Service Specification

Service One City and Hackney Primary Care Mental Health Alliance

Commissioner City and Hackney CCG

Provider City & Hackney GP Confederation

Start Up Period Up to 6 months

Project Start Up Commencement Date January 2015 (start up work has already begun)

Project Start Up End Date End of Q1 (30th June 2015)

Project Duration 15 months

Date of Review Monthly internal to the Confederation, quarterly with the CCG

1. Service Objectives / Purpose

1.1 The Evidence Base

The 2010 Index of Multiple Deprivation placed Hackney as the second most deprived borough in England, after Liverpool (ONS). In the City of London there is considerable variation between wards. Clear socio-economic differences remain between the Mansell Street and Middlesex Street estates in Portsoken and the wealthier Barbican estate in the northwest of the City. Hackney and the City have extremely diverse populations with diverse needs reflecting the range of places and cultures that people come from. Furthermore, the Kings Fund report “Transforming mental health, A plan of action for London”, stated that the mental illness is the single largest cause of disability in the United Kingdom, contributing up to 22.8 % of the total burden, compared to 15.9 % cancer and 16.2 % for cardiovascular disease (World Health Organization 2008). No other set of conditions matches the combined extent of prevalence, persistence and breadth of impact. Furthermore, mental illness has a huge impact on the health and wellbeing of individuals. People with mental health problems are at higher risk of experiencing significant physical health problems; they are more likely to develop preventable conditions such as diabetes, heart disease, bowel cancer and breast cancer, and do so at a younger age. 1.2. Purpose By working in Alliance, we aim to ensure that the mental health service provision is supported by independent and voluntary sector organisations that deliver a range of generic support and specialist provision. The One City & Hackney Primary Care Mental Health Alliance will support fully integrated and as much as possible, preventative Mental Health service for the City and Hackney population. The service will be characterised by the following:

Clear navigation and simple access to the appropriate service;

No duplication of services or gaps between services;

Service providers working together in effectively in support of individual needs

A range of preventative initiatives including support to universal services, that promote resilience and actively target people at risk of ill health and reduce the disease burden;

More people avoiding unnecessary hospital admissions by being supported in the community and those that do go into hospital are supported to return home quickly following admission

1.3 Objectives The Alliance objectives are to:

Promote early intervention through evidence based interventions

Enable individuals to manage their mental health by preventing deterioration; improving coping strategies; reducing anxiety and depression; improving self-esteem and confidence, and increase the self-reporting of improvement in health and well-being

Improve levels of health and well-being and reduce levels of adult, child and young person obesity

Reduce the level of harm and neglect in children and vulnerable adults

Enhance the quality of life for people with long term conditions

Reduce social exclusion, health inequalities, by preparing people to enter mainstream services such as IAPT

Ensure service users receive treatment in a caring environment and are protected from avoidable harm

Be highly informed about local services such as children’s centres, CAMHS, carers’ services and the mental health network etc.

Support the inter-relationship with CAMHS services e.g. Well Family Plus to manage step-down cases from specialist CAMHS provisions

Provide systemic interventions to increase and/or improve outcomes for carers and children and young people that indicate improvements in relationships, education and health and wellbeing e.g. maximising income and helping parents understand the impact of their mental health on their children’s health and wellbeing has long term health benefits for children and families.

Improve socio-economic determinants leading to better health and well being

Work successfully with diverse communities and faiths and improve outcomes in their mental health, preventing escalation into secondary care

Actively prepare service users to access the integrated mental health network and other organisations and statutory agencies as required ensuring a positive experience of care

Support the implementation and performance improvement of the Enhanced Primary Care service

Combining the evidence from local and national data as well as the predicted increase in prevalence of mental health within City & Hackney, the Alliance has taken a proactive approach in supporting early intervention and reducing the need for high costed interventions, thus aiming to ‘rebalance’ the whole system.

Deliverables

In order to meet the objectives listed above, the Alliance will deliver the following.

