Primary and Community Care REVIEW - Welcome to NHS …€¦ · · 2014-01-08General Practice Outcome Standards GP Practice Variation Capacity & Capability Quality & Variability

A report from BDO to Southwark Clinical Commissioning Group

May 2013

ANALYSIS OF PRIMARY AND COMMUNITY CARE TO SUPPORT THE DEVELOPMENT OF THE PRIMARY AND COMMUNITY CARE STRATEGY

Page

Introduction 3

Methodology 4

Analysis Findings 9

Appendix 1 – Data Analysis 21

Appendix 1A – CCG Level Analysis 23

Appendix 1B – Locality Level Analysis 69

Appendix 1C – Strategy and Document Review 91

CONTENTS

INTRODUCTION Background to the Review

Background

Southwark CCG are developing a Primary and Community Care Strategy

for the period 2013/14 until 2017/18. This strategy will articulate the

strategic context for primary and community care, analyse the current

state of services and assess what primary and community care services

will need to look like in order to meet the objectives of Southwark’s

Strategic Plan and the TSA Community Based Care Strategy.

Drivers for the Primary and Community Care Strategy

•The CCG now has a statutory responsibility for primary care

improvement

•Southwark CCG’s Integrated Plan focuses on improving key patient

level outcomes: primary care is often a key provider in achieving these

improved outcomes

•Currently there is significant variation in the quality and outcomes

provided by Southwark practices

•The Trust Strategic Administrator (TSA) proposals for South East

London rely on CCGs delivering a Community Based Care strategy

including improving the quality and responsiveness of primary care

•Southwark’s QIPP plans assume an increasing level of shift of care

from acute services into community and primary care service. We will

need to ensure that there is sufficient quality, capacity and capability

to take on additional responsibilities

•The CCG needs to develop a strong working relationship with the NCB,

and a clear commissioning strategy for primary care improvement will

support this developing relationship.

Strategy Development

There are three steps to developing the strategy:

1. Undertake an analysis of current quality, variation, capacity

and capability and assess against desired levels

2. Generation of options to develop primary and community

care to meet strategic objectives

3. Develop strategy including implementation plan.

This Document

This document summarises and details the analysis phase of the

development of the strategy, and sets out the approach that has

been taken.

The following stage of this process, as described above, will be

for stakeholder engagement to continue, and to focus upon

options for the development of primary care based upon this

analysis.

METHODOLOGY

Data Sources

A comprehensive

range of data have

been analysed from a

variety of sources.

Analysis

The analysis is

categorised into that

which indicates

Capacity & Capability

and Quality &

Variability. It is

presented for the

whole of CCG and for

each locality in turn.

Priorities

Four priority areas

have been identified

from this analysis.

Options

A number of options

will be developed in

order to address

these priorities.

Tbc

Tbc

General Practice

Outcome Standards

Capacity &

Capability

Quality &

Variability Practice Trend Analysis

Southwark Primary

Care Dashboard

GP Patient Survey

Tbc

LES Data/QOF data

Engagement and

Locality Events

Demand & Capacity

Data

Data Sources Analysis Priorities Options

GP Practice Variation

Community Based

Services

Integration (Care

Coordination)

Access

Tbc

Approach

METHODOLOGY Data Sources

Data Sources Analysis

Practice Trend Analysis Indicators analysed – A&E Attendances, Outpatient New Referrals, A&E Band 5 (Minor)

Attendances and referral to Cardiology and Dermatology and the rates used are per 1000

patients to adjust for variations in list sizes. Where the information is available, Southwark

CCG has been externally benchmarked with London SHA and England averages for the same

indicators.

Internal Benchmarking

High volume specialties analysed – Gynaecology, Ophthalmology, Dermatology, Trauma &

Orthopaedics and Cardiology. The graphs show the referral rates (per 1000) by each practice

grouped into localities where the referral is made by a GP.

General Practice

Outcomes Standards

All indicators that are available have been analysed, graphs showing locality level scores

against the total for Southwark with London Averages highlighted.

Quality and Outcomes

Framework

All Clinical Indicators that are available have been analysed at practice level. Graphs showing

locality level scores against the total for Southwark with National Averages highlighted.

GP Demand and Capacity

Primary Research GP Demand and Capacity data was collected by practices completing the Royal College of

General Practitioners treating access toolkit. Data was collated to show demand and capacity

for same day and advance appointments across a named week. In addition practice staffing

levels were recorded. Graphs provide data from a week decided by the by the practice

between 25th February 2013 – 18th March 2013.

GP Patient Surveys We analysed the percentage of standardised answers to three questions in the survey: 1)

When did you want to see/speak to your GP? 2) How long till you actually saw/spoke to a

GP/Nurse? 3) What did you do if you couldn’t get an appointment?

We compared the data for Southwark CCG to the National Average and then compared the

survey results at practice level.



Community Data Combined Community Health Services Reports were reviewed as were CQIN reports where

they related to primary care and/or capacity. The main areas were around immunisation,

Falls, sickness and cancelled appointments.

Strategy & Document

Review

A review of the priorities set out in the CCG’s Integrated Plan was undertaken to ensure

consistency. QIPP plans were also reviewed as it was vital that when considering options,

those which support delivery of QIPP targets are prioritised.

The Dulwich Consultation was also reviewed to ensure that any recommendations made in

this review are consistent with this key, linked project.

The Community Based Care (TSA) Strategy was also constantly reviewed to ensure findings

and plans would support the wider aims of the SEL CBC Strategy.

LES Data A review of the LESs held by the CCGs practices was undertaken to understand the scope and

breadth and performance against targets. Comparisons against target; benchmarking between

practice and locality; and where applicable, against national levels of achievement were

undertaken.

GP Community Services The community services below were also reviewed, and the findings incorporated in this

report:

-Phlebotomy

-Adult audiology

-Dermatology

-Headache/Neurology

-ENT

-Ophthalmology

GP PMS Contract A review of the GP contract to understand the range and scope of services to be provided as

part of the PMS Contract



Southwark Dashboard The indicators analysed are:

Patients with hypertension, as a ratio of expected

Patients with CHD, as a ratio of expected

Patients with COPD, as a ratio of expected

Patients with diabetes as ratio of expected

Dementia prevalence as % of list size

A&E attendance Rate as % of list size

4 week smoking quit rate as % of setters

Diabetic patients with an HbA1c of 8% or less

LTC patients with smoking status recorded by GP

Flu immunisation (wider risk groups)

Patients screened for alcohol use as % of newly registered

Proportion of patients with recorded BMI (Adults)

Medicines management RAG progress on QPI

Patient satisfaction with quality of practice care

Patient satisfaction with access to GP

Benchmarking graphs

Each practice is colour coded by locality. Where the data was available, the England, London

and Southwark averages are displayed. These charts are presented for all of the indicators

above.

National quartile charts

Using the percentile information from the dashboard we grouped the Southwark practices

according to the national quartile they fall into. Related indicators are presented together for

comparison – for example ‘Patients with diabetes as ratio of expected’ and ‘Diabetic patients

with an HbA1c of 8% or less.’

ANALYSIS: FINDINGS

ANALYSIS

The findings from this project have been grouped into four priority areas. These priorities have been selected based upon

the findings from the analysis, and from discussion with the project steering group. The priority areas are as follows:

•GP Practice Variation

•Access

•Community Based Services

•Integration (Care Coordination)

It is recognised that there will be duplication between these priority areas, and that key themes will run through a number

of priorities. However, after discussion it has been agreed that these represent the clearest method for describing the

analytical findings, and can be linked both from existing CCG strategic documents and through to options to be set out in

the Primary and Community Care Strategy.

The following section of the report therefore sets out how the findings of the analysis support the selection of these

priorities for the Primary and Community Care Strategy.

Summary of Findings

ANALYSIS GP Practice Variation (1)

Domain Findings Data Sources

Q&V Outlier Practices

Lower levels of overall variation but with significant outlier practices in GPOS

Identifying Cancer Domain, GPOS Cervical Cytology Domain, Southwark CCG Total

Number of Minor Surgery Procedures.

GPOS Identifying Cancer Domain

GPOS Cervical Cytology Domain

Southwark CCG Total Number of Minor

Surgery Procedures.

C&C Demand and Capacity Variation

Nearly 80% of practices returned data for the sample period. There is significant

variation in demand and capacity between practices. Several practices having twice as

much demand than overall capacity on a weekly basis, about 30% of practices have

approximately equal demand to capacity, however there are around 60% of practices

who have greater capacity than demand (including nursing capacity). On a daily basis

demand and capacity is significantly mismatched, but over the week this may appear

more balanced than is reality on a day-to-day basis.

Southwark Total Weekly

Capacity:Demand Ratio Analysis

Q&V Same Day Appointment Request

There is considerable variability in patients who being report being able to see / speak

to GP or Nurse on the same day they request an appointment.

