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Wessex LMCs email update May 2014

Date sent: Thursday 1 May 2014

Email sent by Wessex LMCs to all GPs and Practice Managers in Wessex, on 01/05/2014.

All my recent emails seem to focus on the future of general practice and the challenges that we face. This one will be no different because it is the topic that unites us all at this time.

Recently the Department of Health and NHS England published a document called:

Transforming Primary Care – safe, proactive, personalised care, for those that need it most”.

The document is worth reading because it pulls together many strands of policy and reinforces the likely future service development for general practice.

The document makes the case for the central role that general practice plays in care outside of the hospital setting.  It recognises the rising workload and expectations and clearly describes the need to integrate community services with general practice.  The Secretary of State reinforces that CCGs will invest £250m to support the transfer of patients to out of hospital care.

Some of the examples detailed are interesting and some seem a bit remote, especially with the level of funding we have locally.

The impact of QOF changes have yet to be felt, especially as Prompts remain for elements of QOF which have now been removed.

I would hope that all practices have now discussed how they will implement the named GP for those patients aged 75 or more and also the admission avoidance DES. 

There has been additional guidance issued yesterday which details the required Read Codes. So hopefully this email will help you implement this.


1. Admission Avoidance DES

2. Technical requirements guidance for 14/15 contract

3. 14/15 QOF point value

4. Pneumococcal vaccine arrangements

5. Hepatitis B Read Codes Published

6. NHS Property Services (NHSPS) guide for customers and tenants

7. Innovation and sharing good ideas


1. Admission Avoidance DES

I have been approached by a number of GPs and Practice Managers who are concerned by the work involved in creating a care plan for these patients.

It is worth remembering that this DES is worth £2.87 per registered patient, which equates to £143.50 for each care plan, if you produce these for 2% of your adult population.

I know that this is not new money, it has been removed from QOF and the Risk Stratification DES, but some aspects of QOF are no longer required and therefore you should be undertaking less work in QOF.

GPs frequently produce care plans and case manage patients but do not do this in a formal way.

The best way to achieve the 2% of the adult population required is to use those patients who have the need for case management  where you are already involved in providing on going care. These are frequently the same group that are identified through risk stratification tools.

If you include patients in Nursing Homes, those who are on your GSF list, those with severe COPD and those on your practice or virtual ward (if you have one) you will probably be close to the required 2%.

The plans do not need to be overly complicated.

What you want is information that would help a GP or Nurse who goes to see the patient and who knows nothing about them. So Past Medical History, medications, allergies, what the current problem is that makes them vulnerable, what your plans are for their future care and what the wishes of the patients and families are.

I recognise the frustration that the full set of Read Codes have not been available but they have now been published.

Table 1: Proactive Case Management Read Codes


Read v2

Read CTV3

Admission avoidance care started



Admission avoidance care ended



Informing patient of named accountable GP



Admission avoidance care plan agreed



Admission avoidance plan care declined



Review of admission avoidance care plan



The admission avoidance care started Read Code will identify that the patient is on the case management register.

All emergency hospital admissions should be coded.


Table 2: Emergency Hospital Admission Read Code


Read v2

Read CTV3

Emergency Hospital Admission



You might wish to Read Code those at risk of hospital admission.


Table 3: At Risk of Emergency Hospital Admission


Read v2

Read CTV3

At risk of emergency Hospital Admission



Using the correct Read Codes will be essential,  it therefore may be helpful to create a Template in your clinical system to assist with this.

You need to have a system in place in your practice so that if a patient is seen in A/E or is admitted to hospital you can identify them as being on the case managed register.

Probably the simplest way of doing this is to have an Excel spreadsheet. The LMC is currently working to produce this.


Remember  for those who are on the case management register:

·        Practices must undertake monthly reviews of all A/E attendances, admissions or readmissions

·        If discharged from hospital an attempt is made so that the patient is contacted by the practice or community staff within 3 days of discharge to ensure co-ordination and delivery of care.

·        You must review the care plan at least every 3 month.


Revisions to the unplanned admissions enhanced services guidance

Further to the negotiated contractual changes for 2014/15, some concerns had been expressed about confused wording in the guidance on unplanned admissions.  Following pressure from GPC, the revised guidance clarifies that:

•           Care plans for patients initially added to the case management register have to be in place by the end of September 2014, not June 2014 as was originally specified. This recognises the difficulty with producing care plans for these patients for the end of June and ensures consistency with the payment structure in place for the enhanced service - Please visit the BMA website.