1. Incentivised Mental Health Registers

The Alliance will establish a primary mental health care practice incentive scheme to cover registers for depression, anxiety, dementia, and frequent attenders in primary care and A&E. We propose that the practices are paid £1.55 per patient for this work. Practices will be supported by the recruitment of primary care mental health workers to set up disease registers, undertake prevalence searches. We will aim to reach total coverage across each quadrant, and if a practice is unwilling or unable to provide this service then the Confederation, through the workers, will be able to cover that particular practice population. The primary care workers will also help practices to better manage these patients, offering extended consultation, greater referral options, including to the voluntary sector and to increase utilisation of social prescribing. There will be different needs for different practices – some of the less advanced practices will need basic help with the register, whilst other practices may be at a more sophisticated level, and so may, for example, be wanting more support to set up joint case reviews with the Tavistock and Portman.

We anticipate that we will run the incentive scheme in a similar way to the other contracts we currently hold (LTC, FHV, etc) We will work with CEG to develop the relevant codes and templates and run these searches on practice systems. We will then support practices in developing call and recall systems so that we start to build a more pro-active management of these patients.

Similarly the primary care workers will support the practices in becoming experts in how to manage

complex care patients and dementia patients, how to ensure these registers are in place at practice level

and that formal reviews are taking place, and how to follow best practice and refer into appropriate local

services.

To support the clinical coding for this, the Alliance will recruit a dedicated Clinical Coding Analyst, based in

the C&HGPC but with a strong connection between the Confederation and the CEG to ensure that all the

mental health registers and templates are in place and working effectively and to analyse performance by

practice as part of our monitoring.

2. Mental Health screening.

The Well Family Plus service run by family action will undertake screening for common mental health

problems using GAD7 and PHQ9. People identified will be added to the depression and anxiety register.

3. Targeted clinical interventions.

3.1 Stratification

We will develop a stratification tool to identify those on the mental health registers, listed above, who are most in need of an intervention. Interventions include: practical advice, recovery goal setting, care navigation, sign posting to other services, social prescribing.

3.2 Primary Care Mental Health Workers

To deliver these interventions we propose recruiting four Primary Care Mental Health Workers, supported clinically by Dr David Keene, GP Lead for the SMI contract in the Confederation and with dedicated group clinical supervision. These staff will be managed by the four Quadrant Managers as part of the developing quadrant teams. They will also work closely with our existing four One Hackney Care Co-ordinators, who are focusing on the frail elderly client group. They will hold a clinical caseload across the Quadrant and will support the practices in their quadrant (between 9 and 12 in number) in managing these patients with increasing skill and confidence.

3.3. Family Action’s Well Family Plus Service The Well Family Plus service model is flexible, holistic and is underpinned by a systemic model, which includes physical health and mental wellness but identifies the wider determinants of wellbeing. The Well Family Plus Service will offer interventions to children and families including care navigation, sign posting, practical support over issues such as accommodation, work, training, healthy lifestyles and finances and recovery planning based on the Family Star, a planning tool. Family action will undertake the following interventions for children and young people:

All those aged under 25 who self-harm will be offered a follow up appointment

All those discharged from secondary care mental health and First Steps will be offered a follow up

appointment.

All 16 year olds will be sent a briefing pack for their health check on services which are available.

Some objectives of this service will be to:

Improve levels of health and wellbeing and reduce levels of adult, child and young person obesity

Reduce the level of harm and neglect in children and vulnerable adults

Reduce social exclusion, health inequalities, by preparing people to enter mainstream services such as IAPT

Support the inter-relationship with CAMHS services e.g. WellFamily Plus to manage step-down cases from specialist CAMHS provisions

Actively prepare service users to access the integrated mental health network and other organisations and statutory agencies as required ensuring a positive experience of care.

Deliver interventions for children and young people, who present with low level mental health need to prevent the escalation to specialist CAMHs

Deliver ‘whole family’ intervention to prevent intergenerational issues as a result of parent/carer mental health needs

4. Better links between mental health and physical health.

We will create better links for patients on these registers, who are particularly affected by medical LTCs:

heart disease, stroke, hypertension, diabetes, into full range of services, etc. All patients with and identified

LTC will undergo a mental health screening using PHQ/GAD7 scores. In addition people on the mental

health registers with an LTC will be identified.