GP Patient Survey Jan-Sept 2012

C&C Demand and Capacity Data Collection

Practices do not routinely collect demand and capacity data. Total numbers/rates of

appointments supplied per annum is not collected or monitored by the CCG.

Verbal Enquiry

Q&V

C&C

ICP Programme

Quantitative analysis suggests that the opportunity to identify and risk manage the

older population is not being maximised due to the poor take up of the Older People

ICP Programme.

LES - ICP Programme performance

graphs

Southwark

CCG

B&R B&W SSWK



Q&V Feedback to Practices

Practices are not provided with regular comprehensive performance against peers;

•Some pieces of data are not being provided at practice level to practices

•Some data is provided but not in a timely/actionable way

•Some data is being provided and in timely way but is not benchmarked against peers

If relative performance information is not provided in a timely and actionable manner then

opportunity to take remedial action is limited.

GP Practice Dashboard

QOF Reports

Primary and Community Care

Review Analysis

Q&V

C&C

Enhanced Service Planning

There is considerable variation at practice level in how and which enhanced services are

provided (e.g. Phlebotomy). No evidence was found that these are arranged in a planned and

strategic manner and no evidence was found this reflects where need exists. There was strong

evidence patients find this confusing and inequitable.

Enhanced services graph

Feedback from Out of Hospital

Engagement event

(DN - Check patient survey and

strategy documents)

C&C Extended Hours

Specifically relating to Extended Hours we have found no evidence that provision is tested

against local requirements and there is variability in provision. In addition to this feedback

suggests patients are dissatisfied and confused with the current configuration of extended

hours.

LES Graphs


Engagement event

Demand and Capacity Analysis

Q&V Healthcheck uptake

Qualitative evidence suggests there is a staggered roll out rates are low and highly variable

(primary prevention)

Southwark CCG - % of patients

with Healthcheck in 5 years

Q&V Cardiovascular Screening and Secondary Prevention

Qualitative evidence suggests QOF Ratio of expected to ratio is overrepresented in the lower

quartile (secondary prevention).

Qualitative analysis suggests Southwark are weak on secondary prevention and disease

management when compared to the national average.

QOF Long Term Conditions

Prevalence as Ratio of

Expected (practices by

quartile) Coronary Heart

Disease Total % Points QOF

Southwark

CCG

B&R B&W SSWK



Q&V Broad Variation

Significant practice variation across Mental Health QOF Domain and Southwark Flu Vaccine

Uptake Over 65s (2012/13 YTD) areas in the Q&V analysis.

Mental Health QOF Domain

Southwark Flu Vaccine Uptake

Over 65s (2012/13 YTD)

C&C Clinician Capacity

Primary research and quantitative analysis suggests overall demand and capacity can be

managed more effectively on a day to day basis without necessarily increasing overall

capacity


Capacity:Demand Ratio

Analysis

C&C Healthchecks Evidence Base

Qualitative information suggests GP are not convinced by evidence base for healthchecks

qualitative – locality meetings

Feedback from Locality

Meetings

C&C Clinician Capacity

Qualitative information suggests there are not enough staff with the right skills available to

undertake healthchecks within practices


Meetings

C&C Clinician Capacity / Capability

Quantitative evidence suggests of the 25% sample who returned the demand and capacity

research under 1 WTE (within the sample of 25%) was identified as a clinician with special

interest within CVR (Hypertension)

GPSI Demand and Capacity

Analysis

Q&V Diabetes Screening

QOF Ratio of expected to ratio is significantly overrepresented in the lower quartile and not

represented in top quartile (secondary prevention)




quartile)

Q&V Diabetic Case Management

Performance on management of patients with Diabetes is below national average (both on

aggregate DM QOF score and key QOF indicators) but appears to be due to (x outlier practices)

rather than sub-optimal performance across Southwark.




quartile)

Southwark

CCG

B&R B&W SSWK



Q&V Childhood Immunisation Completion

Southwark Childhood immunisation data 11/12 shows under 5 completion of all immunisations

is 83% and varies by locality from 79%-88%.

2011/12 Southwark

Immunisation Rates by Locality

Q&V Childhood Immunisation ‘Drop-off’

Southwark Childhood immunisation data 11/12 shows drop off from U2 to U5 of 7% across

Southwark and 13% in B&R.

2011/12 Southwark

Immunisation Rates by Locality

Q&V Performance Management System

Child - Complicated measurement of current year performance – HV CQUIN target relative to

previous GP CQUIN performance. Difficult to attribute performance to each party, and to

monitor overall trend

Childhood Immunisation Graph

11/12

Q&V Childhood Immunisation Performance Management

Child - For contribution by Health Visitors measured by individual immunisation the CQUIN

targets were not met in 11/12

Childhood Immunisation Graph

11/12

Q&V Flu Performance

Flu – Variable performance of achievement against the 65% LES target (for example some

practices are immunising only 50% of over 65’s). Although overall Southwark average is above

65%.

Flu Vaccine - Over 65s Flu

Vaccination Uptake by Locality

(2012/13)

Q&V Locality Flu Performance

Flu - Variability by locality can be seen as B&W are out performing the other localities quite

significantly

(page 36)

C&C IT Systems

Qualitative feedback - IT Systems do not offer easy transparency regarding immunisation

status to primary care

Locality Meeting Feedback

Southwark

CCG

B&R B&W SSWK



Q&V Mental Health QOF Performance

Across QOF mental health (schizophrenia, bipolar disorder and other psychoses) domain,

Southwark is performing below national average (95%) variability by locality and by practice

with eleven practices achieving 100% and three practices achieving 55%.

Mental Health Domain Total %

QOF Points 2011-2012 showing

locality and practice variation

Q&V

C&C

Depression QOF Performance

Overall performance in QOF Depression domain and GPOS depression scores is below national

average and highly variable by practice and locality. These QOF scores mostly pertain to

initial and repeat severity assessment of depression. There is no objective data about the

quality and capacity of subsequent access for therapies (eg. IAPT) in the community for this

group of patients.

QOF & GPOS depression graph

Q&V QOF Cancer performance

Nearly a third of practices are not having regular (at least 3-monthly) multidisciplinary case

review meetings for all palliative care patients. Over 80% of practices were reviewing >90%

patients with a new diagnosis of cancer within 6 months. The remainder were reviewing >80%,

with the exception of one practice who only reviewed just over 50%.

QOF End of Life charts 2011/12

QOF Cancer charts 2011/12

Q&V Cancer screening

39 out of 47 Southwark practices score higher than the London average for Identifying Cancer

(higher scores highlight poorer performance), with 13 practices at Trigger 2 levels (more than

2 standard deviations from expected target).

GPOS 2011/12

Q&V Cervical Cancer screening

Across Southwark, cervical screening performance is slightly below London average, although

there is variation between localities, with SSWK performing above average, and B&R below

average.

GPOS cervical screening charts

2011/12

Southwark

CCG

B&R B&W SSWK

ANALYSIS Community Based Services


Q&V

C&C

Access to Diagnostics (e.g. Phlebotomy, ECGs, Ultrasound scans)

There is considerable variation at practice level in how and which enhanced services are

provided (e.g. Phlebotomy, including near patient testing / Warfarin). There is no quantitative

evidence around the availability of provision of other community diagnostics (e.g. ECG,

Ultrasound Scan) however qualitative feedback from patients suggests this would be valued –

no clear consensus emerging for patients for what form that might take (i.e. Hub or every

practice)

Enhanced Services

Feedback from Out of

Hospital Engagement event

C&C Pharmacist Use

Qualitative feedback from patients and potential providers (e.g. Pharmacists) was that

patients would like to see (and Pharmacists were capable of providing) a far greater range of

services, which would extend the opening hours and ease of access for this type of service.

Extending the range of services where they are already successful and new initiatives where

they have the capability (e.g. Smoking cessation, screening, minor ailment)



LES Smoking Cessation

C&C Community Provider Appointments

Quantitative data on the Community Provider services (Health Visiting, District Nursing, AHP)

suggests there is potential for improvement relating to appointments cancelled by service

Community Performance

Data

Source: CHS Combined

Commissioner reports

January-September 2012-13

C&C Range of GP led Outpatient Services

The following services were identified as being available in the community; Adult Audiology,

Dermatology, Headache / Neurology, ENT, Ophthalmology. There is limited information on the

patient eligibility for these services, performance monitoring or whether this range of services

remains appropriate currently. Patients reported they were unclear about the rationale for

their location.



CCG Community Service

Descriptions

Southwark

CCG

B&R B&W SSWK

ANALYSIS Integration (Care Coordination/ ‘Patient Friendly’ Care)


C&C Information Management

Qualitative feedback from patients suggests there is considerable scope to improve information

management in Primary Care, this includes reporting of results, online appointment booking,

online repeat prescription and potential for online consultations. As a result of the lack of

available information patients reported they were required to ‘repeat their story’ on numerous

occasions.


