Download Appendix 1 - Salford Standard (DEC 2016)

SALFORD
STANDARD
Long Term
Conditions
Business
Management
Medicines
Optimisation
Children &
Young
People
Safety &
Experience
Salford
Standard
Safeguarding
Access
Proactive
Care
Vulnerable
Groups
Public
Health
“Quality Standards for Primary Care”
V1.3 December 2016
FOREWORD
The National Health Service (NHS) is facing unprecedented pressures. Demand for services is
growing, at a time when funding for the health service is relatively static. A significant change has
to occur to health care provision to make the NHS sustainable for future generations. Now, more
than ever before, the NHS has to achieve value for money and the best possible quality so that
patients get the greatest benefit.
An increasing share of NHS spend has been allocated to hospital care in recent years.
Consequently, there has been a reduced percentage spend on Primary Care. This is at a time
when demand on General Practice is growing inexorably. NHS Salford Clinical Commissioning
Group (CCG) is addressing this situation, by introducing a significant extra investment into
Primary Care, despite the finite resource available. This extra resource will be largely used to
increase staffing across the workforce.
The total new investment for 2016-2017 is £6.4 million. The intention is that the Salford Standard
will release savings over the course of this year, at least equal to the new investment.
NHS Salford CCGs Vision for Primary Care:
•
•
•
•
•
To provide significant new investment to modernize and increase the scope of
primary care medical provision
Development of a federated model which is fit for the future and guarantees
stability and sustainability.
Delivery of high quality, safe, effective, integrated, accessible and joined-up care to
our population
Target resources at areas of greatest need.
Implementing a set of quality standards, the ‘Salford Standard’, which will clearly
describe the care that the population of Salford can expect when accessing primary
care.
The aim of the Salford Standard is to:
•
•
•
•
•
•
Reduce unwarranted variation in quality of care
Improve access and experience of care
Improve health outcomes
Ensure future stability, sustainability and growth
Reduce the number of avoidable hospital admissions
Target resources at areas of greatest need
Dr Annette Johnson
GP Quality Lead
NHS Salford Clinical Commissioning Group
2
Salford Standard – Quality Standards for Primary Care
Acknowledgements
We would like to thank all the members who have been involved in the development of the
Standard and production of this document:
NHS Salford CCG Clinical Leads
NHS Salford CCG Commissioners
NHS Salford CCG Primary Care Team
NHS Salford CCG Business Intelligence Team
Greater Manchester Shared Services Data Analysts
Salford City Council
Salford Royal NHS Foundation Trust Hospital
Members of the public who provided their views
This document will be reviewed every 2 years
Review date: December 2017
3
Salford Standard – Quality Standards for Primary Care
CONTENTS
Section
Section 1
Section 2
Section 3
Domain Title
Foreword
Contents
Background
Standard Basis
The Salford
Standard
Introduction
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
Ref
Pg
2
4
6
13
19
Long Term Conditions
Medicines
Optimisation
Children & Young
People
Safeguarding
Vulnerable Groups
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
2.1.
2.2
3.1
4.1
5.1
5.2
5.3
5.4
Domain 6
Public Health
Domain 7
Domain 8
Proactive Care
Access
Domain 9
Safety & Experience
Domain 10
Business
Management
5.5
5.6
6.1
6.2
6.3
6.4
6.5
7.1
8.1
9.1
9.2
10.1
10.2
10.3
10.4
10.5
4
Standards
Holistic Care
Cardiovascular Disease
Respiratory Disease
Diabetes
Chronic Kidney Disease &
Acute Kidney Injury
Chronic Liver Disease
Cancer
End of Life
Medicine Safety
Drug Monitoring
Childhood Asthma
Safeguarding
Dementia & Mild Cognitive
Impairment
Serious Mental Illness
Military Veterans
Learning Difficulties & Autistic
Spectrum Conditions
Asylum Seekers
Carers
Health Improvement
Screening
Health Protection
Sexual Health
TB Screening
Proactive Care / MDGs
Access to Primary Care
Medical Services
Patient Safety
Patient Experience
Demand Management
Membership engagement
Information Governance and
IG Toolkit – including
Business Continuity Planning
/ Resilience
Accessible Information
Declarations of Conflicts of
Interest
Salford Standard – Quality Standards for Primary Care
20
24
29
32
36
41
46
48
51
55
58
65
69
74
79
83
85
89
92
96
102
106
109
111
114
122
126
129
132
134
136
138
141
Section 4
Section 5
Section 6
Section 7
Section 8
5
Education and
Training
Practice
Implementation
Plans
Key
Performance
Indicators
Read Code
Directory
Glossary
Salford Standard – Quality Standards for Primary Care
144
149
153
154
156
SECTION 1:
BACKGROUND
6
Salford Standard – Quality Standards for Primary Care
1.1
Introduction
1.1.1
The vision of NHS Salford Clinical Commissioning Group (CCG) is to commission and
ensure the delivery of accessible, safe, high quality care for the local population, thereby
enabling our population to live longer healthier lives. However, increasing and
unsustainable pressures on Salford’s NHS services mean that this will be unachievable,
unless there is a radical transformation. There is a growing consensus that the
commissioning and provision of current health and social care is not fit for purpose (NHS
England (NHSE), 2013. Ham, 2014).
1.1.2
NHS Salford CCG has developed the Salford Standard to be a vital component in the
steps being taken to impact on the growing pressures of local health and care services.
This Standard is intending to underpin the move to co-commissioning of Primary Care
services, improve prescribing practice, implement strategies for reducing waste and
achieve cost effective use of clinical resources.
1.1.3
An 8 month period of consultation with local GP Members has shaped and influenced the
development of the Salford Standard.
1.1.4
The Local Medical Committee (LMC) has been regularly informed during the development
stages of the new Standard for Salford GPs. The views of the LMC have been taken into
consideration in relation to the overarching principles of the Standard.
1.1.5
The standards have been shared with patients and public via the Citizens Panel, the
Dementia Champions Group, the Health and Wellbeing Board, Healthwatch, GP & staff
newsletters and a variety of patient forums. Feedback and comments have been used to
inform development of the Salford Standard.
1.1.6
The specification of this service is designed to cover the enhanced aspects of clinical care
of the patient, all of which are currently beyond the scope of essential services. No part of
the specification by commission, omission or implication defines or redefines essential or
additional services.
1.1.7
The Salford Standard will provide additional investment to:








7
Reduce health inequalities;
Improve healthcare quality (safety, experience, and effectiveness);
Improve health and wellbeing outcomes through early intervention and the very
best care;
Reduce unwarranted variation in quality of care across Salford;
Improve access to see a GP, Practice Nurse or Healthcare Assistant ;
Ensure future stability, sustainability and growth;
Provide care closer to home and reduce the number of avoidable hospital
admissions;
Target resources at areas of greatest need.
Salford Standard – Quality Standards for Primary Care
1.1.8 To implement the Standard, NHS Salford CCG is applying the following core
principles:







Patient safety should not be compromised;
Patients should continue to receive clinical care, specific to their individual needs;
The incentives should not encourage a uniform or blanket approach to all patients
with the same condition;
GPs should continue to have the flexibility to meet the individual needs of their
patients;
Incentives should be paid in relation to outcomes for large groups, or populations of
patients;
Incentives should not directly reward decisions relating to individual patients;
The new investment should largely be used to increase staffing capacity across
Primary Care which will meet demand, thereby delivering responsive access,
quality services and future stability.
1.1.9 Benefits for Primary Care:



1.2
Guaranteed practice income from April 2016 at a time when Practice income is
under threat from standard negotiations and reviews by NHSE;
Improved payment verification system;
Decrease in administrative burden for General Practice.
Desired Outcomes
1.2.1 Strategic Programmes (2014 - 2019)
The Salford Standard has been developed in alignment with the CCG’s 5 year strategy:
8
Salford Standard – Quality Standards for Primary Care
1.2.2
Quality



1.2.3
Community Based Care


1.2.4
Support and invest in GP practices to work at a bigger scale and in a federated
manner to effectively deliver integrated care with community health and social
care services.
Seek opportunities to enhance the role of community pharmacists and opticians.
Integrated Care



1.2.5
Engage with all sections of our population to encourage their involvement in
improving the quality of care provided. Actively seeking feedback on their
experiences of healthcare and using this information to improve services.
Support our members to deliver primary care that is safe, effective and
accessible.
Aiming to minimise variation and secure continuous improvement.
Jointly plan for integrated health and social care services with Salford City
Council, Salford Royal NHS Foundation Trust, Greater Manchester West Mental
Health NHS Trust and other providers to enable people to retain their
independence and quality of life.
Work effectively with health and social care organisations to support the
assessment and commissioning of NHS funded continuing care from a range of
providers, including nursing and care home providers.
Continue to support and develop the existing integrated commissioning
arrangements with Salford City Council across the areas of mental health,
learning disability, older people, physical and sensory disability and carers.
In-Hospital Care
Support secondary care reconfiguration / service transformation in the conurbation
through the Healthier Together Programme whilst also maintaining a focus on the
delivery of NHS constitutional standards.
1.2.6
Long Term Conditions