We will also start this work with diabetes because of Dr David Keene’s special interest and expertise in this

disease, and will then apply the learning across other LTCs. We anticipate we will need to do some

dedicated training on depression/anxiety and diabetes. Recent research shows that symptoms of

depression in people with type 2 diabetes can be significantly reduced through interventions for diabetes

distress/burnout, suggesting that much of what is being labelled as depression may not be a co-morbid

psychiatric disorder after all, but rather a reaction to living with a stressful, complex disease that is often

difficult to manage. According to NICE, people who are diagnosed with a chronic physical health problem

such as diabetes are 3 times more likely to be diagnosed with depression than people without it.

Depression can have a serious impact on a person's wellbeing and their ability and motivation to self-

manage their condition. Depression is the most common psychiatric disorder witnessed in the diabetes

community. People with diabetes suffering from depression are at greater risk of suffering from an episode

of diabetic distress/burnout which collectively can have adverse effects on physical health and potentially

instigate more long term complications both to do with diabetes and independent from the condition.

5. Support for primary care developments including EPC

The Alliance will support the performance of key primary care developments such as the expansion and re-

design of EPC services. To achieve this the Alliance will sub-contract:

a primary care nurse practitioner (1WTE)

a GP with special interest (3 sessions a week)

a coding analyst (part time on EPC and part time of coding for the mental health registers)

These staff will be undertake the following deliverables.

5.1 Performance Review

i) To review the performance of practices against the agreed KPIs for EPC services contained within the Confederation Contract and to identify practices that need assistance. ii) To assess population coverage for the EPC service iii) To undertake reviews of the EPC Recovery Care Planning process including a review of a sample of about 10% of the completed mental health recovery care plans. This will include looking at the quality of goal setting, navigation to community resources and lifestyle interventions. iv) To conduct qualitative reviews around the extent to which joint working between primary care and secondary care is being achieved in EPC. This will be done partly by evaluating the frequency of contact and strength of the relationship between GP practice staff and secondary care staff. Questionnaires will be used to standardise the approach as well as interviews. v) To conduct qualitative reviews into the patient experience for all primary care mental health services using interviews and questionnaires. vi) To identify gaps in service provision for all primary care mental health services in terms of access to the service and unmet needs for those in the service vii) To identify gaps in practice staff skills and competencies for all primary care mental health services 5.2 Performance Improvement To offer assistance to practices in addressing identified areas for improvement, including:

i) Recommendations for changing practice processes ii) Advice and support iii) Workshops to facilitate change iv) Relationship building v) Recommendations for training vi) Bespoke training delivered in practices as and when particular development needs are identified

5.3 Improving awareness and communication

i) To increase awareness of the function and role of the EPC service within General Practice and highlight the benefits of referring to this service for the patients and for clinicians to utilise the Liaison function as a stepped model to effectively manage and address mental health needs of people seen in primary care services.

ii) To assist GP practices to understand the EPC contract requirements iii) To develop the interface between CCG Confederation, GP practices and East London NHS

Foundation Trust (ELFT) over EPC services.

5.4 Strategic Clinical Advice This role is focused on the delivery of strategic clinical advice and does not involve the direct provision of clinical services such as work with patients or the supervision of clinical practice. The precise remit of this advice needs to be determined in consultation with the City and Hackney GP Confederation and City and Hackney CCG, however potential key areas are:

i) The identification of areas of clinical risk across all primary care mental health services ii) Support for interpreting future clinical demand and gaps in clinical service provision across all

primary care mental health services iii) A review of primary care medication processes including the potential to deliver Clozapine

(identified as needing review by the EPC project’s Clinical Working Group).

6. Staff Stress Support System. We will establish a staff support system to manage and support all

practice staff with stress/anxiety/depression related to workload. We know that such schemes have existed

in the past – we would like to review what works/what would help C&H primary care staff and run a pilot

scheme with a review of effectiveness.

7. Peer Mentoring. The C&HGPC has submitted an application for funding to the Prime Minister Challenge

Fund. If successful, we will be recruiting a team of health peer mentors; people from our local communities

who will work alongside patients to help them on their journey to health. These mentors will work closely

with the 4 Primary Care Mental Health workers and with the practice. We also have established a formal

link with Diabetes UK and will use this as part of our development and evaluation of this service.

2. Key Service Outcomes

To enable delivery of measurable and meaningful outcomes, the starting point will be patient risk stratification and identifying appropriate groups of patients for each category. In addition, ensuring the collection of appropriate data to inform case planning, evidence performance and support future service development, including provision of patient level data as a part of service specification.