Hospital Engagement

event

Q&V

C&C

Co-ordinated Services

Qualitative feedback suggests lack of ‘joined up’, consistent services with different support

workers providing care on a daily basis. This results in repetition of both giving and receiving

information, conflicting information being provided by the service and a lack of trust between

patient and service.


Hospital Engagement

event – Frail Elderly

Group

Q&V Case Management

There is quantitative and qualitative information which suggests patients would benefit from

explicit co-ordination of their care. Patients expressed a lack of clarity of where within the

pathway they sat, a lack of consistency in management and lack of an overall, appropriate care

plan. As a result they were required to ‘repeat their story’ on numerous occasions.


Hospital Engagement

event

LES – ICP

LES - LTC

Q&V Co-production

Patients reported a clear desire to be more involved in the co-production (outcomes, process,

evaluation, monitoring) of their care. In particular they wanted measures and goals which were

more meaningful to them.


Hospital Engagement

event

Q&V Falls

There was no evidence that Falls are being monitored and performance incentivised in 2012/13

Community Services Contract despite non-achievement of CQUIN targets in 2011/12.

CQUIN Graph (11/12)

Q&V Transport

There was significant feedback from numerous stakeholders (including patients and providers)

that existing transport arrangements do not support the current and planned location of services.


Hospital Engagement

event

Southwark

CCG

B&R B&W SSWK

ANALYSIS Access (1)


C&C Demand and Capacity Variation

Nearly 80% of practices returned data for the sample period. There is significant variation in

demand and capacity between practices. Several practices having twice as much demand

than overall capacity on a weekly basis, about 30% of practices have approximately equal

demand to capacity, however there are around 60% of practices who have greater capacity

than demand (including nursing capacity). On a daily basis demand and capacity is

significantly mismatched, but over the week this may appear more balanced than is reality on

a day-to-day basis.


Capacity:Demand Ratio

Analysis

C&C Demand and Capacity Benchmarking

More than 65% of practices in Southwark offer more than the closest available RCGP

benchmark of 83 appointments per 1,000 patients per week *(nursing and GP appointments),

suggesting in general terms that access issues relate more to excess demand on a weekly

basis than a significant shortfall in capacity. However, there may be still some shortfall in

capacity on a daily basis (Figures 37 and 40).

Figures 37 & 40

*RCGP Scotland survey of

total demand in 51 GP

Practices (2010)

** Most English benchmarks

relate to GP appointments

only and use 70

appointments/1000

patients/week

C&C A higher proportion of Southwark respondents stated that there were not appointments for

the day they wanted compared to the national average.

GP Patient Survey Jan-Sept

2012

C&C Of those respondents who could not get an appointment for the day they wanted a higher

proportion attended A&E / Walk in Centres when compared to the national average


2012

C&C A lesser proportion of Southwark respondents were able to see a GP/Nurse on the same day

or on the next working day when compared to the national average


2012

Southwark

CCG

B&R B&W SSWK

ANALYSIS Access (2)


Q&V There is considerable variability in practices seeing / speaking to patients on the same day

they request an appointment.


2012

C&C Extended Hours

Specifically relating to Extended Hours we have found no evidence that provision is tested

against local requirements and there is variability in provision. In addition to this feedback

suggests patients are dissatisfied and confused with the current configuration of extended

hours.

LES Graphs



Demand and Capacity Analysis

C&C Practice Access

There is evidence demand is not always matched to supply, particularly on a daily basis,

although some practices are achieving this. Southwark patients who cannot access a GP

service are more likely to choose and attend A&E as the alternative when compared to the

national average.

Currently A&E attendance data is not being reporting in a format which allows for

benchmarking against national average.

Demand & Capacity

A&E Activity Data

GP Patient Survey

A&E Attendance graph

Q&V Signposting

Feedback suggests that patients would benefit from better signposting of urgent care services

to ensure they access the right place at the right time. Feedback also suggests that

traditional signposting methods are not proving successful.


Meetings



Q&V

C&C

Pro-active Care for Long term Conditions

Data supported by qualitative feedback from patients suggests that some practices are not

embracing proactive care for patients with long-term conditions (take-up of healthchecks,

take up of ICP, screening and management of QOF for long-term conditions).

There is qualitative evidence that this group of patients access urgent hospital services as an

alternative to primary care. Feedback from practices suggests there is both a question

regarding the evidence base for Health Checks and their capacity to be able to deliver them.



(LTC Group)

QOF Data

LES Data (Health Checks and

ICP)


Meetings

Southwark

CCG

B&R B&W SSWK

ANALYSIS Access (3)


Q&V

C&C

Access to Diagnostics (e.g. Phlebotomy, ECGs, Ultrasound scans)

There is considerable variation at practice level in how and which enhanced services

are provided (e.g. Phlebotomy, including near patient testing / Warfarin). There is no

quantitative evidence around the availability of provision of other community

diagnostics (e.g. ECG, Ultrasound Scan) however qualitative feedback from patients

suggests this would be valued – no clear consensus emerging for patients for what

form that might take (i.e. Hub or every practice)

Enhanced Services


Engagement event

C&C Pharmacist Use

Qualitative feedback from patients and potential providers (e.g. Pharmacists) was

that patients would like to see (and Pharmacists were capable of providing) a far

greater range of services, which would extend the opening hours and ease of access

for this type of service.

Extending the range of services where they are already successful and new initiatives

where they have the capability (e.g. Smoking cessation, screening, minor ailment)


Engagement event

LES Smoking Cessation

C&C Range of GP led Outpatient Services

The following services were identified as being available in the community; Adult

Audiology, Dermatology, Headache / Neurology, ENT, Ophthalmology. There is limited

information on the patient eligibility for these services, performance monitoring or

whether this range of services remains appropriate currently. Patients reported they

were unclear about the rationale for their location.


Engagement event

CCG Community Service

Descriptions

Q&V Transport

There was significant feedback from numerous stakeholders (including patients and

providers) that existing transport arrangements do not support the current and

planned location of services.


Engagement event

Southwark

CCG

B&R B&W SSWK

ANALYSIS Access (4)


C&C Dementia Care QOF Performance

Whilst the quantitative analysis does not reveal a problem with dementia care in

identification or management within QOF requirements, qualitative feedback suggests

management of this condition in particular causes GP practices concern. There is no

objective data about the extent of comprehensive provision of care for this group.

Depression QOF & GPOS Domain

Total % QOF Points 2011-2012

showing locality and practice

variation

C&C Capacity and Capability

Qualitative feedback suggests;

•A need for mental health education and training for all healthcare professionals,

•A greater awareness of mental health issues

•Capacity in primary care to indentify and manage mental health issues in an integrated

manner with physical health.


Engagement event

Q&V

C&C

A&E Activity

Qualitative feedback suggests that disproportionate numbers of A&E attendances are

generated by care home residents, with a peak of activity in the afternoon for this patient

group.

Stakeholder Interviews

C&C A&E Attendances

There is considerable variation (>100%) in A&E Minor attendance by practice, feedback from

locality meetings suggests this could be due specific practice demographics rather than

appointment availability. No evidence has been found that specific services or initiatives

are targeting these groups.

A&E Minors Graph

Feedback from Locality meetings

Southwark

CCG

B&R B&W SSWK

APPENDIX 1: DATA ANALYSIS

ANALYSIS

Category Description Appendix

CCG Level

Analysis

The CCG level analysis addresses the quality and variability, and capacity and capability across the

CCG across all metrics. This includes external benchmarking where possible and covers a range of

diverse measures

1A

Locality

Level

Analysis

The locality level analysis compares the three localities with each other and also with the internal or

external benchmarks where information is available. For some indicators, a comparison between the

various practices within each locality is also shown.

1B

Quality and

Variability

Quality is defined as the effectiveness and safety of care provided, together with patient perception

and feedback on the service. This also includes an assessment of the variability of this quality across

the CCG

Within

both 1A

and 1B

Capacity and

Capability

The capacity across primary and community care in Southwark, in terms of available and accessible

services and appointments, and the skills that exist across the CCG area in order to deliver both

existing and extended services

Document

and Strategy

Review

An overview of CCG strategies that impact on the Primary and Community Care Strategy. Note that

the SEL Community Based Care Strategy will be considered in more detail at the development of

options stage

1C

The following sections set out the detailed findings from the analysis. The Appendices are split into CCG level analysis (all

the analysis, focussing on the CCG as a whole) and Locality level analysis (comparison between locality). These appendices

include an assessment of both Quality and Variability, and Capacity and Capability.

Within each Appendix a series of tables highlight key findings from each chart, with the actual charts following the tables.

All findings are referenced to the relevant chart.

