Proposed changes to how practices are funded to manage people living with Long Term Health Conditions

A PRESENTATION FOR CPPEG

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There is strong evidence that early identification leads to better care

Since Oct 2013 the CCG has funded practices to…

Actively find people who are living with or at risk of any of the following conditions:

• Hypertension (persistently high blood pressure)

• Diabetes• Chronic Kidney Disease• Heart Failure• Chronic Obstructive Pulmonary

Disease (lung condition)

Working with the people of Camden to achieve the best health for all4

And…

Regularly review and monitor people who are most struggling to manage their condition

• People living with Heart Failure and COPD – review every 6 months

• People living with Diabetes – care plan every 12 months

Embed treatment templates and protocols – ensuring high standards in all practices

“It’s a bit more thorough now. They talk about diabetes and all the aspects of my condition….”.

October 2013November 2013 December 2013

January 2014 February 2014March 2014

April 2014 May 2014June 2014 July 2014

August 2014

September 2014October 2014

November 2014 December 2014January 2015 February 2015

March 2015April 2015 May 2015June 2015

0

2,000

4,000

6,000

8,000

Number of all diabetics with Hba1c < 9%

(75mmol/mol)

0

2,000

4,000

6,000

8,000

Number of people on practice diabetes

registers

Measure NamesNumber of people on practice diabetes registers

Number of all diabetics with Hba1c < 9% (75mmol/mol)

We know that this is making a difference“It’s now a discussion

between the two of you,

which is how it should be.”

Prevalence

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Diabetes RegisterSize along

RelativeDate

CKD Register Sizealong RelativeDate

COPD RegisterSize along

RelativeDate

Heart FailureRegister Size

along RelativeDate

HypertensionRegister Size

along RelativeDate

Register Sizealong RelativeDate

0%

5%

10%

15%

20%

25%

30%

35%

No

rth

8.0

8%S

outh

17

.00% W

est 6.9

9%N

ort

h2

0.5

9%Sou

th2

7.6

6% We

st 7.7

5%N

ort

h1

7.7

9%Sou

th2

2.1

9%We

st 23

.88% N

ort

h1

9.1

6%Sou

th3

1.3

0% We

st 9.5

8%N

ort

h1

6.1

9% Sou

th11

.26

%W

est 10

.53% N

ort

h6

.33

%Sou

th11

.10

%

We

st 4.3

3%

Sheet 49Locality

North

South

West

Diabetes Register Size along RelativeDate, CKD Register Size along RelativeDate, COPD Register Size alongRelativeDate, Heart Failure Register Size along RelativeDate, Hypertension Register Size along RelativeDateand Register Size along RelativeDate for each RelativeDate (MY) broken down by Locality. Color shows detailsabout Locality. The marks are labeled by Locality, Diabetes Register Size along RelativeDate, CKD RegisterSize along RelativeDate, COPD Register Size along RelativeDate, Heart Failure Register Size along Relative-Date, Hypertension Register Size along RelativeDate and Register Size along RelativeDate. The view is filteredon RelativeDate (MY), Locality, Diabetes Register Size, CKD Register Size, Heart Failure Register Size, Hyper-tension Register Size, COPD Register Size and Register Size. The RelativeDate (MY) filter keeps October 2013and July 2015. The Locality filter keeps North, South and West. The Diabetes Register Size filter keeps non-Nullvalues only. The CKD Register Size filter keeps non-Null values only. The Heart Failure Register Size filter keepsnon-Null values only. The Hypertension Register Size filter keeps non-Null values only. The COPD Register Sizefilter keeps non-Null values only. The Register Size filter keeps non-Null values only.

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£To achieve targets for register sizes both individually and as a locality (promoting federated approach)

Current Payment for GPs

£For each clinical review for defined groups of people

£For improvements in the number of people with high blood glucose levels

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Proposal for the next Phase (from April 2016)

1. Practices to deliver at population level - 50,000 patients plus

2. Practices come together to develop plans for how to deliver service

3. Upfront payment to give practices capacity to make sustainable changes

Also:Include other diagnoses eg cancer, epilepsyBring in contracts for Complex Care, Serious Mental Illness Minimum quality standards3 year agreement

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What will this be like for Camden residents• More people who have a Long Term Condition will be

proactively reviewed and have a Care Plan

• Those living with a Long Term Condition will have better support to manage clinical indicators such as blood pressure, blood glucose and to quit smoking

• People living with epilepsy who are struggling to manage will be proactively contacted by their GP to discuss their condition

• GPs will be well equipped to identify the symptoms of cancer at an earlier stage

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Timeline.