1. Effective – measured by reduction of GP reliance and preventative, focusing on Alliance strength and using the most appropriate service at the right time, i.e. the first time

2. Appropriate – Relevant to the patient need, new patient registers and signposting to the best service 3. Efficient – VfM, reduction in medication, time limited and outcome oriented 4. Accessible – referral rates v.s population, locality and availability of services, reduced waiting times 5. Continuous – Working in Partnership with other service providers, whole person approach, holistic

2.1 Family Action (Well Family Plus) Family Action will be integrated within primary care using the EMIS system to enable swift referral, review and monitoring of impact. The WellFamily Plus service will use validated outcome measures to assess the effectiveness of the interventions and evidence outcomes for service users including:

GAD7 General Anxiety Disorder - a screening tool for the presence of generalised anxiety disorder.

PHQ 9 - The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition and diagnosis of the most common mental disorders in primary care patients. For patients with a depressive disorder, a PHQ Depression Severity Index score can be calculated and repeated over time to monitor change.

CORE10 - This ten itemed measure is part of a collection of the Clinical Outcomes in Routine Evaluation system (CORE). The system was developed for quality evaluation, audit and outcome benchmarking for psychological therapy services and as a generic measure of emotional problems.

Recovery Outcomes Framework (2012-2013) - Family Action uses the Family Star to engage parents and children and provide necessary interventions to change family life and measure and record progress. The Family Star practice tool was developed with Triangle Social Enterprise Consulting piloted by Family Action and is now used extensively across the country. Family Action also uses the Recovery Star - which enables service users to measure their own recovery progress, with the help of mental health workers and others. The 'star' domains cover the main aspects of people's lives, including: mental health, self-care, living skills, social networking, work, relationships, addictive behaviour and responsibilities.

2.2 City & Hackney GP Confederation One of frequently used screening tools is GAD7/PHQ9 which the practices will use for initial assessment. GPs recognise that depression can affect a patient's capacity to deal with their diabetes, including managing blood glucose levels appropriately. We know that the number of newly diagnosed Type 2 Diabetics is on increase in the City and Hackney. However, the prevalence figures use a total practice population which can distort the true numbers. We propose to take the list size and exclude all under 5s for prevalence data. For example, we will take 2% of over 60’s, 9% over 75’s and 20% of 85’s A range of different psychological therapies, which include cognitive behavioural therapy (CBT); mindfulness based cognitive therapy (MBCT). Mindfulness is the therapy of choice recommended by NICE to address recurrent major depression. Using mindfulness to address symptoms of depression is also seen as more appropriate for a person with diabetes as it means there will be no conflicting side effects with their normal diabetes treatment

The new service aims to achieve for patients: 1. Increased emotional wellbeing 2. Reduced stigma of mental health through improved knowledge and awareness 3. Improved mental health and recovery 4. Increased resilience 5. Improved relationships with service users and partners We will develop with the four Mental Health Workers, when in post, a standard on-line self-assessment module for patients to complete as part of their initial assessment on referral. The workers will help patients to complete this, part way through treatment and at the end of treatment. The assessment scores will be re-visited and we anticipate that we will be able to demonstrate improved scores in these areas. If patients are struggling because of how they feel, then they will be advised to visit the GP to find out about ways of boosting how you feel emotionally or physically. We will construct our on-line tool using NHS website (see WEMWBS). Depending on the score achieved, the patients may be advised to get active, connect with others, keep learning, be aware of themselves and the world, etc. There will be additional links to organisations, e.g. Moodzone or Big White Wall (BWW) Due to slower than anticipated uptake for remaining 450 or so BWW places and to ensure that all aspect of Alliance are joined up, we propose that Family Action are enabled to refer patients via the GP to the BWW project.

