NORTH LIVERPOOL PRACTICE BASED COMMISSIONING CONSORTIUM

SERVICE CHANGE PLAN 2010 - 2011

1. Introduction
2. Vision
3. Summary of Progress 2009/10
4. Health Profile
5. Priorities and Targets
6. Demand Management
7. Unplanned Care
8. Health Improvement Model
9. Medicines Management
10. Financial Management
11. Incentive Scheme

1. Introduction

Practice based commissioning plays an important part in the future of healthcare in

Liverpool through clinical engagement, both as one of the major mechanisms to reduce
expenditure and in developing the infrastructure that will allow the downsizing of local
acute trusts.

The previous Service Change Plan was intended to cover 2009-12, providing the PBC
consortia with a degree of stability rather than confining plans to a twelve-month period.
However, as the impact of the current UK financial situation has been modelled, it has
become clear that the priorities of the PCT and, to some degree, the focus of PBC needed
amending. The vision and many of the projects in the 2009 Service Change Plan remain
the same and continue but some of the mechanisms are changing and the urgency to
deliver changes in activity and costs is recognised.

2. The Vision for the Consortium

The Consortium believes that practice based commissioning will be a major force for
improving services for the foreseeable future. The Consortium is not strictly part of the
PCT, but seeks to achieve the same goals; improving the health of the population. This is
best achieved through a partnership approach – the Consortium supports the PCT in
achieving key performance targets and the PCT supports the Consortium in developing
local services.

2.1 Principles

The Executive Committee identified a number of principles that should apply to services
commissioned by the Consortium. These are:

• The Consortium to move towards a neighbourhood approach to care delivery. Each of

the four North PBC Neighbourhoods will act as the focus for local provision of health
related services. Each Neighbourhood will co-ordinate a network of service providers
within its locality, matching patient need to service availability including models for
health improvement (eg Health Trainers / Health Homes / Social Prescribing).
• Commissioning will focus on appropriate priorities
• Services will be delivered in the appropriate setting and should only be shifted if there

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 is a good reason for the change. Standards for care delivery will be mirrored in each
setting.
• Changes should aim for joined up care and proactive identification of gaps between
services
• There should be community engagement and a patient focus
• There should be equity of investment to reduce inequalities in health
• It is the role of the Consortium to support capability and capacity in primary care to
support the priorities of the Consortium.

3. Summary of North PBC progress 2009/10

3.1 Emergency Admissions

The incentive scheme for 2009-10 set targets for practices to focus on reducing
admissions for ACS conditions. Whilst there is still significant work to do, the Consortium
has focussed on this area as a part of the 2009/10 Incentive Scheme with a forecast under
spend on the planned spend. The Consortium has continued to focus on COPD through
the Six Step Approach. Following its success within the Consortiuma a further role out
programme across the 3 other Practice Based Consortia within the PCT is being co-
ordinated. Headline figures in terms of success from this project is a 29% reduction in
acute exacerbations of COPD in primary care and a 47% reduction in emergency
admissions (for one Neighbourhood only).

3.2 Referral to secondary care

The 2009/10 incentive scheme set targets for practices to reduce referrals to secondary
care and practices have been encouraged to use peer review as well as review of
correspondence from secondary care post referral, to ensure appropriateness.

The Consortium has focussed on ENT, Urology, Gynaecology, Dermatology, T&O whilst
monitoring progress against general surgery, rheumatology, gastro, vascular, cardiology
and ophthalmology. The Consoritum has achieved reductions in referrals to the agreed
specialties for NORTH PBC overall

Across the 11 specialities the Consortium has an overall under spend.

3.3 Consortium Engagement

This remains strong with more than 75% of general practitioners at monthly
Neighbourhood and quarterly Congress meetings. Additionally, 80% attendances of
practice clinical and non clinical staff at the Six Step COPD Project education sessions. In
addition to an Executive Committee of five general practitioners and 2 practice managers,
individual Consortium general practitioners have led on specific pieces of work on behalf of
the Executive (eg A&E / cardiology / gastroenterology).

