Dacorum Alliance of Single-Handed practices

No growth

Growth (MPC approved or not req.)

Growth (seeking MPC approval)

Greenfield

764

7419

1002

615

9,800

In PCG/T: 21

Due to the nature of this application, two MPC areas are covered:

• Berkhamsted, Tring – Intermediate (Drs Bulger, Side and Andrews)
• Hemel Hempstead, Hemel Hempstead Rural District (North) – Intermediate (Dr Bhatt)

Lead Provider

PCG/T

Health Authority

52 High Street

Bovingdon

Herts HP3 0HJ

Fernville House

Midland Road

Hemel Hempstead

Herts HP2 5BH

63 Victoria Street

St Albans

West Herts

AL1 3ER

Organisation

Name

Signature

Organisation

Name

Signature

Archway Surgery

Red & White House

The Old Forge Surgery

Dr G Bulger

Dr Andrews

Dr C Side

See supplementary document

The NHS National Plan seeks to change the contractual framework for single-handed practices, either by way of changes to the Red Book, or by way of an enforced change to PMS contract.

Single handed practice is often regarded as an anachronism within a new modern dependable NHS. There are issues about clinical governance and audit. There seems to be a lack of peer review.

There are advantages of single-handed practice which we will not outline here other than to mention greater personal knowledge of patients, consistency of care, and greater access to same day appointments than may be seen in most group practices. We would not wish to lose any of these features.

The supportive arrangement of small practices into a Personal Medical Services pilot would provide practices with a framework within which they can provide high quality, well co-ordinated services and benefit from some of the economies of scale enjoyed by larger practices. This would also enable individual practices to take a lead for specific areas of work, and participate more fully in local processes, such as clinical governance and taking forward national priorities such as National Services Frameworks.

By grouping together and using an extra G.P. the PMS will be able to achieve

1: Enhanced Access (within 24 hour appointments).

2: NSF work on Ischaemic Heart Disease Prevention, obesity and Insulin resistance.

3: Work with disadvantaged groups such as isolated elderly and Travellers

4: Improved clinical Governance role: Much of this would be achieved by the ability the group would have to bring the list size per G.P. down to the national average.

Any new Nurse would be on secondment from the PCT or Hospital Trust; perhaps as a consultant nurse trainee, involving the local education consortium.

• Continue high Quality GMS element of services.
• Access within 24 hours for patients.
• Nurse practitioner role to work on identifying, managing patients who are at risk of ischaemic heart disease, this will include obesity and insulin resistance patients.

• A service (by the new nurse and or doctor visiting sites) for local travellers.
• A record system for travellers which could be accessed on NHS net.
• A PMS Plus element of not larger than the current ex-fundholding virements for in-house services to provide current in-house services and to give consultant input on patient management (particularly of chronic and disabling conditions).
• Liaison with Social Services and other groups for our isolated Elderly since now working as one group within Dacorum PCT.
• Drug Dependency work with Drug Link and other Agencies. We have a few isolated drug addicts who have travel difficulties into Drug Link and require local responsive service.
• Improved Teamworking: for the first time there will be a doctor working in all the practices.
• Centralised data collection for PCG Clinical Governance. This would require enhanced data input onto our current systems, and ensuring correct working of Miquest. We may post data to one of our servers accessible on NHSNet.
• Improved On-call Arrangements.
• Near-miss reporting service and enhanced audit procedures for the group.
• Peer review: missing from standard single-handed practice.
• Current PCG/T Agreed Secondary Care within surgeries

The pilot will continue the current "plus" services, but the pilot is not a vehicle to extend them and there is no intention to bring further services "in house" unless part of any PCT inspired initiative.

Currently the G.P.s provide directly or indireclty to some of their patients

Counselling Services

Sigmoidoscopies

Diagnostic Ultrasound

Doppler peripheral vascular disease assessment

ECG

24 hour BP

24 hour ECG monitoring service

Minor operations outside GMS limits

Development of Dermatology and Dermatology Telemedicine

NHS Plan July 2000

Applicable to this pilot?

HSC 2000/018:

Applicable to this pilot?

Ischaemic Heart Disease Prevention with developing new role for a Nurse Practitioner.

Improved Communications co-operative working amongst single-handed G.P.s and per review

Health Improvement for Travellers.

Better Access to Primary care.

Improved Information systems for clinical Governance.

Single negotiating Unit within PCT.

Identification of all at risk patients of IHD (say 20% or greater and Framingham).

Reduction of risk in those groups.

Patients seen within 24 hours and/or 90% satisfaction of appointment time offered.

Medical record system developed for all travellers on A41 corridor (available to other practices)

Clinical Governance systems in place and quarterly meetings.

Data Collection systems in place.