•           Patients initially added to the case management register have to be informed of their named accountable GP and care co-ordinator by the end of July 2014, not June 2014 as was originally specified. The July deadline for the named accountable GP applies only to patients added to the register who are under the age of 75, as patients aged 75 and over will have been informed of their named GP by the end of June (existing patients) or within 21 days of registration (new patients), as per the requirements of the GMS and PMS regulations for a named GP aged 75 and over.

The changes are made on pages 7 and 15 of the guidance, which can be found on the BMA website.


2. Technical Requirements Guidance for 14/15 Contract

Guidance on the technical requirements for the GMS contract for 2014/15, which includes clinical enhanced services, named GPs for patients over 75, and vaccinations and immunisations, has been published on the BMA website


13/14 QOF Achievement  Payments

NHS England have confirmed that there had been an error in the calculations and on 9 and 14 April HSCIC sent out communications confirming that the incorrect calculation for the QOF achievement and aspiration payments had been used.

Instead of the national average practice list size as at January 2013 (6911) CQRS had used the average list size as at January 2014 (7052), which caused a deduction in payments for many practices. The HSCIC has now recalculated the figures and have informed the affected practices that they can re-declare achievement.

The re-calculation is expected to result in approximately a 1.95% increase in QOF 13/14 achievement on CQRS for most GP practices.

Further information about the re-calculation of QOF 2013/14 achievement and declaring achievement can be found in the FAQs listed on the HSCIC website.

NHS England has also responded to some of the queries in relation to this as outlined below:

Why is the index list size taken as it stood on 01 January 2013, when the year in question is 1 April 2013 to 31 March 2014?

Basing the actual national average practice list size on that at the start of the last quarter before the financial year in question ensures there is transparency going into the financial year.

On the whole, it appears that list sizes are increasing - why is the current list size not taken into account?

Contractors current list size is reflected in the CPI calculation which is the sum of Contractors Registered Population (generally that at the start of the final quarter in the financial year) divided by the actual national average list size as above.

CPI allows QOF payments to reflect comparative list size.

Is the PMS QOF deduction also incorrectly based on the January 2014 CPI figure? The letter from NHS England to area teams  sent on 4 April uses the average list size which is applicable for 2014/15, but the calculation is for the 2013/14 QOF.

NHS England has provided the following briefing in response:

·          The QOF PMS Points Deduction was set in 2004 as £13,050 for average PMS practices – that was a practice with a list size of 5,891 (the average in 2004).  £2.22 is the deduction calculated as the price per patient when you divide the above price by the then average list size (£13,050/5891).

·          The worked example in the letter has used an incorrect CPI figure, but it is just that - a worked example, to demonstrate that the current CQRS calculation will undervalue the QOF PMS Points Deduction.

·          The national average practice list size for use in CPI to calculate 2013/14 QOF achievement is being corrected to 1st January 2013, which is 6911, which is in line with the SFE.  So to run the worked example again, a practice of 6,200 patients should have its deduction calculated as 6200/5891 x 13050 = £13,735, but CQRS will calculate as 13050 x 6200/6911 = £11,707.  So CQRS continues to undervalue the deduction that needs to be made and in this example by £2,028.

·          Another way of looking at is that CQRS will calculate the deduction at £1.89 price per patient (£130505/6911) which is a difference of £0.33 price per patient (£2.22-£1.89).  Using £0.33 might be a simpler basis to calculate the adjustment required.


3. 14/15 QOF Point Value

During the QOF negotiations for 14/15, the GPC highlighted to NHS England  the issue that the QOF point value needed to increase comparatively along with any increase in the national practice list size.  Although there was a 16% rise in the value of QOF points for 13/14, it was pointed out that this would be an ongoing problem every year if QOF was not adjusted accordingly every year. It was argued that due to the 16% increase in QOF point value, this change was meant to be cost-neutral. It clearly has not been, so the GPC are continuing to put pressure on NHS England to sort it out.


4. Pneumococcal Vaccine Arrangements

As part of the recently announced contract changes practices will now be able to offer pneumococcal vaccination both to patients who have achieved the age of 65 during the financial year 2014-2015 as well as to patients identified as at clinical risk as indicated in the Green Book.

However, the scheme will be delivered alongside the seasonal influenza vaccination DES which does not start until 1 August 2014.


5. Hepatitis B Read Codes Published

The Read Codes for the Hep B vaccination programme have now been published by the HSCIC and are available on the NHS Employers website (and in the attached). The technical requirements document will be updated to reflect this - however, this may not be ready for re-publication for a couple of weeks or so.