9
Increasingly support the treatment of long term conditions in primary care and
community settings, with a particular focus upon cancer, circulatory and
respiratory diseases.
Support preventative measures aimed at improving morbidity and mortality rates
in the treatment of long term conditions.
Strengthen community based mental health support to better enable services to
support people at home.
Ensure that mental health services intervene early and work to a recovery ethos,
supporting service users to return to full health.
To provide patients and their carers with access to higher quality, local,
comprehensive community and primary care services to improve clinical
outcomes and experiences.
Salford Standard – Quality Standards for Primary Care
1.3
Challenges
1.3.1
NHSE (2013) highlights the growing challenges to the current models of Primary Care:
 Ageing population – epidemic of long term conditions, increasing co-morbidity,
large growth in consultations for older people;
 Rising costs, constrained financial resources, efficiency savings;
 Growing dissatisfaction with access to services;
 Inequalities in health – access and quality of Primary Care;
 Risk factors – unhealthy lifestyles, wider determinants of health.
1.3.2
Delivering a sustainable system, in the face of one of the most challenging financial and
organisational environments ever experienced, is a daunting task. This is in the context of
a local population in which the burden of disease and cost of medical and social care is
growing. If nothing changes, there will be significant unmet need and threats to quality of
care (Naylor et al, 2013).
1.3.3
Unwarranted variation is known to exacerbate inequalities in health (Salford City Council,
2013). Despite a tremendous amount of work over the last 10 years, the health outcomes
for Salford people have not improved significantly enough to equate with average life
expectancy in England.
England Average
Men
Women
79.55
83.20
Salford Average
Men
Women
76.70
80.7
Table 2. Life expectancy figures at birth, 2012-2014)
1.3.4
On average, Salford people are still living 3 years less than people in other parts of the
country. It is expected that by reducing variation and raising performance across Primary
Care, this will support the agenda to improve life expectancy and reduce health inequalities
right across the social gradient (Smith et al, 2013).
1.4
Achievements
1.4.1
The introduction of new commissioning structures in April 2013 provided a platform for the
CCG to begin implementing changes which would make savings, improve productivity and
reduce health inequalities. So far, NHS Salford CCG can report the following outcomes:
 Improved access;
 Improved management of demand;
 Improve the burden of disease for the population;
 Application of Greater Manchester Standards.
10
Salford Standard – Quality Standards for Primary Care
1.5
Data and Information
1.5.1
Data from various sources will be used to determine individual Practice performance. Data
sources include: practice submissions, Quality and Outcomes Framework (QOF),
Informatica system, bespoke NHS Salford CCG reporting tool, Audit+ and the Data Quality
Team.
1.5.2
Any data that is processed by the CCG, on behalf of GP practices will be managed
securely. The CCG has already achieved Accredited Safe Haven Status and has been
successfully audited to confirm it meets the essential standards of information governance;
mandated by the Health & Social Care Information Centre (HSCIC).
1.5.3
NHS Salford CCG has a culture of transparency. Individual practice data and achievement
is shared amongst all practices in Salford using locally developed reporting mechanisms.
1.6
Standards of practice
1.6.1
The following assessments have been undertaken on this standard:



Quality Clinical Impact (QCIA);
Privacy Impact (PIA) has also been undertaken on this standard;
Equality, Diversity and Human Rights (EDHR).
1.7
Declarations of Conflicts of Interest
1.7.1
In relation to conflict of interests, NHS Salford CCG fully endorses the range of obligations
set out in Good Medical Practice (GMC, 2013). The obligations include:





11
GPs must make the care of their patient the first concern (p. 4);
GPs must give priority to patients on the basis of their clinical need, if these
decisions are within their power (p. 19);
The investigations or treatment GPs provide or arrange must be based on the
assessment made by the GP and the patient, of patient needs and priorities and on
the clinical judgement of the GP, about the likely effectiveness of the treatment
options (p. 19);
GPs must not allow any interests they have to affect the way they prescribe for,
treat, refer or commission services for patients (p. 24);
GPs must not ask for or accept any inducement, gift or hospitality that may affect or
be seen to affect the way they prescribe for, treat or refer patients or commission
services for patients (p. 24) (GMC, 2013).
Salford Standard – Quality Standards for Primary Care
1.8
References

Salford City Council, (2013) Salford’s Health & Wellbeing Strategy 2013-2016.

Salford City Council, (2014) Salford Health Matters Joint Strategic Needs Assessment: Life
Expectancy. Available at:
www.Salfordshealthmatters.org/sites/default/files/Life%20Expectancy%20JSNA%20Chapte
r.pdf

Ham, C., (2014) Reforming the NHS from within Beyond hierarchy, inspection and markets
London: The King’s Fund.

Naylor, C., Imison, C., Addicott, R., Buck, D., Goodwin, N., Harrison, T., Ross, S., Sonola,
L., Tian, Y., Curry, N., (2013) Transforming our health care system Ten priorities for
Commissioners London: The King’s Fund.

NHS England (NHSE), (2013) A Call to Action: the NHS belongs to the people.

Public Health England
www.nhshealthcheck.co.uk

Smith, J., Holder, H., Edward, N., Maybin, J., Parker, H., Rosen, R., Watkins, N., Securing
the future of general practice London: The King’s Fund.

NHS Salford CCG, (2013) Conflict of Interests Policy Salford Available at:
www.salfordccg.nhs.uk/about-the-ccg/what-we-do/plans-policies-and-reports

NHS England (NHSE), (2014) Managing Conflict of Interests: Statutory guidance for CCGs
London Available at:
www.england.nhs.uk/wp-content/uploads/2014/12/man-confl-int-guid-1214.pdf
12
(PHE)
(2014)
NHS
Health
Checks
Salford Standard – Quality Standards for Primary Care
Available
at:
SECTION 2:
CONTRACT
BASIS
13
Salford Standard – Quality Standards for Primary Care
2.0
2.1.1
2.01
2.1.2
2.1.3
2.02
Introduction
The aim of the Salford Standard is to invest in the capacity needed to deliver a
consistently higher standard of General Practice across Salford.
The Standard has been developed using learning from NHS Bolton CCG, where a
similar scheme was introduced. The ‘Bolton Quality Contract’ was informed by NHS
Liverpool CCG where Liverpool Practices successfully increased staffing capacity
and delivered measurable improvements in care.
2.03
For 2016-2017 NHS Salford CCG is investing an additional £2.4 million in Primary
Care making a total investment of £7m. The investment is primarily to increase
staffing / capacity; the aim being to meet rising demand and deliver improved access
and better health outcomes for patients.
2.04
The CCG has extensive experience in designing incentive schemes for practice
performance and outcomes.
2.05
Locally Commissioned Services (LCS), commonly referred to as Local Enhanced
Schemes (LES), which the majority of Salford Practices currently deliver, are being
incorporated into the new Standard. This is in addition to the new investment.
Current Directed Enhanced Services (DES) and Quality and Outcomes Framework
(QOF) will remain outside the Standard.
2.06
The Salford Standard has been developed to:






Set a step-change requirement in quality improvements;
Support the delivery of the Greater Manchester Strategy for Primary Care
2013;
Reflect the balanced aims of improved population health, better quality and
Patient experience of care with value for money;
Incorporate all LCS (including those not routinely provided by all practices);
Provide a consistency of offer to Salford people, no matter which Practice
they are registered with;
Meet commissioning priorities for improved access to General Practice for
Salford’s registered population.
2.1
Standard Basis
2.1.1
This Standard supports the option for Level 3 of Co-Commissioning. The route used
to commission this service will be via the NHS Standard Contract covering 3 years
 2016/17
 2017/18
 2018/19
14
Salford Standard – Quality Standards for Primary Care
2.2
Terms and Conditions

2.2.1

Practices that sign up to the Salford Standard are required to complete the Salford
Standard Implementation Plan (see Section 5) and submit this electronically to
[email protected] by 31st May 2016.

2.2.2

When a practice exercises its’ right to opt out of providing the services as described
in the Salford Standard Local Commissioned Service, the CCG reserves the right to
identify an alternative provider to deliver the described services to patients
registered with that practice. By opting out the practice forfeits its rights to
payments based on the activity of the alternative provider. See section 16 for more
details regarding Opting Out.

2.2.3

When a practice chooses to subcontract the delivery of the Salford Standard to an
approved provider (a practice will need authorisation from the CCG), payments to
the provider will be the responsibility of the GP practice.

2.2.4

It is expected that if practices merge then the Salford Standard funding will also
merge accordingly. Where a practice closes or ceases to exist, it will be for the
CCG to decide how the affected practices’ funding is redistributed.

2.2.5

2.3
Practices will be expected to sign up to the full contract term of 3 years
Payment Mechanism
2.3.1
Each practice commissioned to provide the Salford Standard will receive £24.07
(PMS) per head / £25.66 (GMS) per head (delete as appropriate) above core GMS
Payments. These additional payments will be processed locally by the CCG’s
Finance Department.
2.3.2
Funding will be split into two components
Component 1: 75% Upfront payment will be paid to practices on:
 ½ Funding paid at the beginning of the year on:
o Sign Up to deliver the Salford Standard through the NHS Standard
Contract
o Agreement to using an electronic reporting tool
o Completion of an End of Year Evaluation
 ½ Funding paid during July / August providing the following conditions have
been met:
o Submission of an Implementation Plan by the 31st May 2016
confirming the practice’s intention to deliver the Salford Standard as
described in the specification.
15
Salford Standard – Quality Standards for Primary Care
o
Payment will be made on acceptance of the implementation plan by
the CCG.
Component 2 - 25% Payment is linked to achievement of Standards





2.4
Funding will be based on Achievement of the standards and paid in
increments of every 10 Standards achieved
Funding will be split into 4 quarters and paid quarterly
Funding will be paid on the achievement that is reported at the end of each
quarter.
25% funding has been divided equally across all standards (in increments of
10)
Payment will be based on quarterly achievement of the standard (not annual
achievement)
Payment Schedule
2.4.1
Component 1: 75% of Funding:
 ½ on Sign Up
 ½ on Submission of Implementation Plan
which is subsequently approved
April 2016
July / August 2016
Component 2: 25% on Achievement
 On Achievement of Standard
 Standards will be funded in increments
of 10
2.4.2
This applies to Year 1 only. Revised Payment Mechanisms and Schedules will
be subject to review / revision each year.
Payment for Achievement – Component 2
Amount Attributed to this Component:
25%
Total Amount of Salford Standard (per patient)
GP Practice Weighted List Size 1st April:
16
GMS
Example Used
£128,300
Maximum Amount Available for Component 2:
Number of
Standards
£25.66
5,000
Total Amount Available for Salford Standard
Quarterly:
2.5
Quarterly
£32,075
Quarter 1
Quarter 2
Quarter 3
Quarter
4
Total
10
0.4%
0.4%
0.4%
0.4%
1.7%
20
0.4%
0.4%
0.4%
0.4%
1.7%
30
0.4%
0.4%
0.4%
0.4%
1.7%
40
0.4%
0.4%
0.4%
0.4%
1.7%
50
0.4%
0.4%
0.4%
0.4%
1.7%
Salford Standard – Quality Standards for Primary Care
60
0.4%
0.4%
0.4%
0.4%
1.7%
70
0.4%
0.4%
0.4%
0.4%
1.7%
80
0.4%
0.4%
0.4%
0.4%
1.7%
3.3%
3.3%
3.3%
3.3%
13.3%
10
0.0%
0.8%
0.0%
0.8%
1.7%
20
0.0%
0.8%
0.0%
0.8%
1.7%
22
0.0%
0.8%
0.0%
0.8%
1.7%
0.0%
2.5%
0.0%
2.5%
5.0%
10
0.0%
0.0%
0.0%
1.7%
1.7%
20
0.0%
0.0%
0.0%
1.7%
1.7%
30
0.0%
0.0%
0.0%
1.7%
1.7%
38
0.0%
0.0%
0.0%
1.7%
1.7%
0.0%
0.0%
0.0%
6.7%
6.7%
3.3%
5.8%
3.3%
12.5%
25.0%
Bi-Annual:
Sub Total
Annual:
Sub Total
Sub Total
TOTAL
2.6
Performance Monitoring
2.6.1
Review of practice performance against the indicators will be carried out by NHS
Salford CCG via a series of methods some of which are highlighted below:





IT Reporting Tool – Contract & Audit Plus for example
Data Quality Team Audits
Practice Submissions
National Data Sets
Post Payment Verification Process
2.6.2
Practices will be required to sign up to follow a “Salford Standard Management
Process” which practices will be expected to adhere to.
2.6.3
The CCG will provide updates to other stakeholders as agreed / requested e.g.
NHSE, Salford City Council / Public Health.
2.7
Post Payment Verification
2.7.1
The Salford Standard will be subject to post payment verification which will be
performed internally by the CCG.
2.7.2
The CCG reserves the right to carry out in-depth verifications on an annual basis –
up to 10% of practices. The selection of practices will be done on a random basis.
2.7.3
No practice will receive more than 1 in-depth view in any 3 year period.
2.7.4
Practices will be expected to support the process and provide any additional
17
Salford Standard – Quality Standards for Primary Care
information as requested. The practice will ensure that both clinical and non-clinical
staff are made available as required to support the process.
2.8
Exceptions
2.8.1
Where it is deemed clinically inappropriate for a patient to be excluded from an
identified cohort of patients, exception codes can be applied, blanket expectations
may not be applied to cohorts.
2.8.2
Exception codes are to be applied on a patient by patient basis and any exception
code applied must be accompanied by a narrative as to why the patient fits the
exclusion criteria.
2.9
Disputes
2.9.1
Wherever possible, disputes relating to KPIs will be resolved locally
2.9.2
NHS Salford CCG has an Appeals and Escalation Process in place
2.9.3
The appeals process will be managed by the Primary Care Quality Group and
overseen by the Primary Care Joint Committee.
2.9.4
Appeals from practices will be considered on an individual basis. Practices will be
expected to provide comprehensive evidence to back up their reason for appeal.
This evidence will be subject to further analysis by the CCG.
2.10
References
Department of Health (DH), (2010) How to develop a taxonomy of general medical practices
to support and encourage performance development London
NHS England (NHSE) Greater Manchester Area Team, (2013) Our 5 year strategy for
improving primary care within Greater Manchester 2014-2018
18
Salford Standard – Quality Standards for Primary Care
SECTION 3:
SALFORD
STANDARD
19
Salford Standard – Quality Standards for Primary Care
3.1
Introduction
3.1.1
The Salford Standard 2016 – 2017 has been developed through a 9 month period of
consultation with local GPs, Salford City Council, Public Health England (PHE), NHS
England (NHSE) and other stakeholders.
3.1.2
The ‘Salford Standard’ is a set of quality standards for General Practice which clearly
describes the level of care that all Salford patients should expect.
3.1.3
The 32 Standards have been split into 10 Domains:
Long Term
Conditions
Business
Management
Medicines
Optimisation
Children &
Young
People
Safety &
Experience
Salford
Standard
Safeguarding
Access
Proactive
Care
Vulnerable
Groups
Public
Health
Domains
Standards
1. Long Term Conditions
1.1
1.2
1.3
1.4
1.5
1.6
Holistic Care
Cardiovascular Disease
Respiratory Disease
Diabetes
Chronic Kidney Disease & Acute Kidney Injury
Chronic Liver Disease
1.7 Cancer
1.8 End of Life
2. Medicines Optimisation
2.1 Medicine Safety
2.2 Drug Monitoring
3. Children & Young People
3.1 Childhood Asthma
4. Safeguarding
4.1 Safeguarding
5. Vulnerable Groups
5.1 Dementia & Mild Cognitive Impairment
5.2 Severe Mental Illness
5.3 Military Veterans
5.4 Learning Disabilities & Autistic Spectrum Conditions
5.5 Asylum seekers
5.6 Carers
6. Public Health
6.1 Health improvement
6.2 Screening (national)
6.3 Health protection
6.4 Sexual health
6.5 Tuberculosis screening
7. Proactive Care
7.1 Proactive Care / Multi-Disciplinary Groups
8. Access
8.1 Access to Primary Care Medical Services
9. Safety & experience
9.1 Patient Safety
9.2 Patient experience
10.1 Demand management
10.2 Membership engagement
10. Business Management
10.3 Information Governance and IG Toolkit – including
Business Continuity Planning / Resilience
10.4 Accessible Information
10.5 Declarations of Conflicts of Interest
3.1.4
This section will outline:
21
Salford Standard – Quality Standards for Primary Care




A rationale for each standard and why the CCG has included this within the
Salford Standard;
How each Standard should be delivered and what practices will be expected to
do;
Key Performance Indicators (KPIs). Practice baseline reports will identify the
individual KPIs for your practice;
Key links to supporting evidence for further reading.
3.1.5
The CCG and Clinical leads will provide support to practices when needed.
3.1.6
If you need any additional information about these Standards, the details of a named
contact are included within each section.
For any general information regarding the Standard, please email:
[email protected]
22
Salford Standard – Quality Standards for Primary Care
Domain 1
23
Salford Standard – Quality Standards for Primary Care
Standard 1.1 Holistic Care
Rationale
The need to improve the treatment and management of Long Term Conditions
(LTCs) is one of the most important challenges facing the NHS. Improving care
for people with LTCs must involve a shift away from reactive, disease-focused,
fragmented model of care towards one that is more proactive, holistic and
preventative, in which people with LTCs are encouraged to play a central part in
managing their own conditions.
The LTC Standards included in this document will standardise the process of
treating patients with one or more LTCs with the aim to reduce variation between
practices. This will involve an Annual Review with at a minimum a 6 monthly
follow-up contact. 6-monthly “follow-up appointments” do not necessarily have to
be a traditional face to face appointment and practices may take the form of a text
message, telephone call or email as agreed with the patient.
During their review patients will be able to discuss all aspects of their care and
will follow the 4 phases of care planning, namely:
 Preparation;
 Discussion;
 Documenting;
 Review.
Practices will need to ensure that as part of their discussions with patients during
the annual review and follow up the practice will utilise the “The Patient/Practice
Agreement” which will outline the roles and responsibilities of both the patient and
the practice. The aim of this is to empower patients and ensure a standardised
approach to management of patients with a LTC.
All practices will be required to undertake mandatory training as identified in the
Salford Standard; there will also be a list of optional training sessions. The choice
of participating clinician is up to the practice to suggest; as are the types of
optional sessions to be attended / completed. See Section 4.
Medicines are the most frequent health care intervention in the NHS, which if
prescribed and taken correctly, can make a major impact / improvement on the
health and wellbeing of a population. Inappropriate use of medicines can,
however, result in unnecessary harm to patients, poorer outcomes and a financial
risk to the CCG.
It should be noted at this point the medicine management requirements of the
LTC standards are in addition to those within the Medicines Optimisation Domain
of the Salford Standard.
Local Context
In Salford, one in three people currently have one or more long term conditions
and this is predicted to rise to one in two over the next 25 years; for Salford this
equates to just over 76,000 people out of a population of 230,000 with a steady
24
Salford Standard – Quality Standards for Primary Care
rise to over half the population.
Objectives:
The LTC Commissioning Strategy is focused on the following areas:

Prevention:
To work with Public Health by supporting and promoting initiatives in
preventing people from developing long term conditions.

Early Detection and Early Intervention:
Using opportunistic screening, diagnostic techniques and improved early
warning indicators to identify patients who are at risk or have early signs
of developing a long term condition.

Self-Management/Self-Monitoring:
Ensure patients have the tools, emotional support and clinical support to
manage their own condition on a daily basis from – self-testing to lifestyle
changes.

Patient Engagement/Empowerment/Education:
Ensure patients are better able to make changes if they are aware of their
condition and are provided with the tools to help them.

Reduction in Admissions / Admissions Avoidance:
Reduce inappropriate admissions by ensuring that patients understand
and can help themselves during a crisis e.g. the patient has rescue
medicines to hand, is able to understand how to cope with exacerbations
better and reduce the impact of further deterioration.

End of Life Care:
Support patients to have a dignified death by offering help and support
during the last days of life and supporting their decision to die in their
preferred place of death.
The LTC Commissioning Group is focused on holistic care and it is important,
given constraints within the current economic climate that the CCG focuses on
those conditions that cause the majority of years of life lost. In view of this the
following conditions will take priority within the 5 year strategy and 2 year
operational plan:
 Cancer;
 Cardiovascular Disease (including Coronary Heart Disease & Stroke);
 Chronic Kidney Disease;
 Chronic Liver Disease;
 Respiratory Disease (Asthma & COPD);
 Diabetes;
 End of Life Care.
Delivery
25
Practices will be expected to:
 Move towards delivering a proactive, holistic and preventative system
in which people with LTCs are encouraged to play a central part in
managing their condition/s;
Salford Standard – Quality Standards for Primary Care