Increase in proportion of consultations (especially for Chronic Disease Management) undertaken by nurse practitioner.

This proposal will include bringing in additional GP and Nurse since our list size would normally qualify for such a person(s).

The PMS would then wish to develop other services and for certain deprived groups

• Ischaemic Heart Disease Prevention, working along National Framework Lines, but by developing a Nurse Practitioner role to help identify, monitor and treat these patients and reduce their risk. The nurse would best be seconded from a cardiac unit or a diabetic unit and discussions are under way as how to establish this role. The Nurse would be rotating to each practice and work with current practice nurses. She may be part of an educational programme to develop a consultant nurse in primary care cardiology.

• Travellers. These patients are disadvantaged in that they find it difficult to register, and they have to go through the same registration process at each practice. They do not develop a Health record. Our mainly rural small town/village practices means that at any one time we have travellers somewhere. We would offer a single service, with one medical record available securely on the NHSNet to each other for these patients. If funding was available we could extend this service to patients other than strictly within our current A41 patch. At any one time there is usually at least one traveller settlement in our group with 40 -80 patients. The rate of change and the lack of a common record are a major problem in their care.

• Drug Dependency. Now no longer confined to towns, one of our members can specialise in this area and co-ordinate care amongst the group and with Drug Link. This would be following the Shared Care Scheme as defined recent Drug Links Consultation Document (May 2000). At any one time we have about 20-30 drug addicts, excluding the alcoholics

• Isolated Elderly: This is work that we would do with Social Services and voluntary organisations such as Age Concern, to encourage health check and befriending schemes. We have identified some 200 lonely and at risk patients who need a more comprehensive care packages which can be enabled by the work with our proposed Nurse practitioner, who would be working with local pharmacists to check on the problems of polypharmacy and overstocking of drugs.

• Teenage Pregnancy Prevention work established at high risk practice area

• Research. We are discussing with the University of Herts the possibility of University providing extra funding of the proposed new post(s) to make this an academic placement with a few sessions taken by the University.

The group would also be able to tackle:

The group will address cost and poor Quality of Service from Commercial Deputising Service urgently. This would be achieved by acting as a single negotiating group, and by doing a proportion of our own on-call and call vetting. We would continue to work with the current co-ops. DacDoc is currently considering enlargement and overnight cover. Single-handed could not undertake overnight cover for the whole of Dacorum unless we had a floating doctor as per partnership, to do the following morning surgery. (An enlarged DacDoc would reduce the number of times we would need to be on call)

• Continue high Quality GMS element of services

• A PMS Plus element of not much larger than the current ex-fundholding virements for in-house services to provide current in-house services and to give consultant input on patient management (particularly of chronic and disabling conditions)
• A service (perhaps by nurse visiting sites) for travellers
• Ischaemic Heart Disease prevention
• A record system for travellers
• Liaison with Social Services and voluntary groups for our isolated Elderly
• Drug Dependency with Drug Links
• Improved out of hours service
• Improved Teamworking: for the first time there will be a doctor working in all the practices, and discovering the weakness and strengths of each, which will require addressing.
• Centralised data collection for PCG Clinical Governance. This would require enhanced data input onto our current systems, and ensuring correct working of Miquest. We may post data to one of our servers accessible on NHSNet.
• Improved On-call Arrangements.
• Near-miss reporting service and enhanced audit procedures.

These projects will require a new nurse role for the group of practices and extra medical time.

(see explanatory notes)

PMS, for the first time in the NHS allows Primary Care services to be commissioned. We need to develop simple measurable pointers to assure ourselves and the PCT that we are continuing to provide high quality core services. We also need definable end points for the PMS element of services without creating an audit system that is more burdensome than GMS claims procedures.

Eg:

Reduction of risk in those group to (say) 7% (Framingham) in 75% of those patients by a date

A survey to demonstrate that patients were seen within 24 hours and/or 90% satisfaction of appointment time offered provided by October 2001

A working medical record system developed for all travellers on A41 corridor (available to other practices) by April 2002

By April 2002 Direct booking of patients into at least one practices' clinical system

By July 2002 grouped Clinical Governance systems in place and quarterly meetings.

By July 2002 Data Collection systems in place amongst all practices.

By May 2002 Annual report about each practices problems highlights and difficulties from the new salaried doctor, acting as an independent resource, for use at each practice.

By October 2001 Development of research projects (with new funding) with University of Herts/Hertnet.

Joint practice/PMS Development Plans Developed September 2002

Practices acting jointly on clinical governance issues, and systems in place to provide PCT with data on HIMP and clinical governance targets data.

