THANKS to everyone who attended our last meeting. We had a good debate regarding the diabetes service and extended access.
We took a number of questions from shareholders – ranging from contract funding to how we will manage increased prevalence of diabetes. We have captured all the questions, and updated our responses with the very latest information, in a simple Q&A guide.
For 2017/18 they will be based on last year’s actual figures, with the expectation of similar levels of activity in return. For the first 6 months (April to September), our expectation is that all current providers will receive near equivalent payments to this year for those 6 months (i.e. half of 2016/17’s 12 month payment). For the second six months of the year, payments have yet to be confirmed.
We have been told very clearly from the CCG that there are no additional monies available so we have to work effectively and reduce current spend. To deliver this, we expect that the contract and pathways will develop in the coming months and we will communicate to all providers how this will translate into actual payments based on caseloads etc.
Bradford Provider Alliance (BPA) will be developing the diabetes service to improve patient outcomes. This will inevitably lead to changes to the current model and will require all providers to support these changes to make the service more effective and deliver the patient outcomes that we have been set by the CCG.
Level 3 is a specialised and limited service within diabetes. We will still need to provide a specialist service for patients that need this service within the new model and we will work across the BPA to establish the most effective way of delivering this service and achieving the outcomes required. Further, any requests from practices to provide a level 3 service will need to be looked at closely as the limited patient population for this means it can only sustain a limited number of providers if it is to remain efficient.
At present, those patients who currently use the Airedale L3 services (due to location) can continue to do so.
For the first 6 months we are anticipating that there will be no change to providers as we establish the new contract. As we progress, the key criteria will be for any provider to be accredited (and registered with the CQC). We will be able to discuss with these potential providers the service requirements and payment for the service so that they can make an informed decision as to whether this is the right decision for them and their patients.
Obviously, if a new provider comes on board then this will mean an adjustment to payments to other practices as the money will effectively follow the patient.
Our aim is to ensure as much of the money passes through to practices based on their caseload. There may be instances where we have to “top slice” funds to cover unavoidable costs. A good example will be indemnity fees. This is currently being investigated to ensure we have appropriate, best value, protection and indemnity in place to protect our providers.
The biggest individual spend is prescribing. The working groups have been very clear that we need to change the way we prescribe so that we can make real savings that can then be reinvested back into the service, especially with regards to prevention. It is clear from all of the discussions to date that we will need to change current pathways and working practices to release monies for reinvestment into the service.
The new pathway does not set out a minimum number of patient contacts per year, but focuses on patient need and outcomes. This change will free up resource as well as facilitate the move away from the current reporting structure and “widget counting”.
As mentioned above, there is no additional money available for the service and providers will need to absorb small fluctuations in patient numbers. Where there is a significant increase or decrease in patient numbers due to providers starting or ceasing then payments will be reviewed. The intention being that the money follows the patient.
In the long term, prevention and education will play a key part in how prevalence develops across Bradford.
Patients who are housebound will still need the appropriate care and, as above, the reduction in frequency for some patients will release time for those that are assessed as needing home visits.
We will be monitoring the outcomes and service this specific patient cohort receives as evidence shows the outcomes for these patients is below those of other diabetic patients.
We need to better understand the impact of deprivation and its impact on diabetes care. At this stage we have no plans to differentiate patients by levels of deprivation.
The hospitals will have their own budgets and if they overspend, this will not be a risk to BCA.
Initially, all four contracts will be issued for 10 years, but the plan is to novate these to one single contract as soon as practical. Current expectation is that this will be within the first two years and the legal work to do this has already commenced.
Transformation will be ongoing throughout the length of the contract and some areas of transformation that improve patient outcomes and provide a more efficient service are still being developed as the timescales to develop these was very limited. Providers will play a key part in developing transformation and will continue to have opportunities to engage and influence these through workshops and discussions
We see improvements in patient care being driven by transformation and innovation and not by increasing capacity, medication etc. but we will need providers to engage with and support these changes to make them effective.
We are looking to see how we can ensure providers are incentivised to deliver good outcomes for patients by working differently rather than working harder. We need to also consider the impact of any changes on current providers to ensure we do not de-stabilise the current system.