Ensure systems are in place to provide a clinically comprehensive
annual review and subsequent follow-up as clinically appropriate or as
a minimum standard 6 months after the annual review;
 Use the approved software to record all clinical interventions including
for example recalls, referrals, advice given and agreed actions;
 Offer advice regarding the benefits of an Influenza vaccination to all
patients with a LTC;
 Work in partnership with patients to develop and agree a personalised
care plan at the time of the annual review;
 Ensure clinical staff are released to attend mandated and optional
education sessions as required;
 Utilise the patient and practice agreement to support patients to
understand how they can best help themselves to manage their own
condition;
 Support the raising of awareness of the prevention, screening and
management of LTCs by utilising local and national campaigns materials
i.e. displaying posters and making leaflets available to patients.
As part of the care planning process there should be discussion about the patient /
practice agreement, although it is not mandatory that this is signed
PATIENT/PRACTICE AGREEMENT
PATIENT RESPONSIBILITIES
·
·
I will try to attend all my pre-arranged long term condition review appointments and if I am unable to attend for my review
I will contact the practice to cancel and rearrange
Any timely information my practice gives or sends to me I will read before I go and see my practice nurse
·
I will bring with me any paperwork/letters that I believe may affect my review
·
I will take my tablets/medication as advised and bring them with me to my review.
·
I will work with my practice nurse to develop an action plan which fits with my circumstances and condition.
·
I will try to follow my action plan to the best of my ability
·
When I feel things are not going well with my Long Term Condition I will contact my practice for advice and support
·
I will consider attending any self -help support group and/or education sessions as advised by my Practice Nurse or GP
which are practical in my circumstances.
PRACTICE RESPONSIBILITIES
·
·
·
·
·
·
The practice will ensure you are offered an Annual Review as a minimum and a 6 month follow up which may be a
telephone appointment. This may be more frequent dependent upon clinical need.
The practice will ensure the patient receives all relevant information in a timely fashion prior to their Annual Review and
any subsequent review appointments
During the review the Practice Nurse will work with the patient to support the development of an action plan and ensure
that they understand it.
The practice will ensure there is a system in place to identify patients with a Long Term Condition should they ring the
practice for advice or support
The practice will provide the patient with as much information as is practicable relating to self-help/support groups - this
may be in the form of verbal information, leaflets or web-addresses or telephone contact numbers
The practice Nurse will advise the patient at the time of review of appropriate education and rehabilitation sessions
options available and will refer the patient to the appropriate sessions as agreed.
26
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
27

LTC28a:
Ensure systems are in place to provide a clinically comprehensive
holistic annual review and a subsequent review 6 months later:
≥90% with a LTC and an annual review completed = Achieved;
<90% - ≥ 50% with a LTC and an annual review completed =
Acceptable;
<50% with a LTC and an annual review completed =
Unacceptable.

LTC29:
The completion of 6 monthly reviews will be measured from year 2017
onwards (these reviews do not necessarily need to be Face to Face):
≥90% of pts with a LTC annual review & follow-up = Achieved;
<90%-≥50% of pts with a LTC annual review & follow-up =
Acceptable;
<50% of pts with an annual review & follow-up = Unacceptable.

LTC30:
All patients with a LTC have a current individualised comprehensive
management plan, which includes high-quality information and
educational material about their LTC and its management, relevant to
the stage of disease. Monitored via the LTC electronic management
plan - Good Practice - LTC Standards. Confirm in the practice's LTC
Implementation and Action Plan how care planning will be
incorporated into the holistic annual review.
≥90% of pts with a LTC annual review & follow-up = Achieved;
<90%-≥50% of pts with a LTC annual review & follow-up =
Acceptable;
<50% of pts with an annual review & follow-up = Unacceptable

LTC9b:
Embed the offer of influenza vaccination accompanied by a discussion
relating to the benefits. Information collected over a 4 month period
from Nov- Feb (ImmForm web-site) will be utilised to identify the
number of patients with a LTC recorded as having been offered a flu
and of those the number receiving a flu vaccination.
Measure: No. of patients with a LTC offered the flu vaccination
Total no. of patients with a LTC excluding those recorded as
declined

LTC01-P:
Ensure the appropriate clinician/s attend mandated education sessions
as well as the required number of optional education sessions.
Clinician must have signed register of attendance and remain for the
full education session. Payment will be reduced accordingly if staff
leave the event early or arrive late in line with payments reduction at
neighbourhood meeting.
Threshold: 100% achieved = acceptable;
Salford Standard – Quality Standards for Primary Care
<100% = unacceptable.

LTC02_P:
Support the raising of awareness of the prevention, screening and
management of LTCs by utilising local and national campaigns
materials i.e. displaying posters and making leaflets available.
At the end of the second and subsequent years a “calendar” of
promotional activities they have provided and/or organised for patients
should be available.
Exceptions for KPIs
 Patients identified as End of Life will not be included, but must be
exception reported.
 Where hypertension is the patients only LTC a care plan will only
be required if deemed clinically appropriate; therefore hypertensive
patients will be excluded from any indicators relating to care
planning.
 Where patients are excluded from an indicator on the criteria of 3
refused invitation practices must evidence more than one type of
media used to contact patient and the annual review moved
forward a year.
CCG Support
The CCG will:
 Ensure appropriate training is available;
 Raise awareness in relation to long term conditions utilising National and
Local Campaigns;
 Develop and provide a leaflet for patients which provides help and advice
for living with a long term condition.
Contacts
Clinical Lead: Dr Tom Regan; [email protected]
CCG Contact: Robin Gene, Acting Senior Service Improvement Manager;
[email protected]
References
Coulter A, Roberts’s S, Dixon A (2013): Delivering Better services for People with
Long Term Conditions: The King’s Fund.
28
Salford Standard – Quality Standards for Primary Care
Standard 1.2 Cardiovascular disease

Aims
Rationale
To facilitate early detection of patients with cardiovascular conditions
including stroke, hypertension, atrial fibrillation, coronary heart disease
and peripheral arterial disease.
NICE describe cardiovascular disease as the country's biggest killer, causing
more than 200,000 deaths per year – around 1 in 3 deaths. Early mortality (under
75 years) rates from cardiovascular disease in Salford are significantly higher than
the national rate but have decreased by 57.4% since 1995. Emergency admission
rates for both coronary heart disease and stroke are significantly higher than the
national rate.
Management of people with atrial fibrillation
NICE (2015), summarises the management of atrial fibrillation (AF) and
paroxysmal AF and stresses the need to use 2 scoring tools to assess the risk of
stroke and bleeding:
 Assess stroke risk using the CHA2DS2VASc score tool. This defines 'major'
and 'clinically relevant non-major' risk factors which increase the risk of
stroke;
Delivery

Offer anticoagulation treatment to all people with a CHA2DS2VASc score of
2 or above, and consider offering it to men with a CHA2DS2VASc score of
1, after taking into account the person's bleeding risk assessed using
the HAS-BLED score tool;

An electrocardiogram (ECG) should be performed in all people, whether
symptomatic or not, in whom atrial fibrillation is suspected because an
irregular pulse has been detected, (NICE, 2014). They also recommend
anticoagulants to reduce the risk of stroke and anti - arrhythmics to restore or
maintain the normal heart rhythm or to slow the heart rate in people who
remain in atrial fibrillation.
Practices will be expected to:
Management of people with atrial fibrillation
 Utilise CHA2DS2-VASc scoring system (NICE 180) and discuss bleeding
risk with patient;
 All patients identified with an irregular pulse with no diagnosis of AF to have
a 12 lead ECG and Holter Watch/24-48hr ECG where clinically appropriate;
 Patients diagnosed with AF achieve resting rate 55-95 BPM (<110bpm in
recent on-set).
 Once the patient is anticoagulated the CHADS2Vasc does not need
repeating
Management of people with hypertension
All new patients with OBP ≥ 140/90 have an ABPM/HBP to confirm diagnosis except
in cases where immediate treatment is required or clinically inappropriate to start
treatment.
29
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
Medicines
Optimisation

LTC24:
The number of patients aged ≥75 with an AF Read coded diagnosis that
have a CHA2DS2-VASc Score.
≥95% = Achieved;
<95% - ≥80% = Acceptable;
<80% - ≥75% = Improvement Plan;
<75% = Trigger Alert.

LTC25:
The number of newly diagnosed AF patients with both Read coded diagnosis
and method of diagnosis recorded.
100% = Achieved;
<100% - ≥75% = Acceptable;
<75% = Trigger Alert.

PE6:
The number of patients with AF with pulse rate recorded.
≥95% = Achieved,
<95% - ≥80% = Acceptable;
<80% - ≥75% = Improvement Plan;
<75% = Trigger Alert.

PE7:
The number of patients diagnosed with hypertension (OBP ≥ 140/90)
confirmed by ABPM or HBP. To exclude patients where immediate treatment
is required, those already on hypertensives or on the LTC register.
95% = Achieved;
<95% - ≥75% = Acceptable;
<75% = Trigger Alert.
CVD - AF patients on no treatment
 Target group - All patients on warfarin have their INR therapeutic range
monitored quarterly, use read code 42QE200
CVD1.2:
Measure – No. of patients on warfarin with an INR % time within
therapeutic range treated in line with NICE
Total no. of patients with AF on warfarin
Monitoring – Read code. 6/12 audit with support from MMT team.
Threshold: 50% = acceptable in yr 2016/17 (rising to 60% in yr 2017/18);
<50% trigger alert in 2016/17 (rising to 60% in yr 2017/18).
CCG Support
Contacts
30
The CCG will:
Continue to commission Broomwell Healthwatch, Cardiac Interpretation Service.
Clinical Lead: Dr Tom Regan; [email protected]
CCG Contact: Robin Gene, Acting Senior Service Improvement Manager;
[email protected]
Salford Standard – Quality Standards for Primary Care
References
31

Cardiovascular disease Local Authority health profile, Salford, NICE, Atrial
Fibrillation,
Clinical
Knowledge
Summaries,
May
2015
www.sepho.org.uk/NationalCVD/docs/00BR_CVD%20Profile.pdf

NICE, Atrial fibrillation: the management of atrial fibrillation, NICE Clinical
Guideline 180, August 2014.

NICE, Hypertension Clinical management of primary hypertension in
adults, NICE Clinical Guideline 127, August 2011.