No baselines available as this is a new grouping and these are new services. The variation of current services at each separate practice is too wide in certain areas. Within the short time-scale given to develop this application we have not been able to aggregate any data, and there has been no resources to do so and to provide any meaningful baselines across all four practices. The fact that we cannot easily produce such data emphasises the requirement to form a PMS. Some of the work in the first year will be developing some baseline data such as IHD risk detection.

The practices are spread in a 6 mile radius, with a range of different practice types, relatively deprived area of Hemel Hempstead with deprivation payments, through to Village practice and County town practices, all within Dacorum Primary Care Group. The advent of "free" NHSnet connections makes the geographical spread less of an issue for group working. A server at one of the practices can be accessed by any others of the group (nww.archway.nhs.uk). The use of computers occurs at all practices, but their use in clinical practice varies. This issue, which is common even within partnerships will be addressed in developing the baseline data.

Our ability to respond to the clinical governance needs in data development has been limited by our relatively high list size. New joint doctor(s), working for periods at each practice will enable us to undertake these new projects.

Availability: Surgery hours:

Dr Side 8.30 -6.30 Monday to Friday Sat 9-10.30

Dr Bulger 8.45-6.30 Monday to Friday Sat 9.00-12.00

Dr Andrews

Dr Bhatt

(see explanatory notes)

We will be developing this in the contracting process.

We intend to have Miquest operating at each practice to provide other data as required.

Consistency of data recording is essential. The role of the shared doctor and nurse will aid this, as would a shared administrator/data input clerk.

Financial reporting would be integral part of any PMS partnership agreement between the current practices.

Pending contractual arrangements with PCT

(see explanatory notes)

Close Involvement of PCT.

The Clinical Governance lead for Dacorum has already suggested, that in view of the burden of some of the new clinical Governance work, small practices should band together to provide the necessary data and work. The PMS Pilot is almost the only vehicle that can facilitate single handed G.P. collaboration

We had hoped that PCT to act as the employer of the new doctors under subcontract from the PMS and second their time to PMS. These staff would not only report to the PMS doctors but also to the PCT. However such subcontracting by the PMS may not be practical or possible, so the PMS itself or one of the practices may employ the doctor, but in his contract will be the group clinical governance role

The shared doctor and Nurse roles will glue the practices together and develop an integrated clinical governance policy within the PMS on behalf of the PCT.

The PMS group would nominate a practice manager to give overall PMS management services and robust mechanisms of general management for the whole group.

During the Preparatory phase the doctors will be seeking legal advice as to the best way to proceed to form a working grouping:

1. By way of a PMS "partnership" to give a single contract with the PCT.
2. By way of individual, but identical PMS contracts for each practice, but within each contract each practitioner is bound to work with others in the group as outlined in this application. If the PCT cannot employ the new G.P. on behalf of the project, One of the practices would employ the new G.P. with contractual arrangements in place such that he or she works equitable amongst all four practices.

(see explanatory notes)

Evaluation would be carried by the Health Authority with support of the PCT.

Clinical Governance Lead

Consultant Physicians (Cardiologist) (funding for this is in current virements)

Contractual obligation of the proposed new doctors to help develop and aid the running of evaluation systems for the group.

Views to be obtained from Local Authorities, Social Services.

Views and visits from Community Health Council

Patient questionnaires (eg on appointment time satisfaction)

Details will be developed in the contract.

£ (‘000)

£474

£0

£41

£0

£149

£0

£ to be confirmed

£9

£0

£12

as per current PCG allocation to practices

Expected net National National GP income of £54 – 1.25 GP with NIC / superan etc = £80

Nurse practitioner inc costs £30

IRO: £795

Existing

in Post

Existing vacancies

Proposed

Change

(indicate +/- WTE)

1/8^th Assistant

(Proposed new G.P.)

+1

5.25

2.2

3.2

^{For completion by HA/RO}

Three months notice would then have to be given to the new salaried employed doctor and nurse to reduce the hours worked accordingly, unless the PCT and MPC accepted the continued need for the current hours and funding was available.

For any other joint employees, unless other work and funding was available within the PCG at the time, 3 moths notice would have to be given of the necessary change in contract and hours reduction.

On retirement or sudden death or any of the doctors the PMS would continue to run the practice and seek a replacement doctor.(The doctors would have to have locum insurance in the standard manner) The PCT and PMS would jointly select a replacement. Should it not be practical (say premises no longer available) then the practice and its list would come out of the PCT, and we would follow the arrangements as above.

Lead Provider Organisation

Other Provider Organisation

Other Provider Organisation

DASH

Bovingdon

Herts HP3 0HJ

(e.g. General Practice/Trust)

(e.g. General Practice/Trust)

(e.g. General Practice/Trust)

The table below should be used to provide data for the:

• Specified locality.
• Neighbouring practices within a [ ] km radius.
• Practices included in the proposed Pilot.

Of GP

Deprivation payments