Talks are in progress with the CCG and LMC with regards to payment structures and incentives, with appropriate checks and measures.
Whilst we recognise that there is overlap with ways of working for the core contract, this is not currently an option as it is not possible for the CCG to identify as a tariff and remove from the core contract payment.
BCA also does not have the remit to look at core work unless its Articles of Association are changed.
All contracts will be assessed for risk and not be signed off until all parties are satisfied.
We have been clear with the CCG that BCA will not take on the prescribing risk for the diabetes service. However, we and the Provider Alliance have also been clear that any savings in prescribing must be re-invested in Diabetes and ring-fenced for this service if we are to make a real impact on outcomes across the 10 year contract.
Discussions are ongoing with the CCG re underwriting this over the 10 years and how we deal with cost pressures from a growing population as well as increases in medicines and RPI etc.
As mentioned previously, for us to improve outcomes for our patients we will need to change current working practices and pathways and support each other to provide a high quality diabetic service across all of Bradford.
It needs to be remembered that this is part of the journey to an Accountable Care System (ACS) and not about the risk moving from the CCG to the Provider Alliance. The STP plan means that by 2021 we will all be part of a joined-up health care system.
There will be no change initially in out of hours urgent care. Extended Access (as outlined in the planning document from NHSE) is about extending access to routine primary medical care. This includes both pre-bookable and on the day access to appointments.
The urgent care service provided by LCD will still be in place, but the CCGs would like to encourage BCA to work in partnership with LCD to make best use of the available resources for patients. The commissioners don’t see LCD as being the sole provider of extended hours for BCA, but one of the partners along with the federations in Bradford.
The current LCD contract is up for renewal in 2019 and it is anticipated that this service will look different in the future, with extended hours being rolled out to 100% of the population from 2019/20 across the country.
We need to be clever and innovative with how we deliver the appointments. It is not anticipated that GPs would provide all of the appointments. Delivery needs to be broad with Pharmacists, Physiotherapists, Social Prescribers, Mental Health Workers, Nurses, ANPs all being included.
We also need to think about the logistics of delivering such a service and a hub based model supports this, allowing a GP-led team as above, serving a larger population.
Partnership working is also an option, such as LCD and Network Locum (as used in City CCG and presented at a recent District CF meeting)
There is a possibility of this over time, but as it is a defined number of hours, this can be managed within our organisation.
At present there has been no indication that this will happen after the pilot. There is no current suggestion from NHSE that they will dictate what core general practice is.
The CCGs accept it is a risk but we believe it is a low probability. As the contract stands the flexibility is around how individual practices deliver services – core general practice/essential service provision and the times that this is to be delivered are defined. If the contracts are to change then it would be for the DDRB to negotiate.
Currently they are happy with all appointments that are considered core work. Further, the CCG is happy to see creative ideas to extended access, in fact they would welcome this.
We do not currently have to run our model past NHSE (unlike the Prime Minister Challenge Fund sites) and the operational planning guidance is open around what appointments should be offered – it talks about general practice services, not GP appointments, so the CCG would like to encourage creative ideas as this is how we see the service being sustainable in the long run.
No. We anticipate that extended hours will support access to core access times of 8am – 6.30pm. However, involvement in extended access does not count towards the delivery of the access and demand plans.
In year 1 the service must cover 25% of the population and this includes populations from both City and Districts CCGs. The CCG would like the membership and federations (in partnership with LCD) to establish the hub model for delivery for year 1, which would not be set in stone and could be amended as roll out continues. They would anticipate that this is delivered via a hub model as we do not think that individual practice sites would be sustainable in the long run.
Our current thinking is to work with federations to set up/lead hubs (which it is anticipated that non-aligned practices would also be members of). It is a minimum requirement to have 2 hubs, but it may be more useful to have 3 across Bradford, such as North, South and Central.
This is meant to be normal (routine) work and not an urgent care service and there needs to be a level of trust and assurance within the arrangements that are established. We would expect anyone seen in this service to get an appropriate consultation and referral/investigations as required, which would then be followed up by their own practice. Good quality information within patient records is key to resolving this as an issue.