As part of the five-year GP contract introduced in April last year, it was agreed that the new primary care networks would deliver seven national service specifications – five of which come into effect in April 2020.
The service specifications form part of the network contract DES and therefore all practices signed up to the DES in 2020/21 will be required to deliver these services.
Last month NHS England launched a consultation on the draft outline specifications for the first five services:
- Structured medication reviews and optimisation
- Enhanced health in care homes
- Anticipatory care
- Personalised care
- Supporting early cancer diagnosis.
These have been developed following a 'wide-ranging process of evidence-gathering and engagement’, NHS England says, and are ‘supported by a strong clinical evidence base’. A new ‘network dashboard’ will set out a range of metrics to analyse PCNs' performance for each service.
NHS England says that feedback from the consultation will shape the final service specifcation and guidance on implementation, which will be published later this year. But what do the service specifications currently propose?
There is no dedicated funding for delivering the service specifications. NHS England says funding for the additional workforce roles, which was agreed last year will support delivery of the new service specifications while also addressing current workforce pressures.
The NHS England consultation document says that an average PCN could engage around three whole-time equivalent (WTE) clinical pharmacists, 1.5 WTE social prescribing link workers, 0.5 WTE physiotherapists and 0.5 WTE physician associates from April 2020.
‘This would provide more than sufficient capacity to deliver the requirements across all five services with significant capacity remaining for these additional roles to provider wider support to GP workforce pressures,’ it adds.
PCNs also receive £1.50 per registered patient and additional funding will be available through a new Investment and Impact Fund for those PCNs that ‘make strong progress’ in delivering the service specifications. This fund is worth £75m in 2020/21, rising to £300m in 2023/24. An average PCN could receive around £60,000 in 2020/21, rising to £240,000 in 2023/24, NHS England says.
Phasing in requirements
The structure medication reviews and medicine optimisation specification and the enhanced health in care homes specification will be implemented in full from 2020/21. However, requirements for the remaining three services will be phased in over the next four years. Detail of what happens in each year will become part of the annual GP contract negotiations.
Every PCN will need to appoint a clinical lead for each of the five specifications, who will be responsible across the PCN for the delivery of the service requirements.
The service specifications
Structured medication review and medicine optimisation
- At least every six months, PCNs should proactively identify people who would most benefit from receiving a structured medication review, using an appropriate tool. They should also develop processes for identifying patients who need a review reactively.
- All identified patients should be offered reviews, which should be undetaken in line with detailed guidance that will be developed.
- PCNs should develop an action plan to reduce inappropriate prescribing of antimicrobials, medicines that cause dependency and nationally identified medicines of low priority.
Metrics to assess this could include the number of individual reviews undertaken and the number of review follow-up appointments; outcome measurements to monitor the impact of structured medication reviews; and prescribing rates of low carbon inhalers, medicines that can cause dependency, antimicrobials and medicines identified as of low value.
Enhanced health in care homes
By 30 June 2020:
- Everyone living in a care home should have a named clinical team, including staff from the PCN and relevant providers of community services. Patients should be aligned to a single PCN and its multidisciplinary team (PCNs must agree which care homes they are responsible for with their CCG).
- PCNs should establish and manage a multidisciplinary team working across organisational boundaries to develop and monitor personalised care and develop protocols for information sharing and use of shared care records.
By 30 September 2020, PCNs should:
- Deliver weekly, in person, home rounds led by a suitable clinicians (this must be a GP or community geriatrician at least once a fortnight).
- Coordinate delivery of a personalised care and support plan based on relevant assessments. This should be developed and agreed with each new care home resident within seven days of admission or readmission and reviewed when clinically appropriate.
- Identify opportunities for training and shared learning with care home staff and help the care home coordinate with the wider health system.
- Establish processes to improve efficient transfer of clinical care between care homes and hospices and hospitals.
- Establish clear referral routes and information sharing between care homes, PCNs, out of hours providers and the full range of community services.
Metrics to assess this could include the rate of emergency admissions and urgent care attendances for people living in care homes; the proportion of people living in care homes with a personalised care and support plan; the number who receive an appointment as part of the weekly care home round; and the number and proportion of people who receive a structured medication review and a delirium risk assessment.
The requirements for this service specification will be phased in over the next four years. In 2020/21 PCNs will be expected to build and embed ways of working that will expand and develop in future years.
By 30 June 2020 PCNs will be expected to:
- Assist with developing a population health management approach to identify patients with complex needs who would benefit from anticipatory care.
- Take a lead role in coordinating care and support as patients begin using the service
- Develop data sharing arrangements
- Identify priority patients at risk of unwarranted health outcomes
- Establish and manage a multidisciplinary team to coordinate and manage the care of people on the anticipatory care list.
- Coordinate and deliver comprehensive needs assessments to these patients and record this in a personalised care and support plan. Coordinate the delivery of this plan.
Metrics to assess this could include the number of individuals receiving the anticipatory care model; the number of needs assessments carried out and who have a personalised care plan; the number receiving a falls risk assessment and a delirium risk assessment; the number referred to social prescribing; and the number receiving a structured medication review.
As above, the requirements for this service specification will be phased in over the next four years. For 2020/21 this means:
- Personalised care and support plans should be in place for between five and ten patients per 1,000 weighted patient population. This must include all people in the last 12 months of life and all individuals covered by the anticipatory care and enhanced health in care homes services.
- PCNs must promote personal health budgets.
- PCNs should ensure there is shared decision making for patients with musculoskeletal conditions, which should be led by physiotherapists.
- At least four to eight patients per 1,000 weighted population should be referred for social prescribing.
- The Patient Activation Measure (a tool designed for assessing the level to which people feel confident in taking care of their condition) should be used for people newly diagnosed with type 2 diabetes and those referred to social prescribing link workers.
In subsequent years targets in each of the above will be increased, for example PCNs will be required to ensure a greater number of patients have personalised care and support plans and are referred for social prescrbing and additional clinical conditions will be added to the shared decision making requirement.
Suggested metrics to monitor the service include the number of personalised care and support plans delivered and their quality; the number of shared decision making conversations completed and their quality; the number of social prescribing referrals made; and the number of patient activation measurement assessments undertaken.
Supporting early cancer diagnosis
The full requirements for this service will be phased in over the next four years. In 2020/21, PCNs will be expected to:
- Enable and support practices to improve the quality of their referrals for suspected cancer in line with NICE guidance and by using local data
- Introduce safety netting for monitoring patients referred for suspected cancer.
- Ensure patients receive high quality information on their referral.
- Lead and coordinate practices’ contribution to improving screening uptake and develop a screening improvement action plan.
- Improve outcomes through reflective learning and local system partnership
From 2021/22, PCNs will be expected to increase the proportion of people diagnosed with cancer at stages 1 and 2.
Potential metrics that could be used to monitor this service include the proportion of cancers diagnosed at stages 1 and 2; participation rates in breast, bowel and cervical screening; and the proportion of urgent cancer referrals that are safety netted.
Responding to the consultation
The draft specifications are currently out for consultation, which closes on 15 January. Full details on how to respond are here.