To support deliver of the Service Change Plan, the Consortium has recruited two
Neighbourhood co-ordinators who will support practices to embed the new pathways and
ways of working. These co-ordinators will also support practices with the systems and
processes required to deliver improvements in QoF and ISGP scores. The Consortium is
proposing a Reference Guide for practices outlining the Incentive Scheme targets, referral
templates and pathways to be adhered to as well as other supporting information which
will be updated on a quarterly basis.

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4. Health Profile of North Liverpool

A key part of the movement towards a neighbourhood approach will be the development of
local health profiles. North PBC is made up of wards with significant deprivation and health
issues which reflected in this plan.

5. Priorities and targets – The Approach for 2010/11

The Service Change Plans for all the PBC consortia are based upon the same themes:

• Improving primary care

• Demand management – reduction in planned and unplanned care
• Medicines Management
• Financial management
• Demonstrating the impact of new services

5.1 Improving Primary Care - Improving standards in general practice

The Improving Standards in General Practice indicators remain an important way of

judging the quality of primary care services. The indicators have recently been reviewed
and changes made.

The Consortium has a role to play in supporting practices to increase their level of
achievement on ISiGP, particularly for:

o Clinical and non-clinical QOF – practices with high scores on this indicator have put
in place robust systems and processes. We will be working with a number of
practices to advise on how to make their systems more effective and will continue to
offer this support.

o ACS conditions – the Consortium will be supporting practices with systems and
process to manage ACS conditions through the communication of pathways and
protocols as well as data validation throughout the year.

The main mechanism for improving achievement of these standards will be through the
neighbourhood, Congress, Practice Nursing and Practice manager meetings. The
consortium will use these to roll out pathways and protocols as well as provide education
sessions and review of Neighbourhood progress against agreed targets.

6. Demand Management

6.1 Planned Care

Although referral rates for Liverpool Health Care have reduced, the Consortium is still
above national rates and further reductions should be possible.

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6.1.2 Gynaecology

This new primary care service procured through the Any Willing Provider model will go live
on 1 April 2010. The service will manage a significant part of common Gynecological
problems that are currently being referred to secondary care in a community care setting.
The new service will change patient experience by increasing choice, avoiding
unnecessary attendance to secondary care and the associated cost, offer care closer to
home, and increase access to services within a shorter time period. A key component of
the Service will be to increase the knowledge and skills of all General Practitioners in the
management of routine Gynaecology. This will take place through education sessions run
by the Providers across Liverpool and via management plans prepared for each patient
following their visit. EMIS web will support the information element of the service. The
service is expected to reduce 4,000 new referrals to Liverpool Women’s Hospital per
annum.

6.1.3 Gastroenterology

The North Mersey Dyspepsia Care pathway has been agreed and will be launched during
Quarter 1 2010/11. SC Consortium will adhere to this pathway, a key feature of which is
the testing for the Helicobacter pylori bacteria via the primary care urea breath test service.
This is being commissioned for Liverpool patients as a Local Enhanced Service from 1st
May 2010 and should significantly reduce the number of patients referred for a scope and
the number of patients referred for an outpatient appointment.

6.1.4 Vascular

Adherence to the Claudication pathway with ABPI testing in Primary Care. Wherever
possible the Consortium will endeavour to provide coverage at Neighbourhood level for
this service.

6.1.5 Cardiology

Implementation of the palpitations pathway.

6.1.6 Trauma and orthopedics

The Consortium will continue to utilise T&O services through:-

• Appropriate utilisation of MCAS

• Embedding pathways for the management of upper and lower limbs
• Utilisation of the Locally Enhanced Service for joint injections

6.1.7 Urology

Implementation of agreed pathways and utilisation of LUTS service

6.1.8 Dermatology

Appropriate patients referred to the community based ICATS service

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6.1.9 ENT

Community based ear care clinics

6.1.10 Surgery - Follow up appointments

The value of post-operative follow up has been debated for many years. For many
procedures there are no agreed follow up criteria, resulting in wide variation in
appointment rates between both hospitals and also between surgeons in the same
hospital.

