As part of updates to the overall Network DES Contract, NHS England has set out details of the Investment and Impact Fund (IIF) indicators for 2021/22 and 2022/23. Here Pulse Intelligence presents a summary of the indicators to be implemented this year and next.
As previously set out in the five-year GP contract, the IIF scheme is worth £150m in 2021/22 and £225m in 2022/23.
Some new indicators in 2021/22 are designed as preparatory work – either towards PCN service requirements or the introduction of full IIF performance indicators in 2022/23.
The newly added indicators are organised into five domains in the IIF as follows.
Ethnicity data: from 1 October a new indicator will reward comprehensive recording of ethnicity data in the GP record.
Hypertension case finding: indicator CVD-01 will reward PCNs for proactive follow-up and assessment of patients with elevated blood pressure (BP) readings, while indicator CVD-02 will reward appropriate hypertension diagnoses upon follow up of those with high BP.
(CVD-01 will complement the current QOF indicator BP002, which rewards practices for recording BP.)
A further indicator, CVD-03, will be introduced to encourage statin use in people with a QRISK2 or 3 score of 20% or higher.
Another new indicator, CVD-04, will also be added next year to reward PCNs for upping diagnosis rates for familial hypercholesterolaemia. The ambition is to increase levels of FH diagnosis to 25% by 2023/24, as laid out in the NHS Long Term Plan (only 7% of cases were reportedly diagnosed in 2019/20).
Indicators in this area will reward PCNs for: delivering key elements of the Enhanced Health in Care Homes (EHCH) model; recording of care home residency in GP systems (current data suggests this is only complete for around 50% of residents); and reducing emergency admissions among care home residents and patients whose conditions are deemed amenable to care in the community.
This will include preparatory work in 21/22 to lay the groundwork for delivery of the emergency admission indicators in 22/23.
They will also continue to reward expansion of social prescribing services.
Indicator EHCH-01 will measure patients recorded as living in a care home, as the percentage of care home beds eligible to receive the Network Contract DES Enhanced Health in Care Homes service
Meanwhile indicator EHCH-02 will promote uptake of a Personalised Care and Support Plan, and EHCH-03 the performance of Structured Medication Reviews, in care home residents.
EHCH-04 sets a target of at least three patient contacts per week on average, as part of the weekly care home round.
Newly introduced indicators AC-02 and EHCH-06 will reward PCNs for ‘moderating’ the rate of emergency admissions of care home residents, and those of a subset of patients with Ambulatory Care Sensitive Conditions (ACSCs).
The ACSCs are selected on the basis of being either:
• Amenable to effective long-term condition management in primary care
• Amenable to rapid primary care response to an acute presentation.
(Dental and very low volume conditions are excluded.)
Each of these indicators will have two components for achievement – one measuring improvement from baseline (to give current low performers the opportunity to be rewarded) and the second measuring absolute performance level (so already high performing PCNs can be rewarded for maintaining that level).
PCNs will be rewarded for achieving:
• Improvements in patient experience of access to general practice. This will be through financial incentives linked to a ‘forthcoming survey-based real-time measure of patient experience’ (ACC-06).
• Continued delivery of online consultations. Indicator ACC-02 will be on making sure online consultations continue to be offered to patients consistently across the country.
• Improved use of Specialist Advice services – indicator ACC-07 will support the wider NHS recovery of elective care services through avoidance of unnecessary outpatient activity.
• Reductions in rates of long waits for routine general practice appointments. A new indicator ACC-08 will be introduced to reward PCNs for reductions in the percentage of patients waiting more than two weeks for an appointment. This will be based on a measure of waiting time, using the new national appointment categories as well as a new system of appointment exception reporting (to restrict this to appointments where time from booking to appointment is a valid proxy for ‘true’ waiting time).
A new indicator (ACC-02) will measure the number of online consultations per 1000 registered patients.
The indicator ACC-03 will reward PCNs for helping to identify ways to reduce unnecessary emergency attendances and admissions. Further detail on this is to be provided in ‘forthcoming guidance’.
ACC-04 will require PCNs to work collaboratively with local community pharmacy to develop and implement a plan to increase referrals to the Community Pharmacist Consultation Service, with referral levels to have increased by the end of March 2022.