QRISK2 CVD Score http://www.qrisk.org/

NICE, Lipid modification: cardiovascular risk assessment and the
modification of blood lipids for the primary and secondary prevention of
cardiovascular disease, NICE Clinical Guideline 181, August 2015.
Salford Standard – Quality Standards for Primary Care
Standard 1.3 Respiratory Disease

Aims


Rationale
Reduction of the gap between expected and actual COPD prevalence
and the variance between practices.
To ensure that all COPD and Asthma patients in Salford receive their
annual review in line with NICE guidance/principles.
To improve engagement and empower patients through education to
help them self-manage their COPD.
Rates of death from respiratory diseases (in people under 75) in Salford (2003 –
2012) fell but remain higher that the England average. Although the gap has
narrowed slightly, this is an indicator of the inequality that exists between
residents of Salford and the rest of the country. Respiratory diseases accounted
for 17% of all Salford resident deaths 2008-13 and are the third highest cause of
death.
Patients with COPD MRC 3 and 4 should be prescribed home rescue packs
(steroids and antibiotics) to treat exacerbations – this has been shown to help
prevent hospital admissions and is recommended in the NICE clinical guideline
on COPD as part of self-management of exacerbations. This is to be assessed at
the time of the annual review or follow-up and outcome recorded.
Delivery
Practices will be expected to:
COPD
 Identify patients over the age of 40 who currently smoke or have smoked
in the last five years and screen for COPD using the COPD Risk
Questionnaire;
 At risk patients to be followed up with spirometry;
EXCLUDE: patients with a diagnosis of COPD and patients screened for
COPD within the last 5 years;
 Identify appropriate staff to attend spirometry and/or inhaler technique
training, to be refreshed every 3 years as per national guidance;
 Offer Pulmonary Rehabilitation (PR), to all MRC3 and 4 patients including
housebound who have access to a home-based PR course;
EXCLUDE those not suitable for PR;
 Offer to MRC2 patients who have had a recent exacerbation.
ASTHMA
 Carry out an annual review of all patients with asthma (BTS 1 – 5);
 Carry out a 6 monthly review for all patients classed as BTS 3, 4 and 5;
Where appropriate this review can be conducted by telephone as per
guidance in the Holistic Assessment Standard (1.1).
32
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
COPD
Identification of undiagnosed COPD
Measure LTC15: Total no. of patients aged ≥ 40yrs with a smoking status
‘smoker’ or have smoked in the last 5yrs, with no COPD screening or diagnosis of
at risk of COPD. The COPD Risk Questionnaire is to be utilised.
Monitoring: Monthly clinical system reports.
Threshold: ≥75%* = achieved;
<75%* - ≥60% = acceptable;
< 60% - ≥ 50% = Improvement Plan;
<50% = trigger. *this will rise to 85% in Year 2018/19.
Diagnosis of COPD to be confirmed by spirometry
Measure LTC18: Percentage of patients assessed using the COPD Risk
Questionnaire, identified as at risk and followed up with spirometry.
Monitoring: Monthly clinical system reports.
Threshold: ≥75%* = achieved;
<75%* - ≥60% = acceptable;
< 60% - ≥ 50% = Improvement Plan;
<50% = trigger. *this will rise to 85% in Year 2018/19.
Spirometry to be undertaken by appropriately trained practice staff and
patients prescribed inhalers to be educated in correct inhaler technique.
Measure LTC03_P: Confirmation of practice staff attendance dates for
spirometry and inhaler technique training/refresher course.
Monitoring: Annual declaration.
Threshold: 100%.
All eligible patients to be offered Pulmonary Rehabilitation
Measure LTC19: Percentage of eligible patients with COPD MRC3 or MRC4
offered PR.
Monitoring: Monthly clinical system reports.
Threshold: 100% = achieved;
<100% - ≥75% - acceptable;
<75% = trigger alert.
All eligible patients to be offered Pulmonary Rehabilitation
Measure LTC20: Percentage of eligible patients with COPD MRC2 who have had
an exacerbation and been offered PR within 2 months following exacerbation.
Monitoring: Monthly clinical system reports.
Threshold: 100% = achieved;
<100% - ≥75% - acceptable;
<75% = trigger alert.
33
Salford Standard – Quality Standards for Primary Care
ASTHMA
Annual review of patients with asthma BTS 1- 5
Measure LTC21a: Percentage of patients with asthma BTS 1 - 5 who have had
an annual review.
Monitoring: Monthly clinical system reports.
Threshold: ≥ 85% = achieved;
<85% - ≥ 60% = acceptable;
<60% - ≥50% = Improvement Plan;
<50% = trigger.
Six-monthly review of patients with higher severity asthma
Measure LTC21b: Percentage of patient with asthma BTS 3, 4 or 5 who have
had a 6-month review.
Monitoring: Monthly clinical system reports.
Threshold: ≥ 85% = achieved;
<85% - ≥ 60% = acceptable;
<60% - ≥50% = Improvement Plan;
<50% = trigger.
Medicines
Optimisation
KPI: Review patients with COPD MRC 3 & 4 who are prescribed home
rescue packs of antibiotics, steroids or both twice a year and:
 assess frequency of issues in past 6 months
 ensure use as part of a care plan
 refer those who appear uncontrolled and exacerbating frequently
Measure Resp1.3: Percentage of patients with COPD with review read coded as
being offered and/or discussed Rescue Medication.
Monitor: Read coding via clinical system.
Threshold: ≥85% - achieved;
<85% - ≥60% = acceptable;
<60% - ≥50% = improvement plan;
<50% - trigger alert.
Code all patients receiving rescue packs as Read code 8BMW Issue of COPD
Rescue Pack.
When reviewed code as 661N3 COPD self-management plan review.
CCG Support
34
The CCG will:
 Ensure the COPD Risk Questionnaire is included in the Management Plan;
 Organise spirometry and inhaler technique training and refresher courses
to meet the training needs of practice staff;
 Continue to commission the Breathe Better Pulmonary Rehabilitation
service;
 It is the responsibility of the GP to deliver this standard. Support will be
provided by the Medicines Optimisation Team if required.
Salford Standard – Quality Standards for Primary Care
Contacts
References
35
Clinical Lead:
CCG Contact: Hillary Rothwell

Long Term Conditions Compendium of Information, 3rd ed. London,
Department of Health.

Department of Health, (2010) Improving the health and well-being of
people with long term conditions London.

The King’s Fund, (2013), Delivering better services for people with long
term conditions London.

Salford CCG Five Year Strategic Commissioning Plan 2014/15 to
2018/19.

NICE guidance CG12 Published February 2004, updated by NICE
guidance, CG 101, June 2010.

British Thoracic Society Guideline on Pulmonary Rehabilitation in Adults.
Thorax. September 2013, Volume 68, supplement 2.

British Thoracic Society and Scottish Intercollegiate Guidelines Network
British Guideline on the management of asthma. Published October
2014.
Salford Standard – Quality Standards for Primary Care
Standard 1.4 Diabetes

Aims


Rationale
To reduce the predicted growth in prevalence of diabetes over the next
5 years.
To ensure that all diabetic patients in Salford receive their annual
review in line with National Diabetes Audit and NICE
Guidance/Principles.
To improve engagement and empower patients through education to
help them self-manage their diabetes.
In Salford, approximately 12,000 people have Diabetes and of those around
90% (10,800) have Type 2 diabetes. Diabetes is a serious condition and if not
properly controlled can lead to serious complications. The incidence of Type 2
diabetes is increasing rapidly, with obesity and lack of exercise being significant
risk factors for the development of Type 2 diabetes. At least 7,000 people in
Salford are thought to currently have impaired glucose regulation (IGR) and
50% of these will progress to Type 2 diabetes over the next 5 – 10 years. There
is evidence that lifestyle modification at the IGR stage can delay or prevent the
onset of Type 2 diabetes.
With this in mind, the LTC Commissioning Group agreed to focus on
encouraging:
Delivery

More consistent quality of treatment for existing Type 1 and Type 2
Diabetics, to reduce/delay the complications and additional risks that
accompany the disease;

Early identification of people who have Impaired Glucose Regulation
(IGR), to reverse the condition for those people where lifestyle alterations
could make a difference to whether they develop Diabetes.
Practices will be expected to:
Identification of patients with Diabetes or IGR
 Identify patients with previous test results that indicate a pre-diabetic
condition, where no follow-up has been recorded. Read Code, add recall
and commence yearly reviews.
IGR – identification and onward referral
 Screen patients opportunistically and at LTC review where appropriate for
IGR using a validated risk score tool. The DUK risk score tool is
recommended: https://www.diabetes.org.uk/Professionals/Diabetes-RiskScore-assessment-tool/. If moderate or high risk, check HbA1c and code
and manage appropriately.
 Provide information/ education about IGR/risk of developing diabetes and
give lifestyle advice, including information on healthy diet and exercise. If
the patient is ready to engage, discuss goal setting and offer referral to an
IGR programme which supports behaviour change.
36
Salford Standard – Quality Standards for Primary Care
Treatment of Diabetes
 Ensure patients are aware of the Essential Checks and services they
should receive annually.
 Ensure all 9 review processes are carried out and properly read coded
including foot and eye checks as appropriate.
 Ensure an annual foot check is incorporated into the annual review for all
patients and that patients with increased risk are referred to/are attending
podiatry services according to Salford guidelines. Provide written
information to all patients where required.
 Train new staff in foot checks, where appropriate, as they are recruited.
 Ensure patients are given the opportunity to participate in care-planning.
 Provide information including latest test results to patients prior to review
as appropriate.
 Ensure all new patients are offered the relevant structured education and
identify patients who have no record of attending structured education and
offer this at review.
Participation in local and national programmes
 Participate in the National Diabetes Audit.
 Ensure clinicians participate in Outreach Sessions.
 Engage with CCG and diabetes team to developing and implementing an
improvement plan if practice is identified as requiring additional support.
Key
Performance
Indicators
Identification of patients with Diabetes or IGR

LTC27
Patients with a blood test result indicating IGR will be coded correctly and
receive yearly follow up – to include HbA1c blood test.
 No. of patients with IGR with a HbA1c blood test in the
preceding 12 months (Numerator)
Total no. of patients with IGR (Denominator)
Threshold: 92% = Achieved;
<92% ≥ 52% = Acceptable;
<52% = Trigger alert.
IGR – identification and onward referral

LTC28
Patients will be screened for IGR / diabetes where clinically appropriate
and offered advice and information, with referral to an IGR behavioural
intervention service where appropriate.
 No. of patients coded as having IGR who have been given
lifestyle advice/ information re risk (to include discussion re
referral to an IGR behaviour change programme, where
appropriate) (Numerator)
Total no. of patients coded as having IGR (Denominator)
37
Salford Standard – Quality Standards for Primary Care
Threshold: 100% = Achieved;
<100% - ≥75% = Acceptable;
<75% = Trigger alert.
Treatment of Diabetes

PE11
All GP practices will consistently record the 8 review processes including
foot checks.
 No. of patients on the diabetes register who have the 8 review
processes recorded within the last 12 months (Numerator)
Total no. of patients on diabetes register (Denominator)
Threshold: 95% = Achieved;
<95% - ≥65% = Acceptable;
<65% = Trigger alert.

