulate pathways for stop smoking services during 2015/16

Smoking cessation

There are additional costs of buying equipment (smokelyser), mouthpieces and for calibration of equipment

All kit and consumables should be provided free of charge to practices. Calibration available FOC at update sessions held by specialist service.

We will check that this is happening and feedback to all practices how to access this support.

We will ask Quit 51 to email practices and pharmacies reminding them of how to access free consumables and calibration

Smoking cessation

There have been some issues with payments. Also there are difficulties with log on to the Quit Management system. Practices want access to information to see what they have been paid.

Any difficulties with payments should be referred to [email protected]. Claims are processed by the Public Health team and remittances sent to Practices.

No further action

Substance misuse

What are the dates of the next training? Daniel Parsonage to follow up. The substance misuse commissioner will follow up with information on training



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