And for ACC-05, PCNs will have to use GP Patient Survey results to identify patient groups experiencing inequalities in access to general practice, and develop and implement a plan to improve access for these patient groups.
ACC-06 will be based on how easily patients report they can get a GP appointment or advice/care from their practice, in the GP Patient Survey.
ACC-07 will measure the rate of Specialist Advice requests across 12 specialties.
ACC-08 monitors the proportion of patients having to wait 2 weeks or less for an appointment.
And ACC-09 will be based directly on the rate of referrals to the Community Pharmacist Consultation Service.
This area will build on the service specification for structured medication reviews (SMRs) and medicines optimisation, which PCNs have been delivering since October 2020, and some prescribing safety indicators that were implemented in the 2020/21 IIF.
The 2020/21 IIF included indicators for improved prescribing or to support a reduction in medicines-related harm – more specifically, the prescribing of gastro-protective medicines to those on NSAIDs or aspirin and antiplatelets / anticoagulants. NHS England states that these indicators ensured gastro protective medicines were added ‘for between 75% and 85% of the prescriptions being targeted’.
In response to feedback on these indicators, some new medicines safety indicators will be introduced from 2022/23. Building on the 2020/21 performance, the 2022/23 indicators directly incentivise good prescribing practice for patients prescribed drug combinations that are known to have increased risk of associated harm. Along with the SMR indicator, they will ‘support reduction of unnecessary hospital admissions due to medicines-related harm’.
A new indicator – SMR-01 – will be introduced next year to reward PCNs for high rates of SMR delivery to target cohorts.
In addition, SMR-02A will reward either discontinuation of an NSAID or prescribing a gastroprotective in patients on an NSAID and oral anticoagulants.
SMR-02B will promote discontinuation of an NSAID, or addition of a gastroprotective to an NSAID in the elderly (where not prescribed alongside an oral anticoagulant).
SMR-02C will encourage discontinuation of an anti-platelet or addition of a gastroprotective to patients on both an oral anticoagulant and an anti-platelet.
And SMR-02D will promote discontinuation of aspirin/anti-platelet or prescribing of a gastroprotective in patients on both aspirin and another anti-platelet.
SMR-03 will reward recording of renal function testing, weight and creatinine clearance rate in patients prescribed a direct oral anti-coagulant (and either a change/confirmation of drug dose).
In addition, two prescribing indicators here will overlap with the next domain on improving sustainability in the NHS.
One will focus on increasing the percentage of asthma patients who are regularly prescribed an inhaled corticosteroid (ICS, or preventative inhaler). This should help reductions in unnecessary SABA prescribing (and therefore carbon emissions) by improving disease control.
A further incentive will directly reward PCNs for achieving these reductions in avoidable SABA prescribing.
The aim is that, by 2024/25, 90% of patients on the asthma register will be regularly prescribed an ICS, while only 10% will be prescribed 6 or more SABA inhalers per year.
More specifically – RESP-01 will measure the proportion of patients on the asthma register regularly prescribed an ICS, and RESP-02 the proportion of these patients prescribed six or more SABA inhalers over the past year.
Four new indicators are to be introduced to improve inhaler prescribing to both improve respiratory care and deliver on NHSE/BMA ambitions to cut avoidable carbon emissions, by encouraging use of lower carbon inhalers.
The latter is in line with key aims of the ‘delivering a “Net Zero” NHS’ report, which backed an NHS Long Term Plan commitment to reduce emissions from metered dose inhalers (MDIs) by 403 kT CO2e, and further committed to cutting them by an addition 374kT by 2040.
Two indicators aimed at reducing inhaler carbon emissions will start in October 2021.
The aim is to reduce the mean propellant (F-gas) carbon intensity of salbutamol inhalers prescribed in England to 11.1kg by 2023/24.
Guidance and advice will be provided to support shared decision making and patient choice of inhaler. Pharmacies will be actively encouraging return of unwanted or used inhalers for more sustainable disposal and can provide a New Medicines Service consultation and inhaler technique check for patients prescribed an inhaler for the first time.
Source: NHS England. Annex B – Investment and Impact Fund: 2021/22 and 2022/23. Published 26 August 2021
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