Structure and Presentation

APPENDIX 1A: CCG LEVEL ANALYSIS

Capacity & Capability

Key

In total Southwark weekly demand is less than capacity for GP surgery appointments at the 36 practices

who completed the research

Figure 36

In total Monday and Tuesday both show greater demand than capacity compared to the remaining days in

the week - with the gap at the highest level on a Monday

Figure 36

In comparison Wednesday, Thursday and Friday show greater capacity than demand – with the gap at the

highest level on Thursday

Figure 36

In total demand and capacity both gradually decrease through the week (i.e. Demand and capacity are at

the greatest on Monday and lowest on Friday)

Figure 36

Monday shows significantly more demand for appointments than any other day in the week, with Friday

being the day that least appointments are requested

Figure 36

A proxy for Community Services capacity ‘waste’ is the “cancelled by service” appointments and the

patient “DNAs”. The sum of these two equate to circa 13% of capacity being lost to the service.

Figure 30-33

Southwark

CCG

B&R B&W SSWKANALYSIS CCG Level Analysis

ANALYSIS CCG Level Analysis

Quality and Variability

Key

The data shows considerable variation amongst practices and localities for different indicators around

the usage of secondary care

Figures 1-3

Increase in A&E minor attendances across all three localities. Figure 3

39 out of 47 Southwark practices score higher than the London average for Identifying Cancer (higher

scores highlight poorer performance), with 13 practices at Trigger 2 levels (more than 2 standard

deviations from expected target).

Figure 10

Southwark

CCG

B&R B&W SSWK



Key

A large proportion of practices in Southwark are in the bottom quartile nationally for screening indicators,

particularly for Diabetes

Figures 4-6

Over 40% of Southwark practices fall within the lower or 2nd quartile for patient satisfaction with access.

There is considerable variation amongst practices

Figure 7

Around 2/3rd of Southwark practices fall within the lower or 2nd quartile for patient satisfaction with

quality. High levels of variation amongst practices

Figure 8

Southwark Mental health % QOF scores have huge variability within CCG. Southwark is also considerably

below the national average

Figure 9

Childhood Immunisation (Note: current year LES for immunisation has not been used as performance

figures are only available for Qtr 1 in 2012-13)

Despite the presence of a LES and a Community CQUIN for immunisation, Southwark does not achieve the

national average take up rate of 95% in 2011/12.

Figure 12

The is a marked fall off in rates in 2011/12 after the initial early years immunisations, so that children

appear not to be fully immunised before entering fulltime education.

Figure 12

There is a difference in 2011/12 between localities with South Southwark falling below the Southwark

average of 90%

Figure 12

The current year community CQUIN measurement is unclear in that the aim is to reduce the shortfall in

MMR, but it does not provide a clear indication of achievement. Potentially the targets are set too low at

50% and 40% reduced shortfall respectively for Under 5 and Under 2 years of age.

Figure 13-14

Its is of interest to note that the targets were not achieved at Q4 in the 2011 -12 Community CQUIN for

immunisation .

Figure 13-14

Southwark

CCG

B&R B&W SSWK



Key

A large proportion of practices in Southwark are in the bottom quartile nationally for these indicators,

particularly for Diabetes

Figures 4-6

Minor Surgery (Note: this is 3 months data only)

Wide range of levels of activity undertaken, some practices undertaking much less per year which raises

clinical competency and thresholds for payment questions

Figure 16

Wide range of procedures undertaken, but majority are related to contraceptive care rather than typically

minor surgery?

Figure 17

A small number of practices typically under take the majority of the procedures, particularly relating to minor

surgery ( rather than contraception). Notably P5, P22 and P31 Excision and aspiration; and P35 cryotherapy.

Figures 18-20

Total amount of vasectomies undertaken across the CCGs is small with notable variation between localities

with SSW locality undertaking very few, even noting that this is just one quarter

Figure 21

There is some variation across the Practices for Flu Vaccine take up for the over 65s age group. With P8, P9,

P29 and P35 noticeably below the average

Figure 22

B&W locality are performing notably better than the two other localities for Flu Vaccine take up in the over 65s Figure 23

Very few Health Checks have been undertaken across the CCG by 31st December 2012. All but 5 Practices have

undertaken less than 10% of the Checks for eligible patients

Figure 24

Very few patients have been called for a Health Check demonstrating that the challenge is in the calling for

patients, rather than patients failing to respond

Figure 25

There is a direct correlation between those called for and those having had a Health Check completed for the

most successful Practice – e.g. P42 – it is suggestive that Health Checks are not carried out opportunistically

Figures 24-25

Southwark

CCG

B&R B&W SSWK



Key

Limited outcome data is available on the Integrated Care Programme. Whilst almost half of GP practices have signed

up for the ICP LES, a very small number appear to have created the register to enable Patient to be called for the

Holistic Health -Assessment (HHA) and therefore only a small number (4%) of those eligible for an HHA have had one.

Figure 26

All patients following an HHA have some type of intervention with approximately 20% being given advise by the

assessor and 80% being referred on for further advise/intervention

Figure 26

Community services appeared to not achieve the falls CQUIN target in 2011-12. Although falls are presumably still

measured, there is no CQUIN for Falls in the current year.

Figure 29

The LES Contract for smoking states;

…For Practices that achieve a successful quit ratio of 35% or above that will be rated as green for Practices that

achieve a successful quit ratio between 28% and 34% will be rated as amber. For all practices that achieve less than

28% will be rated as red...

This does not affect payment but may be seen as an indicator for effectiveness with the CCG deciding whether to

take forward Practice LESs where the “Set to Quit” percentage is less than 30%

Figures

27-28

Southwark CCG set to quit rate is currently less than 30%, although it is recognised that the final quarter typically

has a good return. Even the 30% target is well short of London average Set to Quit rate of 46%.

Figures

27-28

It is interesting to note that although Community Pharmacy Set to Quit rate is only marginally higher than that of the

GPs, the verification by CO2 levels is significantly higher.

Figures

27-82

The CCG achievement of 12% Chlamydia screening of the target population for 2011-12 falls very short of the 35%

CCG target.

SSW Locality achieved just over 6% as the lowest performing Locality and B&W Locality the highest with 17%

Figure 34

Interesting to note is those Practices which appear to have a LES are not necessarily the highest performers – P1,

P5, P33, P35 are below the Southwark average for Chlamydia screening

Figure 35

Southwark

CCG

B&R B&W SSWK

ANALYSIS CCG Level Analysis – Outpatient Activity

Southwark

CCG

B&R B&W SSWK

Source: SCCG Practice Trend Analysis, 2012-2013

-

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

200.00

P1

P2

P3

P4

P5

P6

P7

P8

P9

P10

P11

P12

P13

P14

P15

P16

P17

P18

P19

P20

P21

P22

P23

P24

P25

P26

P27

P28

P29

P30

P31

P32

P33

P34

P35

P36

P37

P38

P39

P40

P41

P42

P43

P44

P45

P46

B&

R

B&

W

SSO

SO

U

Rate

per

1000

Figure 1 - Outpatient New

2012/13

ANALYSIS CCG Level Analysis – A&E Activity

Southwark

CCG

B&R B&W SSWK


-

50.00

100.00

150.00

200.00

250.00

300.00

P1

P2

P3

P4

P5

P6

P7

P8

P9

P10

P11

P12

P13

P14

P15

P16

P17

P18

P19

P20

P21

P22

P23

P24

P25

P26

P27

P28

P29

P30

P31

P32

P33

P34

P35

P36

P37

P38

P39

P40

P41

P42

P43

P44

P45

P46

B&

R

B&

W

SSO

SO

U

Rate

per

1000

Figure 2 - A&E (Combined)

2012/13

ANALYSIS


CCG Level Analysis – A&E Minors Activity

-

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

P1

P2

P3

P4

P5

P6

P7

P8

P9

P10

P11

P12

P13

P14

P15

P16

P17

P18

P19

P20

P21

P22

P23

P24

P25

P26

P27

P28

P29

P30

P31

P32

P33

P34

P35

P36

P37

P38

P39

P40

P41

P42

P43

P44

P45

P46

B&

R

B&

W

SSO

SO

U

A&

E M

inor

Acti

vit

y

per

1000 p

opula

tion

Figure 3 - A&E Band 5 (Minors) Activity 2012-2013

Southwark

CCG

B&R B&W SSWK

26

35

27

42

14

7

12

3

5

3 6

1 6

1 1

Hypertension CHD COPD Diabetes

Figure 4 - QOF Prevalence as Ratio of Expected (practices by quartile)