LTC04_P
Practices will ensure staff delivering foot checks are appropriately trained
and to maintain a register of training for these staff.
Monitoring: Details of staff delivering foot checks with dates of
training to be provided as evidence upon request.
Threshold: 100% = achieved;
<100% = unacceptable.
 D_LTCa
All patients with diabetes will be offered a yearly care planning review.
 No. of patients with a coded provision of a care plan
(Numerator)
Total no. of patients on diabetes register (Denominator)
Threshold: 95% = Achieved;
<95% - ≥65% = Acceptable;
<65% = Trigger alert.
Participation in local and national programmes
 LTC05_P
Participation in the National Diabetes Audit.
 Upload or allow upload of GMSS data = Achieved;
 Non participation = Trigger alert.

38
LTC06_P
Attendance of one clinical member of staff at mandated education.
 100% = Achieved;
 <100% = Trigger alert.
Salford Standard – Quality Standards for Primary Care

Medicines
Optimisation
LTC07_P
Engagement in the production of an improvement plan where the
practice is identified as requiring support.
 Meet with, take advice from and embed processes suggested
by the Community Diabetes Team or additional Consultant
outreach sessions;
 Engagement = achieved;
 Non-engagement = trigger alert.
GLP1s
LTC09_P:
Documented weight and HbA1c 6 monthly in all patients prescribed a GLP1.
Discontinue if reduction in HbA1c is less than 1% (11 mmol/ml) and there is less
than 3% weight loss after 6 months (only HbA1c reduction required for dual
therapy).
Commence during Year 2016/17, continue throughout Year 2017/18.
Measurement:
No. of patients prescribed a GLP1 with weight and HbA1c reviewed (Numerator)
Total no. of patients prescribed a GLP1 (Denominator)
Monitor: via Read coding.
Threshold:
≥85% = Achieved;
<85% - ≥60% = Acceptable;
<60% - ≥50% = Improvement Plan;
<50% = Trigger Alert.
Increase in Metformin prescribing
LTC10_P:
Patients who are identified as not taking metformin with no documented clinical
reason should be reviewed and restarted.
Commence during Year 1, continue throughout Year 2.
To be monitored via ePACT data and Read coding.
Measurement
No. of diabetics not on metformin with review and documented evidence intolerance/allergy (Numerator)
Total no. of diabetic patients not on Metformin (Denominator)
Threshold
100%.
Review patients on dual or triple therapy
LTC11_P:
Patients on dual or triple therapy that includes a newer agent where the NICE
clinical guideline criteria have not been met should be reviewed and have the
newer agent stopped as the benefits of treatment have not been achieved.
Commence during Year 2016/17, 1st quarter.
Measurement:
Review of patients identified from search-different for each practice.
Monitor: via Care Plan. Medicines Optimisation Team can support searches to
39
Salford Standard – Quality Standards for Primary Care
identify patients.
Threshold:
Medicines Optimisation Team will review list, identify outliers, offer support and
advise if there are concerns.
CCG Support
The CCG will:
 Provide foot leaflets;
 Ensure that a range of Outreach sessions are available for practices to
select a convenient slot;
 Identify practices that could benefit from tailored input for Diabetes care.
Contacts
Clinical Lead: Dr Sheila McCorkindale; [email protected]
CCG
Contact:
Verity
Gibbons,
Service
Improvement
[email protected]
References
40

Manager;
Salford CCG Five Year Strategic Commissioning Plan 2014/15 to
2018/19.
Salford Standard – Quality Standards for Primary Care
Standard 1.5 Chronic Kidney Disease & Acute Kidney Injury

Aims
To develop a standardised approach for the management of Chronic
Kidney Disease (CKD) in Primary Care.
To prevent progression of CKD to end stage renal disease.
To raise awareness of and minimise the risk of Acute Kidney Injury
(AKI).


Rationale
CKD figures for 2011/12 indicate that Salford has 7,496 adults on the QOF CKD
registers; however, the expected prevalence was an additional 3,550
undiagnosed adults. It is known that there is wide variation across practices.
With an estimated primary care cost of £1.3m and £5.4m across both primary
and secondary care, this is a significant cost to healthcare.
13-18% of patients admitted to hospital have AKI but these patients have not
necessarily been identified in primary care, nor admitted under the renal
specialty. Other specialties in secondary care may not necessarily recognise
the signs of AKI and may be unaware of the optimal care for patients with AKI.
25-33% of deaths in secondary care due to AKI are preventable.
With this in mind, the LTC Commissioning Group agreed to focus on
encouraging:
Delivery

Patient education re what medications to stop taking temporarily whilst
they are ill (Sick Day Guidance project), with the aim of reducing the
number of patients developing community acquired AKI who need
admission to hospital and the severity of community acquired AKI in
those patients who do need admission;

More consistent quality of treatment for existing CKD patients;

Early identification of people who have CKD;

Introduction of AKI e-alerts to all Salford practices - to be acted upon
appropriately by the receiving clinician.
Practices will be expected to:
Identify patients with CKD
 Identify CKD by offering a testing for CKD using eGFR creatinine and ACR
to people with risk factors specified in the guideline.
Treatment of CKD
 Following identification of patients with CKD discuss and agree plan with
patient for investigating cause (particularly if it may be treatable) and
determine and discuss risk of adverse outcomes.
 Classify and Read Code CKD using a combination of eGFR and ACR
categories and monitor and manage patient in line with NICE Guidance.
41
Salford Standard – Quality Standards for Primary Care

Practice to strive to achieve BP targets for CKD patients:
 Non-diabetics <140/90
Target range 120-139 systolic and <90 diastolic (NICE: CG182; 1.6.1);
 Diabetes <130/80
Target range 120-129 systolic and <80 diastolic (NICE: CG182: 1.6.2);
 CKD patients with ACR 70mg/mmol or more <130/80
Target range 120-139 systolic and <80 diastolic (NICE: CG182; 1.6.2).
AKI

Key
Performance
Indicators
Support the management of patients at high risk of AKI within primary care.
Healthcare professionals issuing the cards will ensure patients understand
the information on the cards and the rationale behind the advice. (Guidance
will be provided).

Episodes of AKI that take place during an inpatient stay at SRFT will be
recorded on the discharge summary and patients will have had a
medication review prior to discharge. Practice to record AKI on patients
record and action follow up including further medication review.

Practices to respond to new e-alerts communicated by SRFT according to
guidelines, for results indicating AKI.
Treatment of CKD

LTC23:
Patients will be able to discuss diagnoses of CKD with their clinician,
agree a plan to investigate its causes if appropriate and receive an ongoing care plan to support understanding of their condition and encourage
self-management.
 No. of patients on the CKD register offered an individual care plan
(Numerator)
Total no. of patients on the CKD register (Denominator)
Threshold: 100% = Achieved;
<100% - ≥ 75% = Acceptable;
<75% = Trigger alert.

PE12:
Practice coding will provide an accurate reflection of the prevalence of
CKD within Salford.
 No. of patients on the CKD register read coded using a combination
of eGFR and ACR (Numerator)
Total no. of patients on the CKD register (Denominator)
Threshold: 100% = Achieved;
<100% - ≥ 75% = Acceptable;
<75% = Trigger alert.
42
Salford Standard – Quality Standards for Primary Care
CKD patients
 LTC7:
No. of pts on CKD Register latest BP recorded <140/90 in the last 6
months (Numerator)
Total no. of patients on CKD Register with a BP recorded in the last
6 months (Denominator)
Threshold: ≥80% = Achieved;
<80% - ≥ 60% = Acceptable;
<60% - ≥ 50% = Improvement Plan;
<50% = Trigger Alert.
CKD patients with diabetes
 LTC8:
No. of pts on CKD Register with Diabetes latest BP recorded
<130/80 (Numerator)
Total no. of patients on CKD Register with diabetes with a BP
recorded in the last 6 months Denominator)
Threshold: ≥80% = Achieved;
<80% - ≥ 60% = Acceptable;
<60% - ≥ 50% = Improvement Plan;
<50% = Trigger Alert.
CKD patients with ACR 70mg/mmol
 PE13:
No. of patients on CKD Register with ACR 70mg/mmol or more latest
recorded BP <130/80 (Numerator)
Total no. of patients on CKD Register with ACR 70mg/mmol or
more with a BP recorded in the last 6 months (Denominator)
Threshold: ≥80% = Achieved;
<80% - ≥ 60% = Acceptable;
<60% - ≥ 50% = Improvement Plan;
<50% = Trigger Alert.
AKI

Practices recording and follow up of AKI will increase to ensure best
management for patients who have had an episode of AKI.

No. of patients discharged with AKI status and medication review
recorded (Numerator)
Total no. of patients discharged with AKI from SRFT (Denominator)
Threshold: 100% = Achieved;
<100% - ≥ 75% = Acceptable;
<75% = Trigger alert.
43
Salford Standard – Quality Standards for Primary Care
Medicines
Optimisation
Low-cost renin - angiotensin system antagonists
Offer a low-cost renin -angiotensin system antagonists (ACE inhibitors, ARBs and
direct renin inhibitors) to people with CKD and:
 Diabetes and ACR 3 mg/mmols or more (ACR category A2 or A3);
 Hypertension and an ACR of 30mg/mmol or more (ACR category A3);
 An ACR of 70mg/mmol or more (irrespective of hypertension or
cardiovascular disease).
Commence during the 1st Quarter of 2017/18.
No measurement or threshold specified. To be monitored via Read coding.
NSAID use
Review NSAID use in patients with decreased renal function CKD 3.
Commence during 2016/17, continue through 2017/18.
The practice pharmacist will input the data onto the SMASH Dashboard.
To be monitored via Read coding.
Measurement
No. of pts with CKD3 and above on an NSAID with a review (Numerator)
Total no. of pts with CKD3 and above on an NSAID (Denominator)
Thresholds
≥85% = Achieved;
<85% - ≥ 60% = Acceptable;
<60% - ≥ 50% = Improvement Plan;
<50% = Trigger Alert.
Support
Contacts
References

The CCG will provide guidelines for acting on the e-alerts received from
secondary care in relation to AKI.