There is evidence that, for many procedures, patients without follow up do not have a
larger complication rate than those with a routine post-operative appointment. Discussion
with general practitioners indicates that most post-op complications are picked up in
primary care, usually within the first one to two weeks. However, GPs do not have access
to a timely system that allows them to return the patient back to the surgeon if appropriate.
For some patients the only way to access a surgeon is through the Emergency
Department.

There is evidence that a number of procedures do not require follow up for the vast
majority of patients. This is supported by the fact that most surgeons have changed their
practice and do not routinely follow up many procedures

Liverpool Health Care Consortium is working with surgeons at the Royal to identify
procedures where a routine follow up appointment is not necessary and to put in place a
system to allow a GP to refer a patient for a same day / next day review by a surgeon,
possibly utilising the existing HOT clinic arrangements.

Following a pilot within LHC Consortium, North PBC will adopt this process.

7. Unplanned care

The unplanned element of the Service Change Plan will focus on the Consortium’s
approach to reducing non-elective admissions and AED use by focussing on:

7.1 Patients with multiple admissions

The Consortium has put in place a programme to identify patients with multiple admissions
for a particular condition. This information is fed back to their GP and the practice is asked
to review the patient to make sure they are receiving appropriate treatment and, if
necessary, referred to a specialist.

7.2 Patients with multiple attendances at AED

The Consortium audits AED data to identify patients with multiple attendances. Practices
will be putting processes in place to review these patients as appropriate.

7.3 In Hours Attendances at Aintree AED

In partnership with Sefton and Knowsley PCTs and Aintree Hospital, a retrospective study
will take place during May 2010 to understand the detail behind the data of 7 days

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attendances at the A&E department. This will be combined with a patient questionnaire to
understand patient choice of venue for unplanned care. The results of this study will feed
into the QIPP Urgent Care Programme for consideration of a model of care to reduce in
hours attendances which should be treated elsewhere.

7.4 Zero length of stay

North PBC will audit to identify whether there are particular conditions that account for zero
LOS and, if so, develop means to reduce the incidence.

7.5 ACS conditions not covered by major projects

The list of ACS conditions includes admissions for a number of problems which may cause
sizeable numbers of admissions but which have not been considered by the Consortium
as the focus has been on admissions due to long term conditions. The Neighbourhoods
will review each of these areas through sampling patient records to identify potential
primary care issues and, if appropriate, develop guidance on primary care management.

7.6 Heart failure

Liverpool Health Care is leading a project to improve the quality of care and management
of patients with heart failure.

Objectives

o To reduce the number of emergency admissions and readmissions due to heart

failure, relative to the recorded prevalence
o To improve the quality of life of patients with heart failure
o To reduce unnecessary costs

In 2009 a pathway way agreed and the aim for 2010 is to implement this pathway. This will
take place in two phases.

The initial phase, of approximately six months, involves the establishment of the
necessary infrastructure to deliver high quality care and management of
heart failure

o Improved diagnostic processes

o Disease registers
o Support for self care
o Clear roles and responsibilities for all services and staffing groups
o Clinician competencies, particularly for practice nurses
o Optimal drug therapy
o Referral to, and discharge from, different services
o Development and implementation of management plans

This will involve:

o Agreeing measures of success, KPIs and mechanisms for data collection

o Accurate disease registers in primary care
o Defining and supporting practice nurse and specialist nurse competencies

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 o Monitoring and improving prescribing
o Referral criteria and processes to reduce inappropriate referrals to specialist
services
o Referral criteria and processes to improve appropriate use of HFSN team
o Aligning community nurses with the HFSN team
o Identifying the impact of the pathway on all clinician groups
o Establishing pathways for non-emergency admissions
o Defining content for standardised patient education
o IT solutions for transfer of clinical data between secondary care clinicians and
between secondary care and primary care

The second phase involves the mainstreaming of processes developed in the first phase
across all practices. Some changes may not be complete or may not have delivered the
required outcomes and may require further input.

Currently the HFSN team accept referrals for patients with LVSD. In the first phase on the
programme the team will accept all newly diagnosed heart failure patients from the ten
pilot practices. Rolling out wider criteria for the second phase will only be undertaken as
part of a review of the service specification and contractual changes.