Lower quartile 2nd quartile 3rd quartile Upper quartile

This graph shows the number of

practices in Southwark falling into

each national quartile, for the

screening indicators when comparing

patients with clinical conditions as

ratio of expected

ANALYSIS CCG Level Analysis – Long Term Conditions

Source: Southwark Primary Care Dashboard, QOF 2011-2012

4238

3

6

11

Diabetes as ratio of expected

HbA1c <8

Diabetes Indicators

Lower quartile 2nd quartile

3rd quartile Upper quartile

14

9

15

12

15

20

25

Satisfied with Quality Satisfied with Access

GP Survey Satisfaction Indicators

Lower quartile 2nd quartile 3rd quartile Upper quartile

Figure 5 Figure 6


Southwark

CCG

B&R B&W SSWK


These graphs show the number of

practices in Southwark falling into

each national quartile

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

P37

P40

P43

P6

P19

P16

P5

P29

P27

P18

P9

P42

P4

P17

P3

P32

P26

P25

P46

P15

P33

P30

P23

P14

P20

P11

P24

P10

P21

P22

P8

P44

P39

P31

P36

P34

P45

P1

P12

P13

P28

P38

P7

P41

P2

P35

Figure 7 - % of patients satisfied with access

SSWK

B&R

B&W

England Average

London Average

Southwark Average

ANALYSIS CCG Level Analysis – Patient Satisfaction


Southwark

CCG

B&R B&W SSWK

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

P6

P37

P14

P29

P27

P11

P15

P42

P21

P32

P13

P18

P30

P33

P40

P45

P22

P4

P9

P44

P43

P19

P16

P10

P3

P5

P23

P34

P12

P1

P26

P17

P46

P35

P31

P39

P38

P7

P20

P36

P25

P8

P24

P2

P28

Figure 8 - % of patients satisfied with quality

SSWK

B&R

B&W

England Average

London Average

Southwark Average

ANALYSIS CCG Level Analysis – Patient Satisfaction

Southwark

CCG

B&R B&W SSWK


ANALYSIS CCG Level Analysis – Mental Health

Source: Quality Outcomes Framework, 2011-2012

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

% P

oin

ts S

core

d

Figure 9 - Mental Health Domain Total % QOF Points 2011-2012 showing locality and practice variation

B&R B&W

National

Average

SSWK Sou

Southwark

CCG

B&R B&W SSWK

For Southwark Mental Health

Domain Total % QOF points graph

below there are three practices

scoring below 55.5% and eleven

practices scoring 100%

ANALYSIS CCG Level Analysis - Cancer

Southwark

CCG

B&R B&W SSWK

Source: General Practice Outcomes Standards, 2011-2012

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Poin

ts S

core

d

Figure 10 - Identifying Cancer Points Achieved using General Practice Outcomes Standards Framework showing Southwark


London

Average

SSWK Sou B&R B&W

The dots on the chart show that

for Southwark Cancer Domain

Total % QOF points there is one

practice scoring below 0.50 and

one practice scoring 3.0

High scores highlight good

performance

39 out of 47 Southwark practices score

higher than the London average for

Identifying Cancer (higher scores

highlight poorer performance), with

13 practices at Trigger 2 levels (more

than 2 standard deviations from

expected target).

ANALYSIS CCG Level Analysis - Screening

Southwark

CCG

B&R B&W SSWK


30.00

40.00

50.00

60.00

70.00

80.00

90.00

% P

oin

ts

Figure 11 - Cervical Cytology Points Achieved using General Practice Outcomes Standards Framework showing Southwark


London

Average

SSWK Sou B&R B&W

The dots on the chart show that

for Southwark Mental Health

Domain Total % QOF points there is

one practice scoring below 40.0

and one practice scoring above

84.0

High scores highlight good

performance

ANALYSIS CCG Level Analysis – Childhood Immunisation Rates

Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

B&R Average B&W Average SSWK Average Southwark Average

% o

f C

hildre

n I

mm

unis

ed

Figure 12 - 2011/12 Southwark Immunisation Rates by Locality

U2 Average

U5 Average

National Target*

Source: Southwark Childhood Immunisation data 2011/12 *Department of Health Strategic Document, 2011 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Childhood-

Immunisation-Appendices.pdf

Source: Community CQUIN Report Qtr 3 2012-13 v5

CCG Level Analysis – Childhood Immunisation Rates

ANALYSIS

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4

% a

chie

vem

ent

of

targ

et

Figure 13 - Reduced shortfall of MMR 2 immunisations through Health Visitor

Team involvement

Actual

Target

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4

% a

chie

vem

nt

of

targ

et

Figure 14 - Reduced shortfall of preschool booster immunisations

through Health Visitor Team involvement

Actual

Target

Southwark

CCG

B&R B&W SSWK

CCG Level Analysis – Childhood Immunisation Rates

ANALYSIS

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1st DTaP/IPV/Hib PCV 1st MMR 2nd MMR Preschool Booster

Figure 15 - Reduced shortfall of preschool booster immunisations through Health Visitor Team involvement, FU

and immunisation

Q4 target

Q4 actual

Source: GSTFT CHS CQUIN report 2011/12 Qtr 4 v2

Southwark

CCG

B&R B&W SSWK

Source Document: “QMS Stats on date 2012/12/31for Southwark PCT” Data for latest 3 months available ending 31 Dec 2012

CCG Level Analysis – Minor Surgery

ANALYSIS

0 50 100 150 200 250 300 350

Injection of sclerosing substance into haemorrhoid

Morning after IUDs fitted

IUDs replaced

Other minor surgery

IUDs removed

Check of Mirena coil

Bilateral vasectomy for contraception

Patients with IUS (Mirena) removed

Removal of Mirena coil

Cautery

Implant insertion - non-contraceptive

Patients with Dermal implant removed

Removal of subcutaneous contraceptive

Use of non-specific minor surgery codes

IUDs checked

Patients with IUD removed

Injection

Patients with IUS (Mirena) fitted

Patients with IUD fitted

Introduction of Mirena coil

Patients with Dermal implant fitted

Insertion of subcutaneous contraceptive

IUDs fitted

Cryotherapy

Excision

Aspiration

Injections of Goserelin / Leuprorelin Acetate

Number of Procedures in 3 months

Figure 16 - Minor Surgery - All Procedure Types (Southwark CCG)

Southwark

CCG

B&R B&W SSWK

Source Document: “QMS Stats on date 2012/12/31for Southwark PCT” Data for latest 3 months available ending 31 Dec 2012


ANALYSIS

0

50

100

150

200

250

300

350

400

P5

P35

P1

P11

P31

P21

P2

P30

P38

P22

P34

P10

P32

P45

P15

P20

P42

P46

P8

P28

P44

P47

P6

P29

P14

P37

P17

P33

P39

P18

P27

P26

P7

P19

P12

P36

P23

P13

P25

P16

P24

P40

P4

P41

P3

P9

Num

ber

of

Pro

cedure

s

Figure 17 - Total Number of Minor Surgery Procedures - Southwark CCG

Southwark

CCG

B&R B&W SSWK

Source Document: QMS Stats on date 20121231 for Southwark PCT. Data for latest 3 months available ending 31 Dec 2012


ANALYSIS

0

10

20

30

40

50

60

P35 P1 P38 P11 P5 P22

Num

ber

of

Pro

cedure

s in

3 m

onth

s

Figure 18 - Cryotherapy (Total procedures = 170)

0

5

10

15

20

25

30

35

P5 P31 P22 P45 P30 P33 P44

Num

ber

of

Pro

cedure

s in

3 m

onth

s

Figure 19 - Aspiration (Total procedures = 229)

0

10

20

30

40

50

60

70

P5 P31 P22 P34 P11 P1 P10

Num

ber

of

pro

cedure

s in

3 m

onth

s

Figure 20 - Excision (Total procedures = 207)

0

5

10

15

20

B&R B&W SSWK SouthwarkTotal

Num

ber

of

Pro

cedure

s in

3 m

onth

s

Figure 21 - Bilateral Vasectomy for Contraception (shown by Locality due to low volume) (Total

procedures = 17)

Southwark

CCG

B&R B&W SSWK

Source Document: Flu take up Current Year to Date: Flu payments (report) Sept-Jan 2013 as at 20130219

CCG Level Analysis – Flu Vaccine

ANALYSIS

0

10

20

30

40

50

60

70

80

90

P4 P19 P23 P30 P38 P41 P7 P14 P17 P22 P32 P43 P1 P3 P9 P12 P15 P25 P28 P34 P36 P40 P44

% o

f pati

ent

upta

ke

Figure 22 - Flu Vaccine Uptake Over 65s (2012/13 YTD)

% Uptake

Southwark Average

LES Target

Southwark

CCG

B&R B&W SSWK

CCG Level Analysis – Flu Vaccine

ANALYSIS

66

67

68

69

70

71

72

73

74

75

B&R Average B&W Average SSWK Average Southwark Average

% o

f pati

ent

upta

ke

Figure 23 - 2012/13 Over 65s Flu Vaccination Uptake by Locality

% Uptake

Source Document: Flu take up Current Year to Date: Flu payments (report) Sept-Jan 2013 as at 20130219

Southwark

CCG

B&R B&W SSWK

Source Document: “QMS Stats on date 2012/12/31 for Southwark PCT “ *Health checks started in January 2012

