One of the things I love about being a practice manager is the surprise gifts you get from NHS England, the latest being the publication of the draft first five (of seven) service specifications in late December. In this article we will unwrap this draft and look what is inside.
After careful perusal, there are a few positives to take from the document. Firstly, NHS England is looking for feedback on the proposed specifications which will allow practices as well as other providers to feedback their thoughts and concerns to help shape the final draft set of service specifications.
Secondly, there will be a phasing in of the service specifications over several years. The first two of seven specifications (i.e. structured medication reviews and optimisation and the enhanced health in care homes) will be implemented in full from 2020/21. Three specifications (anticipatory care, personalised care and early cancer diagnosis) will start to be rolled out from 2020/21 and finally the last two service specifications (cardiovascular disease prevention and diagnosis and tackling neighbourhood inequalities) follow in 2021/22.
The final positive to take from the document is that primary care networks should receive additional support from their CCGs, if they require it. Support should predominately take the form of assisting with recruitment and negotiating workforce arrangements with other providers.
As with any new service there are concerns which either need to be worked through, put into context or require clarifying. One of the main concerns is that, where locally commissioned services are in place which overlap with the draft service specifications, CCGs can withdraw these services but only when the network service specifications are implemented.
In addition to having a financial impact on some GP practices, the question needs to be asked whether patients will receive the same level of care and input or will this just create another layer of care, which will inevitably end up in front of a GP irrespectively? Avoiding any gaps in patient care and unpicking any commissioned service will be a tough nut to crack and will need to be handled diligently through discussion and planning.
Another concern is the lack of detail about target setting and if there are any financial incentives or disincentives. It has been widely published how much investment is going into the NHS and specifically around PCNs. At present, it is not clear what happens if a network fails to perform by not hitting targets (if any are to be set) or delivering expected savings, for example.
Now, let us turn our attention to the first two service specifications which need to be implemented in full by 2020/21.
The structured medication review and optimisation service requires the identification of a network clinical lead, who will be responsible for the delivery of this service. In addition, a decision about which appropriate audit tool to identify patients who fit the criteria for a ‘proactive’ structured medication review (SMR) is required, plus the development of a system for ‘reactive’ SMRs, as well as decisions upon a reasonable appointment length for SMRs, the development of a robust call and recall system (however this may be delegated to practices) and IT system specific templates to record the review and any referrals.
Some Networks will have multiple IT systems, so the creation of any searches, reports, call and recall systems and templates will take time to develop. However, with the SNOMED coding coming into place this may make the task easier.
With this service, 100% of eligible patients need to be offered SMRs. Unless in exceptional circumstances the CCG agrees otherwise. It will be interesting to see how networks approach this. For example, could a network develop a SMR process for specific conditions/medicines to be delivered via educational sessions or even group/shared consultations?
At any rate, networks need to calculate the demand vs capacity at an early stage, to determine what the workload looks like and begin discussions with the CCG.
For practices already delivering the care home enhanced service, the network enhanced health in care homes service specification will look vaguely familiar.
Again, this service requires the identification of a network clinical lead who will be responsible for the delivery of this service. Networks should be assessing which of their practices are delivering the care home enhanced service and meet with the clinicians and managers involved to see how they deliver the service at ‘practice’ level and discuss ways to expand and deliver the service to ‘network’ level. It would be prudent to assume that the clinical lead will come from one of these practices.
On top of identifying a clinical lead, the creation/development/management of a network level multi-disciplinary team (MDT) which will be accountable for the delivery of care needs to be in place, along with the requisite paperwork and governance arrangements.
In the next few weeks, the clinical leads should be scheduling meetings with the MDT to discuss workload vs. demand, how care will be delivered, how a weekly ‘home round’ will be organised and managed, how personalised care planning will be instigated and reviewed and so on.
With multiple teams, working across a network size demographic, communication will be the key to success. It will be a new experience for all providers involved and therefore requires a high level of commitment and a degree of flexibility in the initial stages to review and unpick current arrangements (i.e. any locally commissioned services) and ensure care and communication pathways are developed appropriately.
The development of standardised IT system specific templates to document the review, share information across teams and any required referrals are essential.
With existing NHS workloads, it is a daunting task. Therefore, it is crucial that you have the ‘right people’ in the ‘right roles’ with the required clinical and business skills to enable your PCN to progress and deliver.
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We will unpack the other three service specifications in our next article.