The Steering Group will not expect major changes in the outcome measures from the first
phase of the project. Ongoing audit of KPIs in the second phase should demonstrate
improvement in outcome as well as process indicators.

7.7 COPD

Since 2008 the Consortium has focussed on COPD utilising the Six Levels approach. This
will continue in 2010-11 with the aims of:

• Reducing the number of emergency admissions for COPD

• Reducing the mortality rate for COPD

As the Six Level approach comes to an end within the Consortium, consolidation is
required to ensure the early wins are sustained. The key to management of COPD is the
effective use of inhaled medication. Review of COPD patients will be the main focus of the
Medicines Management Team support to North Liverpool PBC through 2010 as well as
embedding the pathways to develop from the COPD QIPP group.

In October 2009, the focus for COPD shifted to a city wide footprint (Royal and Aintree
facing) and in December 2009 moved to a North Mersey approach as part of the QIPP
agenda which Liverpool PCT is heavily involved in. This has resulted in a change of focus
for the Liverpool PCT Project Team for COPD and the need to define a clear model of care
for COPD patients in Liverpool. More detail in relation to the COPD work proposed for
2010/11 can be found in section 7.2.1.

Alongside this, work is underway to define the model of care for COPD patients in
Liverpool in line with the development of the general practice specification. The pathways
and the Liverpool model of care for COPD will be formally agreed by April 2010 and it is
anticipated this will take a period of 12 – 15 months to implement and any benefits to be
realised. In order to meet the timescales of the QIPP programme, there are a number of
“quick wins” to be identified which will achieve the goals set i.e. a reduction of 10% overall
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cost by December 2010. A process for deciding these areas of work has been developed
along with criteria for selection and this will be led by the members of the clinical pathways
work stream and presented to the QIPP Management board in April 2010 for approval.

Each consortium will be required to fully participate in the implementation of the model of
care. Practices will do this by effectively managing COPD patients in line with agreed
standards of care and to the agreed clinical pathway.

7.8 Diabetes

The Consortium will implement the North Mersey Pathway through the agreed Liverpool
Model. Implement strategies to reduce complication rates. Reduce gap between expected
and actual prevalence rates, increase percentage of patients with HbA1c at or below 7%.
Continue to achieve the offered and screened targets for retinal screening. Reduce the
variability in practice provision and agree the model of care for more complex patients.

7.9 Paediatric Asthma

The paediatric asthma pathway was developed several years ago but was never
successfully implemented; North PBC will implement this pathway during 2010/11.

Implementation will involve:

o Review of admission data by practice

o Educational events for GPs and practice nurses
o PDSA cycles that encourage practices to review their own systems and processes
o Regular feedback of activity and cost data

8. Neighbourhood Health Improvement Model

The clear and unequivocal intent of Liverpool PCT is to address health inequalities and
secure meaningful health improvements for our communities. The need to work with local
government, the third sector and independent sector has never been greater, if we are to
raise our ambitions, and meet the challenges of addressing health inequalities, and
promote health and well-being in local communities. Health inequality in Liverpool is
significantly based on postcode and the neighbourhood you live in. It is therefore
necessary to develop an approach to tackle health inequalities and secure health
improvement that has a neighbourhood focus. Ellergreen Neighbourhood has launched
the Health Improvement Model with a disease prevention focus around Health Homes,
Health Trainers and Social Prescribing.

9. Medicines Management

Medicines use is one of the most important tools for a GP and accounts for substantial
proportion of the Consortium’s expenditure.

Cost reduction

Better care, better value indicators

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Statins – statins have been part of the better care, better value indicators and therefore
PBC targets for several years and, although there are still savings to be made, there is a
lack of enthusiasm for further switches to low cost statins in existing patients. Instead, the
work of the MM service will focus on appropriate statins for newly prescribed patients.

It is well documented that many patients do not take medication as intended by the GP
and there is evidence that this is a particular problem with drugs for asymptomatic
diseases like hypercolesterolaemia and hypertension. The MM service will identify and
review patients who are not achieving cholesterol targets due to poor compliance. In the
short term this will avoid the need for more expensive drugs of higher potency and, in the
long term, reduce hospital admissions.