CCG Level Analysis – Health Checks

ANALYSIS

0%

5%

10%

15%

20%

25%

30%

35%

P41

P3

P9

P36

P39

P38

P29

P8

P30

P19

P4

P40

P16

P43

P28

P46

P13

P24

P12

P23

P45

P33

P18

P1

P44

P20

P25

P22

P7

P10

P15

P2

P35

P21

P26

P31

P27

P32

P11

P34

P5

P37

P6

P14

P17

P42

Figure 24 - Southwark CCG - % of patients with NHS Health Check in last 5 years* (eligible at time of check)

% o

f eligib

le P

ati

ents

wit

h H

ealt

h C

heck c

om

ple

ted

LES target % expected to

be invited in 12-13

LES target % expected to

be completed in 12-13

Southwark

CCG

B&R B&W SSWK

CCG Level Analysis – Health Checks

ANALYSIS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

P41

P3

P9

P42

P17

P14

P6

P37

P11

P32

P5

P34

P27

P21

P35

P7

P26

P31

P2

P15

P10

P22

P23

P25

P44

P1

P18

P20

P33

P45

P24

P46

P13

P43

P12

P28

P16

P40

P19

P4

P30

P8

P29

P38

P39

P36

Figure 25 - Southwark CCG - % of patients currently eligible for NHS Health Check, WITHOUT an invitation (or check) in last 5 years

% o

f eligib

le P

ati

ents

wit

h n

o H

ealt

h C

heck o

r invit

e

Source Document: “QMS Stats on date 2012/12/31 for Southwark PCT”

Southwark

CCG

B&R B&W SSWK

Source Document: “QMS Stats on date 2012/12/31 for Southwark PCT”

CCG Level Analysis – Integrated Care Programme

ANALYSIS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percentage of Practicessigned-up

Patients on ICP Register- Elderly at Risk

Patients on the ICPregister who are eligible

for a Holistic HealthAssessment

HHAs carried out yearto date

Of patients having hadan HHA % referred orsignposted to other

services

Of patients having hadan HHA % given healthpromotion and lifestyle

advice

% A

chie

vem

ent

Figure 26 – ICP Achievement Against Range of Requirements (2011-2012)

Southwark

CCG

B&R B&W SSWK

Source: Local Outcome Summary Report: GP YTD 220213 (Smoking) and Local Outcome Summary Report: CP YTD 220213 (Smoking)

ANALYSIS

•CCG target % Quitters at 4 wks (Set to Quit) = 30%

•London average % Quitters at 4 wks 2011-12 = 46%

CCG Level Analysis – Smoking Cessation

0%

10%

20%

30%

40%

50%

60%

70%

% quitters at 4weeks

% CO verified(of quitters)

% not quit % lost to followup

Figure 27 - Southwark CCG GP Totals: Quitters at 4 weeks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% quitters at4 weeks

% COverified (ofquitters)

% not quit % lost tofollow up

% notreported

Figure 28 - Community Pharmacy Totals: Quitters at 4 weeks

Southwark

CCG

B&R B&W SSWK

Source: GSTFT CHS CQUIN Report 2011-12 Qtr 4 V2; Actual number of falls for patients admitted to community services at GSTFT except Inpatients

ANALYSIS CCG Level Analysis - Community Services

0

5

10

15

20

25

30

35

40

Q1 Q2 Q3 Q4

Num

ber

of

Falls

Figure 29 - Number of falls 2011-12 outturn Lambeth and Southwark

Number of Falls

Target

Southwark

CCG

B&R B&W SSWK

Annual target only appears to have been

set; showing in Q4

ANALYSIS CCG Level Analysis – Community Services

0

500

1000

1500

2000

2500

3000

3500

4000

1 2 3 4 5 6 7 8 9

Num

ber

of

Appoin

tments

Month

Figure 30 - Number of Cancelled Appts in Community Services

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9

Num

ber

of

Appoin

tments

Month

Figure 31 - Percentage of Cancelled Appts in Community Services

0

500

1000

1500

2000

2500

1 2 3 4 5 6 7 8 9

Num

ber

of

Appoin

tments

Month

Figure 32 - Number of DNAs to Community Services

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8 9

Num

ber

of

Appoin

tments

Month

Figure 33 - Percentage of DNAs to Community Services

Source: CHS Combined Commissioner reports January-September 2012-13

Southwark

CCG

B&R B&W SSWK

ANALYSIS

Source: Southwark Chlamydia LES Payment 2011-2012 (report)

•SWCCG target is

35% of eligible

population

CCG Level Analysis - Chlamydia Screening

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

B&R Average B&W Average SSWK Average

% o

f popula

tion s

cre

ened

Figure 34 - Chlamydia Screening - % Screened 2011/12

% Screened

Southwark Average

Southwark

CCG

B&R B&W SSWK

ANALYSIS

Source: Southwark Chlamydia LES Payment 2011-2012 (report), sorted by LES holding Practices

•SWCCG target is

35% of eligible

population

CCG Level Analysis - Chlamydia Screening

0%

10%

20%

30%

40%

50%

60%

P1 P2 P5 P7 P11 P18 P21 P24 P30 P33 P35 P38 P43 P46

% o

f pati

ents

scre

ened

Figure 35 - Chlamydia Screening - % Screened Practices with LES

% Patients Screened

Southwark Average

Southwark

CCG

B&R B&W SSWK

ANALYSIS

The Demand and Capacity analysis represented the first of a several stage process, and as such is only a ‘snapshot’ of

the annual picture. The findings should be viewed simultaneously in order to provide a complete picture of the situation

for the period studied- no single graph can be interpreted in isolation. It is possible to infer the following conclusions:

a) Southwark weekly demand and capacity graph highlights that, broadly speaking patient demand is met by capacity

supplied during the week across the CCG- but see note (f) on capacity supplied (Figure 36).

b) When investigated further, total practice level demand:capacity suggests there is considerable variation between

practice demand and capacity, with many practices having more capacity than demand over the week. However

some of this may include excess nursing capacity (Figure 37).

c) In order to understand this variation on a daily basis, two practices which showed equal demand and capacity (i.e.

Offering equal appointments to patient demand) were chosen to be analysed from the perspective of daily variation.

This highlighted that one practice was consistently offering appointments equal to demand (or offering extra

appointments on a daily basis), whereas the other had significant fluctuations in daily appointments (on certain days

they were offering too many appointments for the demand but on others they were offering less than the total

demand (Figures 38-39)).

d) To provide benchmarking where available, RCGP research in England suggested practices routinely offering more

than 70 GP appointments per 1,000 patients per week were more often able to meet patient demand than those

offering fewer than 70. Those offering a supply of less than 70 GP appointments per 1,000 per week often

experienced difficulty with access.

e) In addition, the RCGP estimated that in the closest available benchmark for total capacity (GP and nursing) the

contact rate for Scottish practices was approximately 83 face to face contacts per 1,000 patients per week, (62 of

these being GP contacts) for an average standardised practice. It is likely that many practices would require more

than this in order to meet demand.

f) More than 95% of practices in Southwark offer more than 70 total appointments per 1,000 patients per week, and

65% offer more than 83 total appointments per week, suggesting in general terms across the CCG that access issues

largely relate to daily demand variation, and high levels of demand, rather than capacity supplied (Figures 37 and

40).

Demand & Capacity Analysis - Key Findings

Southwark

CCG

B&R B&W SSWK

Source: GP Demand and Capacity Primary Research, March – April 2013

0

5000

10000

15000

20000

25000

30000

Monday Tuesday Wednesday Thursday Friday Total

Weekly

Dem

and a

nd C

apacit

y

Figure 36 - Southwark Total Weekly Demand and Capacity

Capacity

Demand

Southwark

CCG

B&R B&W SSWKANALYSIS Demand & Capacity Analysis - Key Findings


Capacit

y >

Dem

and

Dem

and

>

Capacit

y

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

P20

P2

P5

P30

P21

P33

P46

P9

P35

P10

P40

P15

P8

P1

P34

P25

P42

P29

P36

P17

P37

P16

P11

P12

P19

P45

P13

P38

P43

P7

P32

P18

P27

Weekly

Rati

o o

f C

apacit

y:D

em

and

Figure 37 - Southwark Total Weekly Capacity:Demand Ratio

Southwark

CCG

B&R B&W SSWK

Outlier practices excluded

ANALYSIS Demand & Capacity Analysis - Key Findings

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

Rati

o o

f C

apacit

y:D

em

and

Figure 39 - Practice 9 Daily Capacity:Demand Ratio

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

Rati

o o

f C

apacit

y:D

em

and

Figure 38 - Practice 30 Daily Capacity:Demand Ratio


Southwark

CCG

B&R B&W SSWK

Illustration of practices with seemingly well matched demand and

capacity on a weekly basis – this can mask daily variation which is critical

to consider – see Figure 39

ANALYSIS Demand & Capacity Analysis - Key Findings

Source: GP Demand and Capacity Primary Research, March – April 2013 Benchmark provided by RCGP Guidelines - http://www.rcgp.org.uk/rcgp-near-you/rcgp-scotland/~/media/Files/RCGP-Faculties/Scotland/RCGP-Scotland/RCGP_master_Treating_access.ashx