6. NHS Property Services (NHSPS) Guide for Customers and Tenants

New guidance for tenants has now been launched by NHSPS and this can be found here (under the general publications tab).


7. Innovation and Sharing Good Ideas

I am always impressed when I visit practices at the variety of ways that have been found to solve common problems that we all face. Sometimes the idea is to address the rising demands but often it is to provide a better service to patients and is addressing an issue that is not required of the practice but one they want to address because they care about their patients.

If you have a good idea, don’t be shy, please share it with us and we can share it far more widely.


Below is some work I have been involved in locally which relates to schools.

I work in a small town of 25,000 people, which has 3 practices, 7 primary schools and one large secondary school.  We suffered from the usual barrage of requests:

·          Johnny needs a letter to be off games

·          Lucy has ADHD and the teacher wants you to refer her because it is quicker

·          Fred had a cold and did badly in his exams can we have a letter

·          Sarah is missing too much school so the teacher wants you to see her every time she is ill and report this to the Head teacher

Does this sound familiar?

As an LMC we have written to many schools pointing out the GP is not required to do this unfunded work.

Locally we decided to take a different approach, and arranged a meeting with all the local Head Teachers to discuss our “grievances”.  To our surprise the Head Teachers were fair and reasonable people who were actually quite nice and easy to talk to. None came with a cane and no punishments were dealt out.

We addressed all the issues above and the Heads broadly accepted and agreed with our concerns.  So almost immediately the stupid requests stopped.  

The Heads were concerned about the label of ADHD as they believed that some children were well behaved at school but still were diagnosed by CAMHS as having ADHD when the real issue was parenting.  They were frustrated that the CAMHs service would not listen to them.

We spent some time talking about the pupil who was off school for recurrent minor illness and the impact that might have for their future. This led to The Arnewood Pyramid – Health, Wellbeing and Attendance Partnership

The practices and Arnewood Pyramid of schools formed a partnership to address poor school attendance levels.  Whilst this is not part of core work and the practices are under no contractual obligation to participate, we have found it useful to work with local schools on health and wellbeing issues, particularly with regard to attendance where it is felt that particular children may be vulnerable. 

To that end, the partnership was established so that local schools could ‘refer’ children to their local practice who will confirm whether a child’s absence is appropriate following telephone triage or a face to face appointment.  However, the onus is on the parent to cooperate and to actively participate in the programme.  It is only intended for those children and families where there are long term ongoing concerns, where there have been previous efforts to engage with the family and the family is already aware of the initiative.

The Head Teacher identifies the child and family and meets with them to discuss the situation – so we are only talking about the extreme cases.  In the 3 years this has been running we have only had 4 children put though the scheme.


Before referring a child onto this scheme Head Teachers will:

·             Have had long term ongoing concerns about pupils whose attendance has dropped below 85% with the significant majority of absences being reported as ill health

·             Be able to demonstrate that they have tried to work with the family to improve attendance

·             Have engaged the services of Education Welfare Officer as appropriate

·             Have referred the case to the School Nurse

·             Have met with the family to explain the HWBAP scheme before referring them

Upon receiving a referral from the school the participating GPs surgery will:

·             Aim to see the pupil on the first day of illness

·             Recommend a return to school in the afternoon if it is felt appropriate

·             Recommend a return date to school if it is possible to do so

·             Complete the HWBAP pro forma for return to the school

·             Liaise with the school as appropriate to support the child and family

I have just had a second child see me on the scheme and I have to say I have quite enjoyed working with the child, parents and the school.

If you would like to consider a similar scheme in your area, we have re-produced the Arnewood Pyramid’s documentation (attached).

Following our initial meeting we planned to meet every 3-4 months, which has been useful.  We worked with the schools who planned a “healthy schools week” and got several GPs to go into schools to talk to the children on a range of subjects.  I have been involved in one schools programme for the last 3 years.  I think I have got more out of it than the schools have!  The children are interested, knowledgeable, attentive, enthusiastic and appreciate what you do for them.

Although, talking to a group of 100 pupils aged  8 and 9 is far more frightening than talking to 100 GPs!

We did this because we wanted to rather than because we had to.

Best wishes



Dr Nigel Watson

Chief Executive

Wessex LMCs

Churchill House, 122-124 Hursley Rd

Chandler's Ford, Eastleigh

Hants. SO53 1JB (Registered Office)

Tel: 02380253874

Mobile: 07825173326


Attached file: Arnewood-pyramid-partnership.docx

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Updated on 04 June 2014 2344 views