Low cost statins

High cost statins still high cost area although less growth. Atorvastatin top spend drug
accounting for 6.2% of total drug spend, patent to expire mid 2011 although likely to have
at least 6mth extension (recent paed research completed which can grant 6mth
extension), so probably will be mid 2012 before prices significantly drop. Consortium is
below PCT average. There are still some gains from considering switching patients on
atorvastatin 20mg/rouvastatin 5mg, 10mg and reviewing patients on atovastatin 80mg
3mths post ACS

Clopidogrel

Accounts for 2.2% of spend, 5th top spend drug. Now off patent, price reducing.
Consortium above PCT average with potential gains to ensure all new patients reviewed
after 12mths

PPIs

Esomeprazole , while reducing, still accounts for 0.9% of spend (10th top spend drug).
Pantoprazole now off patent so with 3 low cost PPIs further potential to reduce use of high
cost options (esomeprazole and rabeprazole).

Low cost statins Clopidogrel Low cost PPI

Consortium at 3rd 60.1% 445.5 85.4%

qtr 2008-9
Target for 2009-10 Min of 60% aim 421 Min 85% aim for
for 63% 88%
Consortium 61.7% 403.5 87.4%
Current position at
3rd qtr 2009-10
PCT current 63.6% 357 87.6%
position at 3rd qtr
2009-10
North PBC 64% 375 90%
Target 2010-11

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10. Financial Management

Finance – North Liverpool

During the financial year 20009/10 the Consortia services provided were done so at the
cost below
0910 Budget 0910 Cost 0910 Variance 10/11 Plan
884321 - Executive Annual Costs (North) 119,318 119,611 293 125,449
884324 - PBC Incentive Scheme (North) 30,824 311,129 280,305 321,657
First Payment 102063 107,219
Second Payment 101615 107,219
Third Payment 107451 107,219
884325 - Innovation Fund (North) 8,949 2,000 - 6,949 -
884334 - Practice Nurse (North) 149,148 154,021 4,873 154,021
884336 - COPD Community Matron (North) - 39,173 39,173 -
Total 308,239 625,934 317,695 601,127

During 0910 an additional GP was added into the Executive Annual Costs. The plan for
2010/11 has been increased to account for this addition. It is currently unclear as to
whether the COPD Community nurse will incur any more costs in 2010/11. The incentive
schemes for 09/10 were not paid at 100% on the first and second payments and there has
also been an adjustment on the population to change the plan for 2010/11.

Service Change Plans

Targets: Target Actual Variance
1st OP attendances as a result of GP referral 1,575,589 1,779,221 203,632
Emergency Admissions for ACS Conditions 4,509,391 4,389,004 -120,387
Unplanned Care 3,681,531 3,669,428 -12,102
Prescribing Targets 3,693,240 3,490,124 -203,116
Total 13,459,751 13,327,777 - 131,974
*these figures are based on M10 reconciled data forecast to year end

1st Outpatients – the consortia has achieved 3 of the GP referred 1st outpatient targets this
year on T&O, Urology and ENT. There are considerable gaps between the targets and
actual on the other areas. The most significant of these are Gastroenterology with an over
performance of 57%, Vascular Surgery with an over performance of 47% and
Ophthalmology over performing by 38%.
ACS Conditions – the consortia appear to be meeting their targets on ACS conditions
overall however this is caused by a large saving being created on COPD and Angina. The
consortia still need to target areas such as Diabetes which is over performing by 31% to
maximise its savings.
Prescribing targets – the consortia is currently meeting its target on all areas

11. Incentive Scheme

North Consortium’s incentive scheme will operate as per Liverpool Incentive Scheme
Model.

First £1 for participation – This will be paid on completion of an action plan (by 30 June
2010) outlining the areas the practice will need to focus on in order to achieve the agreed
“green line” targets. In addition, 75% attendance will be required at monthly

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Neighbourhood and quarterly Congress meetings by a general practitioner. Practices
managers and practice nurses are of course welcome to attend, however the content of
the meeting will essentially have a clinical focus and will therefore require the input of
clinicians. Practice managers will be expected to attend bi-monthly practice manager
meetings and where possible, practice nurses to attend quarterly North PBC nurse forums.