3. Service Delivery

3.1 The Well Family Plus Care Pathway Family Action's Well Family Plus service will link directly with GP practices and will work to improve whole family wellbeing by reducing stress, improving health, providing support to individuals to end abusive relationships and improving family relationships. The service will be delivered from community-based settings and will provide a "single door" or point of access for service users with multiple and complex health and social problems. Key guiding principles are to achieve equity of access to the service; where surgeries do not have space to accommodate a Family Action worker, neighbouring surgeries and primary care settings will be sourced. Family Action workers will work flexibly across a number of different surgeries/venues each week as required. GPs and Primary Health Care Providers will refer service users via written referrals or using the EMIS clinical information system to supports the Early Intervention in Long Term Condition Management – Primary Care Pathway. The Well Family Plus model of delivery will:

Promote high levels of referral from GP surgeries to reduce incidents of depression, isolation, practical and emotional support for the individual also catering for the broader needs of the individual as a parent, the children and whole family.

Be highly visible in GP surgeries to support ease of access, marketing and promotion,

Deliver interventions for people with complex needs in primary care to identify wraparound complex needs services and address gaps in the pathway,

Deliver ‘whole family’ intervention to prevent intergenerational issues as a result of parent/carer mental health needs.

The service will fit within care pathways - between GP, primary care, hospital clinical support and access to other more specific or community based/group work provisions in order to support service users to access other services in the longer term. The WellFamily Plus service will integrate with services commissioned as part of the Integrated Mental Health Network and identify a clear pathway for service users to access services within the network. This is shown in the diagram below. Figure 1: The Well Family Care Pathway

Patients will have a coordinated experience of care; the WellFamily Plus service will use a RAG (Red, Amber, and Green) system to prioritise referrals. From receipt of referral, patients will be allocated a named WellFamily Plus Worker (WFPW) prior to initial contact. The allocated worker will remain the patient’s named contact ensuring continuity. Service users should only have to provide information once; this will be effectively recorded and used by professionals to work with them in shaping personalised and coordinated packages of care. The allocated WFPW will undertake a holistic assessment which will identify the support needed to maximise engagement. Every service user will have a Health and Wellbeing Plan and be offered 6-8 client facing sessions according to the needs of the assessment and RAG rating. Information on sources of voluntary and community support will be kept up-to-date at all times; such information is central to a co-ordinated experience of care. The service user will be provided with information if signposted, and kept informed about referrals to other services – such as IAPT, Integrated Mental Health Network, secondary care or other statutory or voluntary agencies. WellFamily Plus will use a Performance Management Framework to demonstrate successful contract delivery and impact. This will detail key performance indicators, how they will be reported and the processes and systems support this reporting. To measure success WellFamily Plus will adopt standardised key performance indicators and include any variations required by funders. Performance reports will include demographic details and an outcome profile included the service users EMIS number. Performance report will be adapted to meet City and Hackney Clinical Commissioning Group requirements.

Referral to WellFamily Plus

Admin

Allocated WFPW contacts patient within 5 working days

WFPW offers assessment within 10 working days

Green Amber Red

Health and Wellbeing Plan

Provide resource information

Agree HWP and offer 6-8 Sessions

Refer to Integrated MH network and/or other

agencies

Agree HWP - offer 6-8 sessions subject to risks

Refer to secondary care and/or statutory services

Follow up within 10 working days to ascertain progress

Follow up within 5 working days to ascertain progress

Follow up within 10 working days to ascertain progress

Report to referrer Report to referrer Report to referrer

3.2 Care pathways – C&HGPC With all Partners within the One Hackney programme and ethos of joined up working for the benefit of the patients and residents of City & Hackney Integration and Partnership working:

To ensure that protocols for engagement/referral, early intervention and support are agreed between all agencies.

To ensure that the needs of complex LTC patients with, severe and persistent behavioural and mental health needs are met through a multi-agency approach

To reduce admissions to inpatient care through ensuring that appropriate community services are available closer to or in home.

4. Performance Monitoring Quality Indicators

Measurable outcomes will be further developed during Q1. However, the following list is proposed as a starting point. Identification and registration

1. Improvement in dementia diagnosis rate against prevalence in relation to national target

2. Improvement in the coverage of people identified with anxiety and depression

3. Increase in the numbers on registers. It is proposed that GPs are incentivised to identify and add

people to the registers. The Incentive Scheme for practices will comprise:

- Identification of a Lead GP to be submitted to the C&HGPC - Official signup to the Incentive Scheme, with a paper submitted to the C&HGPC - Running the CEG search templates. This will be setup by the C&HCGC (refer to the role of CEG

Clinical Coder and Analyst) to identify prevalence of:

Anxiety

Depression

Frequent attendance with the GP or A&E

Dementia

Patients with any/all of the above plus a physical health long term condition. - Monthly reviews of all patients on the register with Quadrant Primary Health Mental Health Workers

which will mirror the One Hackney ethos. - New patients will be added and reviewed on a quarterly basis.

