Frequently Asked Questions and resources

Will practices be required to provide their own phlebotomy service?

The ICB are aware of the constraints on phlebotomy and is working toward improving access. They recognise that some practices will need to send patients elsewhere to do their blood tests, and this is absolutely appropriate. However, practices will need to ensure all results are back before moving on to the next stages of the Model of Care. 

How much time do we need to set aside for the Check and Test and discussion appointments? 

This will vary within each practice depending on how the appointments have been set up. However, it is likely that the Check and Test appointment will require around 20-30 minutes to ensure enough time for all checks to be completed, and the discussion appointment will likely be at minimum 30 minutes to allow a high quality, personalised and patient centred conversation to take place. 

Can a Health Care Assistant (HCA) do Check and Test?

Yes, absolutely, for most patients this is a good choice of clinician for this appointment.

Is it not helpful to have bloods done prior in order to calculate Q risk etc?

It could be - it is up to practices to decide how they wish to do this. QRISK can be calculated at Check and Test or as part of the review process.

How long on average is each checkpoint likely to take?

The Model has been funded based on a 30-minute average. A 30-minute appointment is not a mandatory requirement.

If we block off 35 30-minute appointments and the patient doesn't show up, are we wasting resources and also a lot of the face to face capacity?

This is a valid concern and GPIT is trying to make that process as straightforward as possible in terms of using the searches to help you find the right patients, and to know where they are. Roles that can help with this are Care Coordinators and Administrators to guide that process and the care planning aspects in terms of the length of appointment times.

Looking at the reports when you run the searches can allow you to see how many conditions your patient has which will help in planning appointment times. You can also see how many conditions a patient has in the LTC LCS pop up alerts.

What is different in the chart of register vs case finding the subset needing some reviews this year? 

The register is for patients who have been coded with a long-term condition. The case finding is patients who may have a condition but need some intervention.

Has there been any work done on how much clinical time expected per patient population of how many appointments needed per week for LTC in order to meet targets?

This could quite easily be calculated using Month of Birth searches. The number of patients born in each month with an LTC will indicate how many patients should be invited.

How do you mitigate the time spent ticking all the boxes and clinical care. Also, some of the care planning has been started - can you put in retrospectively 'Check and Test appointment complete.'

Most of the payments are block contract. This means that you can continue to get used to the Model of Care for new patients for whom the process has not been started and use the new Model for patients that have not been reviewed yet if you choose to without any penalty for the practice. The aim going forwards is that at the Check and Test appointment, patients will have the Model of Care explained so that they are prepared to engage in the care planning appointment with their results.   
 
Funding allows 30-minutes for Check and Test appointments and for clinical discussion. If the Check and Test appointment is used well for data collection, this should hopefully free clinicians for good discussions away from box ticking  

What is the role of the MDT meeting? 

Are we supposed to discuss all our LTC patients that we have seen during stage one at the MDT meeting? 

The MDT Review is for high risk or high risk + complex patients and ensures that high risk or high risk + complex patients can benefit from holistic thinking about their needs ahead of a review appointment, e.g., patient may benefit from referrals to other organisations e.g., palliative care, advanced care planning, district nurses, dieticians, community diabetes teams, smoking cessation. This also helps prepare clinicians to discuss more complex care plans with patients.

Clinicians may find it helpful to briefly review the desktop review template before all discussion appointments. It is a really useful tool to summarise the clinical needs of the patient.

If a patient is not high risk or high risk + complex, when do we complete the review?

All patients should be offered a discussion appointment 2-4 weeks after the Check and Test. When to offer the review should be determined by what is in the care plan and the patient's needs.

How do we organise and implement the MDT, and how will we fit them around busy clinical schedules?

There is no prescribed schedule or recurrence for these meetings, and it is up to practices to determine how best to implement the MDTs. You may be able to include them in existing clinical meetings, or you may decide to organise something new.  As the MDT is only for high risk or high risk + complex patients, the frequency of these meetings is likely to be dictated by the number of patients in the high risk or high risk + complex cohort.

Will patients see notes from the MDT in the results letter? 

No. Notes from MDT Reviews will not be sent out in the results letter.

If a patient rejects a care plan - would you need to still do touch point 4?

We cannot force patients into the process but a review of any goal, even if not recorded in the care plan, would be good practice.

Are touch point 3 & 4 also desktop reviews? 

No. These are reviews with the patient.

What is after desktop review if no further appointment is needed, i.e., well controlled asthmatic/diabetic? 

All patients should be offered a discussion appointment for care planning which could be on the telephone if there are no face-to-face requirements. This is an opportunity to discuss any patient concerns and promote good lifestyle and disease management. 

Do the new care plan and review of the care plan take place at separate appointments? If so, how long is advised between each appointment? Is there a timescale this must be done within? 

Yes. The initial care plan is sent to the patient with the results post the Stage 1 Check and Test appointment, then finalised at the stage 3 Discussion Appointment.  
 