Second £1 for achievement – This will be paid on achievement of a 50% move towards
the “green line” target.

Third £1 for consortium achievement of the green line (see Appendix A)

Baseline Position
Consortium and practice achievement against the ‘green line’ target in each of these areas
is charted below. In each case the red line is the Consortium baseline spend (2009). The
green line is the consortium target spend.

2009 Actual Rate 2009 ConsortiumBaseline 2010-11Target

North A&E Attendance
62.83

70.00
58.85

54.69

52.22

60.00
47.37
47.52

45.26

44.04

43.78

50.00
40.82

40.22

38.22

37.57

37.43

37.32

35.18

33.51

33.02

32.42
40.00

30.15

30.06

28.63
30.00

20.00

10.00

0.00
GERG RK

GHOSE SL

LUCK SE
EL-SAYED

BAJAJ V
SENDEGEYA C
RASTOGI TK

SHAH DK

ROBERTS JW
LOCK JDT
CHILVERS

CHIVERS
O'HARA DP
SYED OA

DHARMANA
PATEL NM

HUBBERT CM
ALEXANDER
RAZVI SAH

KUKASWADIA
WOODS IMM

MCRAE
REDMOND SJ
MCRAE

FEHA

WHITE
SR

ARH

Red line = £299,248.00 Green line = £228,927.45

North ACS 2009 Actual Rate 2009 C onsortium Baseline 2010-11Target

40.0

35.0

30.0

25.0

20.0 £4,454,863.97
£4,099,671.23
15.0

10.0

5.0

0.0
GERG RK
GHOSE SL
LUCK SE

SENDEGEYA C
BAJAJ V
SHAH DK

RASTOGI TK
ROBERTS JW

CHILVERS
CHIVERS MCRAE

PATEL NM

HUBBERT CM
DHARMANA SR

ALEXANDER
LOCK JDT

EL-SAYED FEHA

SYED OA

O'HARA DP
RAZVI SAH

KUKASWADIA

WOODS IMM

REDMOND SJ

MCRAE
WHITE
ARH

Red line = £4,454,863.97 Green line = £4,099,671.23

11
 cost per 1000 weighted population

0
20
40
60
80
100
120
140
160
180
200
RE
DM
GERG RK 145.25

20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000

0
ON
D
SJ
HUBBERT CM 139.06
North OP

PA
TE
LN
GO M
DD LOCK JDT 122.66
AR
D
M ALEXANDER
L 122.48
WHITE
LU
CH CK
ILV SE LUCK SE 113.94
ER

Red line = £2,491,536.71

SM
CR
AE EL-SAYED FEHA 106.77
HU
BB
ER
TC SENDEGEYA C 99.39
M
SH
2009 A ctual Rate

AH WOODS IMM 93.58

DK
RO
BE REDMOND SJ 92.64
RT
SJ
W

Forecast Outturn for 2009-10

LO O'HARA DP 92.49
CK
JD
EL T CHILVERS
-S 88.93

12
AY
ED MCRAE
FE
HA
RA RAZVI SAH 88.51
ST
OG
IT
K BAJAJ V 88.43
O'
HA
RA
DP SHAH DK 82.91

baseline per 1000 w popn

2009 Consortium B aseline

BA
JA (target saving=£1.376m) SYED OA 81.98
JV
W
OO
DS
IM ROBERTS JW 78.80
CH M
Green line = £2,482,086.34

ILV
North Prescribingtargets2010-11

ER
SM
CR RASTOGI TK 78.24
AE

GE CHIVERS MCRAE 73.11

RG
RK
GH PATEL NM 71.11
KU OS
KA ES
SW L
GHOSE SL 67.17
2010-11Target

PCT wide target per 1000 w popn

AD
IA
AR
DH H
AR DHARMANA SR 64.14
M
AN
A KUKASWADIA
SR 58.05
RA ARH
ZV
IS
AH
SE
ND
EG
EY
A
C
SY
ED