The total incentive scheme price to a practice will be £1.55 per patient on the register, for the life of the contract i.e. 15 months. This payment will not be increased if patients are on multiple registers i.e. a patient on an anxiety and dementia register will still receive £1.55. The register will record whether a patient has either the absence or presence of the above conditions. Hence all patients in the practice should be included on the register and are eligible for the £1.55 payment.

LTC Screening 1. Screening of people with LTCs for mental health problems using PHQ9/GAD7. Increase in no. of

people with LTCs identified with a mental health problem against expected prevalence.

Targeted interventions

1. No. of reviews done for a stratified section of the register.

2. A reduction in the number of unsatisfactory GP consultations by 70%

3. A reduction in the GP out of hours calls by 30%

4. A reduction in unnecessary hospital admissions by 30%

5. Increased navigation to community resources baseline Q2 against Q4

6. Increased social prescribing baseline Q2 against Q4

7. Reduction in the over-use of anti-depressants

8. Improvements in psychological wellbeing for people engaged by Family Action and by the Mental

Health workers as measured by scored questionnaires on assessment and every 6 months.

CAMHS

1. No. and % of pregnant women with a 16 week antenatal screening for depression using the

Edinburgh scale. The screening will be undertaken by GPs.

2. Self-harm follow up. No and % of those under 25, who self-harm are a) offered b) attend a follow up

appointment with Family Action.

3. Step down follow ups. No. and % of those discharged from secondary care and ‘First Steps’ who

are a) offered b) attend a follow up appointment with Family Action

4. 16 year health check. No. and % of 16 year olds offered a health check in their GP practice. No.

issued a briefing pack produced by Family Action.

EPC Performance Improvement

9. Increase in number of completed recovery care plans on EMIS web with evidence of goal setting

and care navigation. Target 85%+

10. Demonstrable improvement in EPC joint working between psychiatrists, liaison workers and practice

staff based on a questionnaire delivered in Q1 2016 and Q1 2017.

11. Greater parity in referral rates to EPC based on Q1 2016 and Q1 2017 analysis.

12. Lifestyle interventions at target level 80%+ for those above threshold level.

6. Finance – Family Action

For £285,000 the WellFamily Plus model can provide 5,760 sessions per year across 43 surgeries. This equates to each surgery paying just under £7,000 per annum to have a Well Family Plus Worker provide a service within their surgery. An analysis of the Hackney Social Care Forum Infrastructure undertaken by Bristol University suggests a Social Return on Investment (SROI) of £5.96 for every £1 invested in Family Action Well Family. The high return observed is attributable to Family Action having:

Specialist services available to meet growing demand and different client needs

Strong business model with clear processes for successful client intervention

Outcomes duration likely to be long term with lasting changes in quality of life

Value in the work conducted with other institutes such as schools If every WellFamily Plus attender had just one less GP appointment per year (at a unit cost of £300 per attendance - to include overheads, prescriptions and GP time), the service would be "cost neutral" to the health economy. There is converging evidence that the WellFamily Plus service will also achieve clinically significant impact on clients' wellbeing and social adjustment and represents a cost-effective investment for commissioners. The service achieves sustainable outcomes and decreased rate of re-referrals. Evidence from WellFamily in Hackney where it is used extensively by GPs shows that: Evaluation of WellFamily service in Hackney: January 2014

90% of the GPs said WellFamily reduced repeat or inappropriate visits

One patient sample shows a 70% reduction in unnecessary GP visits

It has capacity to prevent attendances at A & E representing a cost saving

GPs appreciate the WellFamily worker role in writing letters to housing/benefits agency which would otherwise attract a fee of £35-£50 per letter

As a current provider, we are ready to deliver service and are mobilised, the continuation of services we anticipated a Q4/15 payment

5. Finance and Mobilisation Plan – C&HGPC

Family Action £

Expenditure 2014/16

Staff Salaried (incl on-costs)