The review of the care plan happens at the Stage 4 Follow-Up Appointment. This is to support progress against goals - the timeframe should be set up depending on the needs of patient. This is no different for example, from seeing a hypertensive patient, agreeing a BP goal, up titrating medication and deciding a timeframe to review them. However, it may be about more lifestyle oriented goals for some patients.

What sort of time should we be allocating for each consultation? 

The Model assumes 30-minute appointments.

How will this Model work with housebound patients?

Practices should follow the usual protocol and process that they would normally use for their housebound patients, for example, face to face visit to patient's home instead of at the practice. 

See example scenarios below that may occur when considering the new MoC and dealing with housebound patients: 

Stage 1 - taking bloods as part of the check and test appointment, HCA or Nurse may only be able to administer certain tests at the patient's home. So, in this instance they may have to arrange transport for the patient to be taken to the hospital for that part of the test. 

Stage 3 - the discussion appointment, they could have a patient who is hard of hearing, therefore, they would require the use of a sign language interpreter to attend this appointment. 

Alternatively, practices could explore working with their PCN to resolve the issues arising with stages of the model for those housebound patients.

How will this work in care homes?

Care Home patients will still be required to have this proactive and personalised approach. Care Homes already benefit from the PCN DES, GP Led Enhanced Care home and in Enfield, the CHAT team, so would suggest tweaking the current proactive model to make it more personalised.

More information on the Model of Care can be found here.

Can we send collaboRATE to patients after the Discussion Appointment?

We have co-designed the process with community members and the feedback was that by undertaking the survey after a whole cycle of care i.e. after the follow-up appointment the patient will be more able to provide feedback on the whole model. As such we would ask that practices do the survey after the follow up

Concerns about people not attending:               

As the ICB are only asking practices to have a certain number of forms completed, they should not be impacted by those who do not attend the Stage 4 Annual Review

My practice has only just started delivering the new MoC so we will not be able to get enough people to Stage 4: 

It would be fine for practices/PCNs to delay till next year, however this will mean that they will need to undertake the collaboRATE survey over two quarters in Y2.

Practices should have started delivering this service in October so in theory would have got to the follow up appointment by the end of Q4 so enabling them to have completed the collaboRATE survey on 25 patients. However, for some practices this may not need the case so we would suggest that practices do 25 of their year 1 collaboRATE surveys in Q1 and then do a further 25 surveys for their Y2 requirements in Q4 of 24/25.

• Previously, when I have asked if my patients whom I have completed stage 1-3 during the preparatory period could have stage 4 done in Q1 of 24-25, I was advised that the ‘clock resets’ so they need to do the full MOC in the financial year April 24-March 25 to achieve funding. Can we do stage 4 in Q1 and achieve funding for these patients?’

  • If a patient had a Check and Test appt in mid-February, the likelihood is that that person discussion appt will be in March and their follow-up appt in June. Even if when you reset for Y2 and start seeing patients born in April practices will still be doing follow up appts from the previous year and so can do the collaboRATE surveys for these people.

We are considering holding a PPG at scale for our PCN rather than individual PPGs - is this acceptable?

Absolutely, however you should collate the results from all the practices CollaboRATE results and share the learning or recommendations back to all practices so there is an ethos of continuous quality improvement.

Is there an assurance form for LTC the end of the financial year?

No, however we are building a dashboard that will show practices service delivery as well as how practices/PCNs are achieving against outcomes in year 2. The block payment for service delivery is guaranteed.

• Will this be based on the proportion of our reviews that are coded?

  • Yes

With regards to case finding - when we are tracking progress on the LTC healthy intent dashboard our lines seem to be static although most of us have done a lot of case finding work. Why is this not impacting our overall numbers - are we not coding activity correctly - is there further advice coming about this? My understanding is that this feeds into remuneration when baseline data is taken at end of Q4 for year 2 so just keen to get this right?

This is happening as there is not currently a code that removes patients once a case finding intervention has happened. GPIT is working to rectify this issue.

• Will this be rectified before the financial year end or after? Practices are not sure whether to work on this or not as they work does not seem to be able to be demonstrated especially if they have to go back to retrospectively code regardless.

  • We will ask GPIT to advise on when these codes will be ready. In the meantime please can practices continue to undertake case finding. The ICB is not paying on activity so please just do what you can.

7. Are any mop up searches/housekeeping searches available for patients with language barrier but no recorded need for interpreter - could the ICB create these to help support this component of the case finding for this cohort for end of Q4?

We are happy to develop something if you can make a suggestion on how we would do this.

• So at the minute the searches will only remove a patient if they have had all the codes to the point they are at - but a patient may have missed the 2nd code for example but actually be at stage 4. Can they create a search to pick out these cases where continuity is askew?

  • We are working on this now.

How should practices provide feedback for the collaboRATE audit – do they need to let the ICB know that they have completed this task?

The expectation is that they share the results with their PPG, seek feedback and then consider what they may need to do differently to improve the score.

The ICB is not asking for evidence that this task has been completed, however their CDs may request this information as it will enable them to evidence that they have completed the requirements of the Personalisation specification of the PCN DES.