SRFT renal consultants will be offering academic detailing to all practices
i.e. learning around AKI based on peer review of AKI cases.
Clinical Lead: Dr Sheila McCorkindale; [email protected]
CCG
Contact:
Verity
Gibbons,
Service
Improvement
[email protected]
Manager;

NICE guidance CG182 Sections 1.6.1, 1.6.2 and 1.2.3 – 1.2.6.

NHS Salford CCG Five Year Strategic Commissioning Plan 2014/15 to
2018/19.
http://www.nice.org.uk/guidance/cg169/evidence/cg169-acute-kidney-injuryfull-guideline3
44

http://www.rcpe.ac.uk/sites/default/files/files/Final_statement_0.pdf

Challiner et al (2014).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046061/
Salford Standard – Quality Standards for Primary Care
45

Harty (2014). http://www.ums.ac.uk/umj083/083(3)149.pdf

Perazella MA, Coca SG. Three feasible strategies to minimize kidney injury
in 'incipient AKI'. Nat Rev Nephrol 2013; 9(8):484-490.
Salford Standard – Quality Standards for Primary Care
Standard 1.6 Chronic Liver Disease

Aims


Rationale
To identify patients early in the pathway with the potential for liver disease
using improved technology.
Improve utilisation of appropriate clinics; using Fibroscanner to detect
early liver disease e.g. Identify patients with LFT results that indicate an
abnormal liver function and ensure referral to the Abnormal LFT Clinic
NOT general Gastro-Clinic.
Increase awareness and education amongst healthcare professionals i.e.
Ensure Healthcare Professions have the right information to enable them
to access education, training and support from secondary care clinicians;
this may be in the form of outreach sessions, clinician to clinician
meetings, practice visits, open visit to secondary care clinics or webinar.
In October 2010, the Government announced that a National Liver Disease
Strategy (NDLS) would be developed. It is anticipated that the National
Commissioning Board will launch the ‘National Liver Plan’ (overdue at February
2013).
The Chief Medical Officer called for comprehensive action to address the rising
rates of liver disease. This report recommended that local health and wellbeing
strategies should aim to prioritize liver disease and aim to focus on prevention,
identification and treatment.
Salford has some of the worst outcomes with regards to liver disease:
 Mortality rates are above the regional and national average;
 Salford years of life lost is 44.5 compared to England best at 16.3;
 Emergency admission and readmission rates are above the regional
and national average;
 Average length of stay and excess bed days are above the national and
regional average.
Delivery
Practices will be expected to:




Key
Performance
Indicators
Refer patients to the Abnormal LFT Clinic based on test results;
Ensure clinicians are aware of the new pathway and clinics;
Facilitate and support healthcare professionals to utilise the training and
support available from secondary care colleagues;
Follow any referral guidelines and shared care pathways between primary
and secondary care for Alcoholic Liver Disease (ALD) and Non-Alcoholic
Fatty Liver Disease (NAFLD).
No specific Key Performance Indicators identified for Year 2016/17, indicators for
Year 2017/18 will be dependent upon the availability of suitable Read codes.
Education requirements yet to be decided education will be either mandated or
will be optional to be renewed at required interval.
Information relating to key performance indicators will be shared with practices as
46
Salford Standard – Quality Standards for Primary Care
soon as it is practical to do so, regarding thresholds and/or reporting
requirements.
CCG Support
Contacts
References
The CCG will:
 Ensure Abnormal LFT Clinics are accessible through Choose and Book;
 Ensure pathway, once agreed, is widely communicated to Healthcare
professionals and available on the website;
 Promote and support the delivery of education/training events in an
appropriate format;
 Request the development of Read Codes to enable practices to record
referral to and subsequent results of the fibroscan.
Clinical Lead: Dr Tom Regan; [email protected]
CCG
Contact:
Andrea
Lightfoot,
Service
[email protected]
Improvement
The years of life lost impact of liver disease is in fact higher than both COPD and
Stoke
(AQuA,
2012).
Y:\Commissioning\LTCs\Disease
Areas\Liver
Disease\Reference\AQuA Improving Outcomes Pack\Chronic_liver_disease__Salford_CCG.pdf
The link to the referral guidelines can be found here
47
Manager;
Salford Standard – Quality Standards for Primary Care
Standard 1.7 Cancer

Aims




Rationale
To improve the quality of cancer referrals to be compliant with NICE
guidelines (2015) for suspected cancer recognition and referral.
Ensure discussions about referral take place between clinicians and
patients, their families and/or carers and information is provided.
To ensure patients in Salford living with and beyond cancer receive the
care and support they need to lead as healthy and active and as long a life
as possible.
To provide an on-going programme of education for GPs and practice
based staff on supporting early detection.
Ensure GPs and Practice Nurses / practice Staff can identify and are
empowered to provide on-going supportive care for an increasing number
of people living with and beyond cancer.
One in two people will develop a form of cancer during their lifetime. National
cancer strategies published in 2011 and 2015 focus on improving early detection,
better survival and longer life expectancy focussing on people living with and
beyond cancer. The 2011 and 2015 strategies both highlight national inequalities
and variations in mortality and survival rates, which despite efforts to improve
cancer outcomes in the past 10 years, remain poor compared to the best
outcomes in Europe.
Cancer is now the main cause of death in Salford. Data shows that incidence of
all cancers in Salford is 15% higher than the national average (469.3 vs 398.1 per
100,000 population) meaning that there are 986 new cases of cancer per year.
Local cancer mortality for the four commonest cancers (Lung, colorectal, prostate
and breast) are also higher than the national average Nationally 23.7% of
cancers are diagnosed by the emergency route, in Salford the figure is 30.1%.
Therefore cancer is an issue for Salford due to high incidence and mortality rates
and also much too frequently diagnosed via an urgent hospital admission rather
than through a two-week wait referral. National Institute for Health and Care
Excellence (NICE) guidance for primary care for suspected cancer was updated
in 2015 in order to support national strategies of earlier diagnosis, reducing
variation and saving lives. Salford GPs will need to be informed and trained
about these new guidelines to support local improvements to early detection and
longer survivorship.
With this in mind Salford CCG will focus on:
48

Standardising 2 week wait query cancer and urgent referral forms /
procedures for GPs;

Providing a Cancer Care Review for patients diagnosed with breast or
prostate cancer every year for the first 5 years after diagnosis to be
performed by their GP practice. As capacity allows this program will be
rolled out to the other tumour groups. The Cancer Action Taskforce report
Salford Standard – Quality Standards for Primary Care
“Achieving world class outcomes; a strategy for England 2015-2020”
stipulates the implementation of the “Recovery Package” and cancer care
reviews in primary care are an integral element of this.
These two cancers have been chosen firstly because of their relatively
good prognosis (Breast 78% 10 year survival rate, Prostate 84%),
meaning that they can truly be considered as long term conditions and
also because primary care is involved in the provision of common
hormonal manipulations (Tamoxifen, Aromatase inhibitors and
Gonadorelin analogues) used in these diseases.

Delivery
Encouraging the monitoring and management of the increased
cardiovascular risk and adverse effects on bone health caused by
hormonal manipulation in breast and prostate cancer. (see references
below).
Practices will be expected to:
Two-week wait referrals
 Utilise the appropriate two week proforma.
 Offer Patient Information Leaflet to all patients and or family member or
carer if appropriate.
Breast and Prostate Cancer Reviews
 Put in place a process to identify all patients diagnosed with either breast
or prostate cancer in the last 5 years.
 Add an appropriate recall system for annual review.
 Ensure annual review incorporates all elements as specified in the
electronic management plan.
Key
Performance
Indicators
Cancer Reviews
 LTC15_P:
Establish a recall process for annual reviews of all patients identified with
a diagnosis of either prostate or breast cancer in the last 5 years.

CCG Support
49
LTC13:
Undertake an annual cancer care review for all patients identified above.
Threshold: > 90% = achieved;
< 90% - ≥ 50% = acceptable;
< 50% = unacceptable.
The CCG will:
 Ensure new and/or revised two week wait referral proformas are loaded
onto GP clinical systems in a timely manner;
 Ensure new and/or revised patient information leaflet is loaded onto GP
clinical systems in a timely manner;
 Work in partnership with Public Health colleagues to ensure Cancer
Profiles are available to practices;
Salford Standard – Quality Standards for Primary Care

Ensure Cancer Care Review Template specifies the requirements for an
annual review;
Facilitate/Commission a Cancer Education Programme for Health Care
Professionals.

Contacts
References
50
Clinical Lead: Dr Steven Elliot; [email protected]
CCG Contact: Service Improvement Manager;
[email protected]
Annette
Donegani;

Department of Health (DH),(2011) Improving Outcomes: a strategy for
cancer London.

Achieving World-Class Cancer Outcomes A Strategy for England 20152020 (DH 2015).

National Cancer Intelligence Network (NCIN August 2013).

National institute for Health and Care Excellence (NICE), NICE Guidelines
(2015): Suspected Cancer Recognition and referral (NG21)
http://www.nice.org.uk/guidance/ng12/chapter/introduction

NICE Osteoporosis: assessing the risk of fragility fracture. CG146 August
2012.

Gandaglia G, Sun M, Popa I, Schiffmann J, Abdollah F, Trinh QD, et al.
The impact of androgen-deprivation therapy (ADT) on the risk of
cardiovascular (CV) events in patients with non-metastatic prostate
cancer: a population-based study. BJU Int 2014;114:E82-9.

Alibhai SM, Duong-Hua M, Sutradhar R, Fleshner NE, Warde P, Cheung
AM, et al. Impact of androgen deprivation therapy on cardiovascular
disease and diabetes. J Clin Oncol 2009;27:3452-

Zhao J, Zhu S, Sun L, Meng F, Zhao L, Zhao Y, et al. Androgen
deprivation therapy for prostate cancer is associated with cardiovascular
morbidity and mortality: a meta-analysis of population-based observational
studies. PLoS One 2014;9:e107516.