- All Alliance staff 230,663

Delivery Costs

- Training Costs 3,973

- Transport Cost (around the City & Hackney) 3,500

- IT Support Costs 757

- Premises Costs 10,000

- Running Costs 7,550

- Professional Fees

Management Costs 28,500

Total requested 284,943

We anticipate to use 10% of the above funds to cover start-up costs in the following way:

6. Exit Plan

C&HGPC Clearly this is non-recurrent funding. If it proves successful and we can show reduced utilisation of ELFT services, A&E services, hospital admissions we may be able to switch this funding to a recurrent basis. We

Population based 290,000

C&HGPC £

Expenditure 2014/16

Staff Salaried (incl on-costs)

- Mental Health Support Workers x 4 186,585

- CEG Clinical Coder and Analyst x 1 44,084

- C&HGPC Project Management (Dr Keene & K Banjac) 25,000

- Primary Care Nurse Practitioner 48,000

- GP with Special Interest 24,000

Other Staffing Costs

- IT - Mobiles, Laptops for MH Workers 27,083

- Transport Cost (around the City & Hackney)

- Monthly Group Clinical Supervision

- Training and Development

- Additional Diabetic/LTC training

- Professional Fees

Set up a support system to prevent ALL practice staff stress 15,000

Total Staff Costs 369,752

Performance Related Pay (Practice Incentive Scheme)

**NB This is based on current population numbers

Total Incentive costs 449,500

Total requested 819,252

C&HGPC Mobilasation 10% £

Expenditure 2014/16

Practice Pilot (re stress) 15,000

IT 5,000

Training costs 5,000

Recruitment 10,000

10% Incentive scheme for 14/15 44,000

Management 2,000

Total requested 81,000

will need to develop methodologies for measuring this early in 2015/16. We would also argue that if we can demonstrate better care for this client group this should be considered for recurrent CCG funding. Family Action We will evaluate the impact of the service throughout the duration of the contract in order to demonstrate the capacity of the model and to support the potential to secure sustainability of funding. Family Action’s Business Development, Sales and Marketing and Fundraising teams will plan for sustainability and expansion of the model and have already developed potential routes as follows:

Identify alternative sources of funding to enable expansion of the model beyond the funding period

Utilise our key relationships with Clinical Commissioning Groups to secure future contacts and networks

Build a network of community resources that GPs can refer patients to directly when there is a clear need for additional non-medical support

Work with GPs to identify funding for a non-medical triage role within the surgery environment to ensure that patients with additional but non-medical needs can be assessed and signposted to appropriate community services from within the surgery

Work with the GP Confederation to streamline services into GP practices and quadrants and source funding

We are committed to sustaining the service and the continued employment of the staff team. In the event of no future funding being available Family Action will demonstrate best practice and lessons learnt at relevant events and in relevant publications. This will enable existing and future stakeholders to benefit from the work undertaken by the team ensuring key intellectual property and examples of best practice are preserved.

7 Mobilisation Plan

Mobilisation Plan ASSUMPTION MADE – ALL deadlines subject to CCG approval and will be updated accordingly and prior to contract commencement We anticipate this to be done by: -

Communicate the Plan via the Newsletter and discuss at GP Confederation meeting

20 January 2015, 28 January 2015

Done

Establishing the Project Team, incl. the Lead GP and Quadrant Manager Develop guidance on incentive scheme and discuss template with CEG

2 February 2015 26 January 2015

Done In discussion

Develop job description and advertise for Primary Care Mental Health Support Workers (PCMHSW)

26 January 2015 Done

Develop job description and advertise for CEG/Clinical Coder and Analyst (CC&A)

26 January 2015 Done

Issue guidance and template to practices on incentive scheme

2 February 2015

Interview for PCMHSW

16 February 2015

Quadrant Managers to support the practices to establish disease registers and to carry out searches

End of February onwards

Interview for CC&A 17 February 2015

Identify a list of suitably qualified Clinical Supervisors

23 February 2015

Complete recruitment and process HR documents, agree start dates

End February 2015

Induction period for new starters

March – April 2015/as they join Confed

Training event on this contract and emerging 2015/16 SMI contract

2 March 2015

Allocate Workers to Quadrants, relationship building, etc.

From mid-March onwards