Southwark

CCG

B&R B&W SSWKANALYSIS Demand & Capacity Analysis - Key Findings

78

108

76

85 84

121

88 80

122

78

95

67

110

97

85 92

76 80

130

113

75 72 77

113

82

91

108

141

85

96

61

99

90 85

106 103

0

20

40

60

80

100

120

140

160

P20

P2

P5

P30

P21

P33

P46

P24

P6

P28

P9

P35

P10

P40

P15

P8

P1

P34

P25

P42

P29

P36

P17

P37

P16

P11

P12

P19

P45

P13

P38

P43

P7

P32

P18

P27

Num

ber

of

appoin

tments

off

ere

d p

er

1000 r

egis

tere

d

pati

ents

per

week

Figure 40 - Southwark practices number of appointments (GP & Nursing) offered per 1000 registered patients per week

RCGP Benchmark for GPs

RCGP Benchmark for GPs & Nurses

ANALYSIS CCG Level Analysis - GP Patient Survey

Source: GP Patient Survey Results Jan – Sept 2012

Southwark

CCG

B&R B&W SSWK

38

28

3

12

2

11 7

39

25

4 9

3

13 10

Went to theappointment Iwas offered

Got anappointment

for a differentday

Had aconsultation

over the phone

Went to A&E/ awalk-in centre

Saw apharmacist

Decided tocontact my

surgery anothertime

Didnt see orspeak toanyone

Figure 42 - What did you do on that occasion?

Southwark

National Average

52

20 11

7

49

18 11 13

There weren'tappointments for the day I

wanted

There weren'tappointments for the time

I wanted

I couldnt see my preferredGP

I couldn't book ahead atmy GP surgery

Figure 41 - Reason for not being able to get an appointment/ appointment offered inconvenient

Southwark

National Average



Southwark

CCG

B&R B&W SSWK

0

5

10

15

20

25

30

35

40

On the same day On the next workingday

A few days later A week or morelater

Figure 43 - How long was it until you actually saw or spoke to a GP/Nurse

Southwark

National Average



Southwark

CCG

B&R B&W SSWK

0%

10%

20%

30%

40%

50%

60%

70%

P4 P19 P23 P30 P38 P41 P7 P14 P17 P22 P32 P44 P1 P3 P9 P12 P15 P25 P28 P34 P36 P40 P45

% o

f appoin

tments

on t

he s

am

e d

ay

Figure 44 - How long was it until you actually saw/spoke to a GP/Nurse? (% On the same day)

Southwark Average

ANALYSIS

The Phlebotomy Review (July 2012)

- 83% of practices take blood at the practice

- Of those which don't, 43% said they would be willing to do so

- There is an average of 15 sessions per practice per month that patients

can access phlebotomy

- Most practices reported requesting up to 500 blood tests per month

from their practice-based phlebotomy services (with two significant

outliers of over 1200) – however with significant variation between

practices

- 83% of Practices reported that they fund the Phlebotomy services that

are provided on site. However, no evidence of specific LES payments

associated with these services could be found in primary care contracts.

Other providers account for the other 17%.

Suggested improvements:

- More sessions available at the practice – wider hours of opening

- More flexible locations – including co-locating with other diagnostic or

therapeutic services to save unnecessary patient journeys

- Shorter waiting times from ordering a test to getting results

Three options described (none selected as yet):

- Universal practice-based services (except in the smallest practices)

- Locality-based services

- Mobile services

Community Diagnostics - Phlebotomy

Southwark

CCG

B&R B&W SSWK

APPENDIX 1B: LOCALITY LEVEL ANALYSIS

ANALYSIS Locality Level Analysis – South Southwark (SSWK)


Key

Lowest scoring depression assessment scores compared to localities with one practice scoring significantly

below national average which is bringing the average for both locality and CCG down

Figure 50

Overall South Southwark Locality is performing below CCG average and below B&R and B&W for Under 2

childhood immunisation rates

Figure 46

Four practices are the main drivers of South Southwark Locality’s below average performance for

childhood immunisation in the under 2s and the under 5s

Practice P3, P29 , P34 and P36 are the main contributors to the low averages

Figure 46

There is variation in the amount of minor surgery undertaken across the South Southwark locality with

one practice (P35) undertaking the most and some undertaking very little

Figure 45

A number of practices in South Southwark are performing well for Flu Vaccines, notably P20, P25, P34,

P36, P37 and P44

Figure 47

A number of practice in South Southwark are not performing as well for Flu Vaccines, notably P9, P29,

P35 and P45

Figure 47

A small number of South Southwark Locality GP practices are achieving high rate of Quitters at 4 weeks: –

P35, P37 and P45

Figure 48

South Southwark Locality is performing below the Southwark CCG level of achievement for Chlamydia ,

particularly P1, P2, P15, P20, P36 and P40

Figure 49

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: SSWK Minor Surgery

Figure 45

0

50

100

150

200

250

P3

5

P1

P2

P3

4

P1

0

P4

5

P1

5

P2

0

P4

2

P4

6

P2

8

P6

P2

9

P3

7

P2

6

P1

2

P3

6

P1

3

P2

5

P4

0

P3

P9

Total Number of Minor Surgery Procedures -SSWK Locality

QMS Stats on date 20121231 for Southwark PCT. Data for latest 3 months available ending 31 Dec 2012: sorted by Locality Practice

Southwark

CCG

B&R B&W SSWK

Locality Level Analysis: SSWK Childhood immunisation ANALYSIS

Southwark Childhood Immunisation data 2011/12 sorted by Locality Practice

Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

P1 P2 P3 P6 P9 P10 P12 P13 P15 P20 P25 P26 P28 P29 P34 P35 P36 P37 P40 P42 P44 P45

%

Figure 46 - 2011/12 Childhood Immunisation Rates % - SSWK Locality

U2 Average

U5 Average

SOU U2

SOU U5

ANALYSIS Locality Level Analysis: SSWK Flu Vaccine

Flu take up Current Year to Date: Flu payments (report) Sept-Jan 2013 as at 20130219, sorted by Locality Practices

Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0


% U

pta

ke

Figure 47 - 2012/13 Over 65s Flu Vaccine Uptake for SSWK Locality

% Uptake

Southwark Average

Locality Average

ANALYSIS Locality Level Analysis: SSWK Smoking Cessation

Figure 48

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%


2012/13 % Quitters at 4 Weeks - SSWK Locality

Locality Average

Southwark Average

Local Outcome Summary Report: GP YTD 220213 (Smoking)

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: SSWK Chlamydia Screening

Figure 49

Southwark Chlamydia LES Payment 2011-2012 (report), sorted by Locality Practices

0%

5%

10%

15%

20%

25%

30%


2011/12 Chlamydia Screening - % ScreenedSSWK Locality

Southwark Average

Locality Average

SWCCG target is

35% of eligible

population

Southwark

CCG

B&R B&W SSWK

ANALYSIS

Southwark:

Max Score N = 13

Min Score N = 1


Locality Level Analysis: SSWK Depression

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Figure 50 - Depression Domain Total % QOF Points 2011-2012 showing locality and practice variation

National

Average

SSWK Sou B&R B&W

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis – Bermondsey & Rotherhithe (B&R)


Key

All practices within B&R scoring above national average for Anti Coag / Anti Platelet for AF from GPOS

data. Variability is also significantly less compared to other localities

Figure 56

B&R locality performs well against its fellow localities with immunisation rates for Under 2s, but with the

rates dropping away somewhat for the Under 5s

Figure 53

Majority of practices are achieving the Southwark average immunisations rates for Under 2s and Under 5s

P4 have a data collection issue as the average return is very low for U5s. P23 and P29 have the lowest

averages in the locality

Figure 53

Four practices in B& R locality – P21, P30, P31, and P38 - are undertaking the majority of minor surgery

activity; raising the question if are the remaining practices undertaking enough to be competent

Figure 51

P8, P31 and P41 are achieving below average take up rates for the Flu vaccine. P38 and P39 appear to be

performing ahead of the average

Figure 52

More of the Practices in B&R are closer to achieving the 30% target of Quitters at 4 weeks – notable

achievers are P23 and P30. P19 and P41 maybe missing data at this point

Figure 54

There is variation across the B&R Locality for Chlamydia screening with one Practice – P39 – being

responsible for the overall achievement of 14%. The majority of Practices have achieved less than 10%

Figure 55

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&R Flu Vaccine


Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

P4 P8 P19 P21 P23 P27 P30 P31 P38 P39 P41

% U

pta

ke

Figure 51 - 2012/13 Over 65s Flu Vaccine Uptake for B&R Locality

% Uptake

Southwark Average

Locality Average

ANALYSIS Locality Level Analysis: B&R Minor Surgery

Figure 52

0

20

40

60

80

100

120

P31 P21 P30 P38 P8 P39 P27 P19 P23 P4 P41

Total Number of Minor Surgery Procedures -B&R Locality


Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&R Childhood Immunisation

Southwark Childhood Immunisation data 2011/12 sorted by Locality Practice

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

P4 P8 P19 P21 P23 P27 P30 P31 P38 P39 P41

%

Figure 53 - 2011/12 Childhood Immunisation Rates % - B&R Locality

U2 Average

U5 Average

SOU U2

SOU U5

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&R Smoking Cessation

Figure 54


0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

P4 P8 P19 P21 P23 P27 P30 P31 P38 P39 P41

2012/13 % Quitters at 4 Weeks - B&R Locality

Locality Average

Southwark Average

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&R Chlamydia Screening

Figure 55

0%

10%

20%

30%

40%

50%

60%

P4 P8 P19 P21 P27 P30 P31 P38 P39 P41

2011/12 Chlamydia Screening - % ScreenedB&R Locality

Southwark Average

Locality Average


SWCCG target is

35% of eligible

population

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&R Anti-Coag for AF

0.80

0.82

0.84

0.86

0.88

0.90

0.92

0.94

0.96

0.98

1.00

Figure 56 - Anti-Coag/ Anti Platelet for AF Total % Points 11-12

National

Average

Southwark:

Max Score N = 21

Min Score N = 2


SSWK Sou B&R B&W

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis – Borough & Walworth (B&W)


Key

Highest Hypertension % QOF scoring locality with all practices scoring above the national average.

Moreover, little practice variability compared to two other localities

Figure 62

B&W locality appear to have the most consistent approach to achieving immunisation rates, with the

least drop off in rates between the Under 2s and the Under 5s

Figure 59

The locality appears to less variation in performance between practices with no practice dropping below

a rate of 75% and P14 only significantly below the averages

Figure 59

One practice in B&W Locality – P5- appears to be undertaking the majority of minor surgery, calling into

question the competency of the others with very low levels of activity

Figure 57

There is more consistency across B&W for Flu vaccine take up, with only I Practices – P17- failing to

achieve the Southwark CCG average take up rates; all the remaining Practices are above the Southwark

CCG average

Figure 58

There is variation across the B&W Locality for % quitters at 4wks from 80% by P5 to 18% by P11.

Counting and verification by CO2 would be of interest to understand this variation.

Figure 60

The majority of practices in B&W locality achieve the Southwark CCG average rate of Chlamydia

screening, but it should be noted that the Southwark CCG rate falls short of its target for the year of 35%.

P43 is the only Practice in B&W to over perform against this target.

Figure 61

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&W Minor Surgery

Figure 57


0

50

100

150

200

250

300

350

400

P5 P11 P22 P32 P44 P47 P14 P17 P33 P18 P7 P16 P24

Total Number of Minor Surgery Procedures -B&W Locality

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&W Flu Vaccine


Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

P5 P7 P11 P14 P16 P17 P18 P22 P24 P32 P33 P43 P46

% U

pta

ke

Figure 58 - 2012/13 Over 65s Flu Vaccine Uptake for B&W Locality

% Uptake

Southwark Average

Locality Average

ANALYSIS Locality Level Analysis: B&W Childhood Immunisation


Southwark

CCG

B&R B&W SSWK

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

P5 P7 P11 P14 P16 P17 P18 P22 P24 P32 P33 P43 P46

%

Figure 59 - 2011/12 Childhood Immunisation Rates % - B&W Locality

U2 Average

U5 Average

SOU U2

SOU U5

ANALYSIS Locality Level Analysis: B&W Smoking Cessation

Figure 60


0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

P5 P7 P11 P14 P16 P17 P18 P22 P24 P32 P33 P43 P46

2012/13 % Quitters at 4 Weeks - B&W Locality

Locality Average

Southwark Average

Southwark

CCG

B&R B&W SSWK

ANALYSIS Locality Level Analysis: B&W Chlamydia Screening

Figure 61


0%

10%

20%

30%

40%

50%

60%

P5 P7 P11 P14 P16 P17 P18 P22 P24 P32 P33 P43 P46

2011/12 Chlamydia Screening - % ScreenedB&W Locality

Southwark Average

Locality Average

SWCCG target is

35% of eligible

population

Southwark

CCG

B&R B&W SSWK

ANALYSIS


Southwark:

Max Score N = 26

Min Score N = 1

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Figure 62 - Hypertension Domain Total % QOF Points 2011-2012 showing locality and practice variation

National

Average

SSWK Sou B&R B&W

Southwark

CCG

B&R B&W SSWK

Locality Level Analysis

APPENDIX 1C: STRATEGY AND DOCUMENT REVIEW

STRATEGY AND DOCUMENT REVIEW CCG Level Analysis

Document

Dated Key Messages for the Primary Care Review

Integrated Plan and

Commissioning

Intentions

Sept-12 CCG Vision: The care local people receive is high quality, safe and accessible

CCG Goals:

1. To achieve a reduction in the rate of premature mortality

2. To achieve a reduction in health inequalities

3. To achieve a reduction in the variability of primary care outcomes & quality

4. To have all Southwark GP practices actively involved in commissioning

5. To have patients play a central role in clinically‐led commissioning

Priorities:

1. Better outcomes for people with Long Term Conditions

2. Outpatient services that enhance patient experience

3. Improve rates of early diagnosis and to provide better quality of life for people with cancer

4. Develop a well‐integrated and high quality system of urgent care

5. Support more people to stay healthy and prevent ill‐health

6. Improve outcomes for people with mental health needs

7. Embed clinically‐ and cost‐effective prescribing across care settings

Performance Priorities:

1. Referral to Treatment

2. A&E performance

3. C.difficile

4. 62 Day Urgent Referral to Treatment

5. Immunisation

6. Smoking Quitters

7. Health Checks

Southwark

CCG

B&R B&W SSWK


Document


QIPP Sept-

12

Primary Care: Implementing Year of Care. Primary Care Education and Development Programme. McMillan

Programme for Primary Care. Extended Access Diagnostic Provision for Primary Care. Mental Health

Development Programme. Primary Care Prescribing Programme

Challenging: 11m required in 12/13, but strong track history (detail on worksheet)

Additional 6m required in 13/14 (6.7m identified) and further 5m in 14/15 (including delivery of 1% surplus

in each year)

Planned savings (risk adjusted) from primary care are - 2.6m in 12/13 with no further savings identified for

the future 2 years

Dulwich

Consultation

Not

Dated Health Centre will be built on site of Dulwich Community Hospital (currently 60% office space, 40% clinical).

It currently costs 2.3mpa. In future the health centre will be leased back to the CCG (most likely)

Option A: (three levels - GP, extended GP, Health Centre) More services at your local GP practice or one

nearby, and a health centre for a limited range of extra services. This approach to providing local health

services would mean that you would receive a range of non-hospital based health services from your GP

surgery or one nearby

Option B: (two levels - GP, Health Centre e.g. no minor surgery in practices) More services in a health

centre and core services from GP practices. This approach to providing local health services means that

your GP surgery will provide only core services. A local health centre will provide many other health

services, that you will not be able to get from your GP in future even if you can now

Southwark

CCG

B&R B&W SSWK


Document


Primary Care

Development

Programme

(which this

work

supports)

Not

dated

Aims are to:

- Support high quality care in primary care and community settings

- Improve the identification and management of a range of conditions

-Provide more care closer to the patient and by doing so decreasing reliance on acute hospital care.

The primary care development programme will operate using a variety of different training approaches

including:

– peer‐to‐peer and specialist‐led programmes; formal learning events; clinical protocols and practice‐based:

audits – to achieve targeted improvement in the following areas included in the Integrated Plan:

- Early identification and accurate diagnosis of long‐term and other priority high prevalence conditions

- Enhanced ability to manage long term conditions, to avoid hospital referral and support better patient

outcomes

- Medicines management knowledge in order to provide quality, cost‐effective prescribing and support

management of patients in primary care where part of an agreed pathway

- Good understanding of agreed local pathways and local service configuration to enable referrals to be made

to the right service for each patient’s needs, at the right time.

Practice staff training will focus on our strategic priority areas, which include long‐term conditions (diabetes,

respiratory and CVD) mental health (including dementia care) and planned care aimed at supporting a shift of

care setting in specialities like dermatology, gynaecology and ophthalmology.

The scope of the development programme does not include formal GP training, nor is it intended to replace

the CPPD programme. The programme is designed to be complementary to other training resources for

primary care staff and will operate in alignment with formal training programmes including those set by the

Local Education and Training Board (LETB) and the London Deanery

Southwark

CCG

B&R B&W SSWK

Documents

Primary and Community Care REVIEW - Welcome to NHS …€¦ · · 2014-01-08General Practice Outcome Standards GP Practice Variation Capacity & Capability Quality & Variability