Meta-analysis of breast cancer outcome and toxicity in adjuvant trials
of aromatase inhibitors in postmenopausal women. Aydiner. A.
Breast. 2013 Apr;22(2):121-9.
Salford Standard – Quality Standards for Primary Care
Standard 1.8 End of Life

Aims



Rationale
To ensure that patients who are nearing their end of life (EOL) are supported
in their own homes or care home.
To ensure that patients die in their preferred place of choice.
To standardise the approach of resuscitation in the community.
To improve the patient pathway for the last days of a patient’s life
The first national End of Life Care Strategy (2008) generated significant
momentum to reverse the upward trend of people dying in hospital. However,
there is still much to build on. In Salford, hospital deaths decreased by 13%
between 2006 and 2014 whilst deaths at home and in care homes increased
respectively by 6% and 7%. Deaths in usual place of residence have been
benchmarked across Greater Manchester and are seen as a proxy measure to
increasing choice in place of death as most people would choose to die at home.
Since 2010/11 Salford has seen a steady increase in the percentage of deaths in
usual place of residence.
The chance of survival following cardiopulmonary resuscitation (CPR) in adults is
between 5-20% depending on the circumstances. Although CPR can be attempted
on anyone, there comes a time for some people when it is not in their best
interests to do this. It may then be appropriate to consider making a Do Not
Attempt CPR (DNACPR) decision to enable the person to die with dignity. It is
important that any DNACPR decisions are communicated to every healthcare
professional who will be involved in the patient's care to ensure that no
inappropriate attempts at CPR are made.
NICE states that all people whose deaths are not sudden or unexpected should
have their end of life care needs recognised and provided for in the last year of life.
In Salford this would be approximately 1,600 individuals each year. An indication
of improving equity of care across Salford can be seen by the ratio of patients
receiving input from the Specialist Palliative Care team at Salford Royal. Another
example of improving practice is the collection of data from GP systems that
demonstrates GPs are taking a more pro-active approach to caring for this group
of patients and their families by updating the EPaCCS system prior to death.
There is still some variation across Salford in the percentage of patients being
added to EPaCCS although some very good practice is emerging.
Delivery
51
Arrange an extended Gold Standard Framework Meetings for Advance Care
Planning
 Use a structured approach to Gold Standard Framework meetings to
identify a process that ensures all new end of life care patient information is
uploaded onto EPaCCS.
 Arrange one extended Gold Standard Framework meetings facilitated by
specialist palliative care staff to improve advance care planning.
 Keep a record of the discussions i.e. minutes and a log of attendees.
 As a minimum 1 GP and 1 practice nurse per practice should attend the
training. Practices with more than 4 GPs would require 50% of GPs to
Salford Standard – Quality Standards for Primary Care

attend.
Utilise the knowledge and skills learnt in the extended meeting in your
discussions with patients.
Arrange a Gold Standard Framework Meetings for either an After Death
Analysis OR a Significant Event Analysis
 Arrange a one hour long ‘After Death Analysis’ meeting to reflect on ONE
death of a patient and what lessons were learnt or what could have been
done differently.
 OR arrange a one hour long ‘Significant Event Analysis’ relating to a patient
in the last days of life, to understand what worked well or what could have
been done differently.
 The practice to provide the times and dates of the After Death Analysis OR
Significant Event Analysis meeting where these discussions took place and
provide a copy of a completed and implemented action plan on request.
 As a minimum 1 GP and 1 practice nurse per practice should attend the
training. Practices with more than 4 GPs would require 50% of GPs to
attend.
DNACPR & ICD Deactivation Awareness Training
 GPs to attend taught sessions on communication issues including
DNACPR and ICD deactivation awareness.
 Patients added to EPaCCS have their resuscitation status.
discussed and the DNACPR and ICD Deactivation policies are adhered to
 Every GP in the practice will need to attend this session.
 Practice to keep a log of the dates and a list of attendees who participated
in the DNACPR training sessions.
Optional education training events can be attended as required.
Key
Performance
Indicators
Improve Advanced Care Planning for EOL patients
Arrange a quarterly extended Gold Standard Framework Meeting for
Advance Care Planning
Measure LTC12_P: Ensure all new EOL care patient information is uploaded
Submission of minutes of meetings and action plans if requested.
Monitor: via EPaCCS annually and retrospective audit of minutes of meetings.
Threshold: 100%.
Arrange a Gold Standard Framework Meeting for either an After Death
Analysis OR a Significant Event Analysis
Measure LTC13_P: Submission of minutes of meetings and action plans if
requested.
Monitor: Annual audit.
Threshold: 100%.
52
Salford Standard – Quality Standards for Primary Care
All GPs to undertake DNACPR & ICD awareness Training
MeasureLTC14_P: Submission of training records as requested.
Monitor: Annual audit.
Threshold: 100%.
Optional e-learning EOLC training sessions are available, please refer to section 4.
CCG Support
Contacts
References
53
The CCG will:

Develop and facilitate education sessions for end of life care and
communication training to support DNACPR and ICD awareness;

Agree threshold following practice baseline audit of the EPaCCS system
and communicate to practices.
Clinical Lead: Dr Tin Aye; [email protected]
CCG
Contact:
Andrea
Lightfoot,
[email protected]
Service
Improvement
Manager;

Department of Health (DH), (2008) End of Life Care Strategy London
Available at:
www.gov.uk/government/uploads/system/uploads/attachment_data/file/1364
31/End_of_life_strategy.pdf

National Institute for Health & Care Excellence (NICE), (2011) Quality
Standard for End of Life Care for Adults Available at:
www.nice.org.uk/guidance/qs13
Salford Standard – Quality Standards for Primary Care
Domain 2
54
Salford Standard – Quality Standards for Primary Care
Standard 2.1 Medicines Safety
Rationale
The NICE medicines optimisation Guidance (2015) highlights that getting the most
from medicines for both patients and the NHS is becoming increasingly important
as more people are taking more medications. Data suggests (HSCIC) that
between 2003 and 2013 the average number of prescription items per year for any
one person in England increased from 13 (2003) to 19 (2013). As the population
ages and life expectancy increases, more people are living with several long-term
conditions that are being managed with an increasing number of medicines.
Medication safety is an important consideration. A Department of Health report,
‘Exploring the cost of unsafe care in the NHS’, found that 5% to 8% of unplanned
hospital admissions are due to medication issues. Effective systems and
processes can minimise the risk of preventable medicines-related problems such
as side effects, adverse effects or interactions with other medicines or
comorbidities.
A number of medication safety priorities have been identified including:
•
•
•
Delivery
Management of AKI – see Standard 1.5;
Sick day guidance for AKI – see Standard 1.5;
PINCER indicators.
To deliver this standard practices will be expected to:
Apply the principles of the PINCER intervention to reduce the number of
medicines-related patient safety incidents focusing on the following specific
indicators:
 Patients prescribed aspirin or clopidogrel who have a history of peptic
ulceration or gastro-intestinal bleed and are not prescribed a gastroprotective medicine;
 Patients prescribed aspirin and warfarin together without a gastroprotective medicine;
 Patients prescribed a non-steroidal anti-inflammatory drug (NSAID) and
warfarin or NOAC rivaroxaban, apixaban, Dabigratan or Edoxaban
together without a gastro-protective medicine;
 Patients aged 65 or over who are prescribed an oral NSAID without coprescription of an ulcer-healing drug (NB. Aim is to focus particularly on
patients with additional risk factors for GI bleed);
 Patients diagnosed with chronic kidney disease (CKD) stage 3B, 4 or 5
or with a latest eGFR of <45mL/min who are prescribed a NSAID.
 Patients with CKD stage 3B, 4 or 5 or with a latest eGFR of <45 mL/min
who have been prescribed an ACE inhibitor and a NSAID;
 Patients with CKD stage 3B, 4 or 5 or with a latest eGFR of <45 mL/min
who have been prescribed an ACE inhibitor, loop diuretic and a NSAID
(the ‘triple whammy’).
55
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
CCG Support
Contacts
References
2. PINCER II indicators
Indicator
coding
threshold
monitoring
MS01: Patients prescribed aspirin or
clopidogrel, or prasugrel or ticagrelor
who have a history of peptic ulceration
or gastro-intestinal bleed and are not
prescribed
a
gastro-protective
medicine
MS02: Prescription of warfarin and
aspirin in combination (without coprescription of an ulcer-healing drug)
MS03: Prescription of warfarin or
NOAC
(rivaroxaban,
apixaban,
dabigatran) in combination with an
oral NSAID
MS04: Patient aged ≥65 years
prescribed an oral NSAID without coprescription of an ulcer-healing drug
(NB. aim is to focus particularly on
patients with additional risk factors for
GI bleed)
MS05: Patients diagnosed with
chronic kidney disease (CKD) stage
3B, 4 or 5 or with a latest eGFR of
<45mL/min who are prescribed a
NSAID
Patients with CKD stage 3B, 4 or 5 or
with a latest eGFR of <45 mL/min who
have been prescribed an ACE
inhibitor and a NSAID
MS06: Patients with CKD stage 3B, 4
or 5 or with a latest eGFR of <45
mL/min who have been prescribed an
ACE inhibitor, loop diuretic and a
NSAID (the ‘triple whammy’)
Medication
optimisation
8BMa.00
5%
6
monthly
review
Medication
optimisation
8BMa.00
Medication
optimisation
8BMa.00
10%
6
monthly
review
10%
6
monthly
review
Medication
optimisation
8BMa.00
20%
6
monthly
review
Medication
optimisation
8BMa.00
20%
6
monthly
review
Medication
optimisation
8BMa.00
10%
6
monthly
review
Medication
optimisation
8BMa.00
10%
6 monthly
review

It is the responsibility of the GP to deliver this standard. Appropriate support
will be provided by the Medicines Optimisation Team.
Clinical Lead: Dr Peter Budden; [email protected]
CCG Contact: Claire Vaughan, Head of Medicines
[email protected]
Medication Safety
 NICE guidelines [NG5] (March 2015) Medicines optimisation: the safe and
effective use of medicines to enable the best possible outcomes
https://www.nice.org.uk/guidance/ng5

56
Optimisation;
http://cks.nice.org.uk/nsaids-prescribing-issues#!topicsummary NSAIDs prescribing issues (Last revised in January 2013.
Salford Standard – Quality Standards for Primary Care

Acute
Kidney
Injury
Programme
–
Think
http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/
PINCER
57
Kidney

https://www.nice.org.uk/guidance/ng5/

Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information
technology intervention for medication errors (PINCER): a multicentre,
cluster randomised, controlled trial and cost-effectiveness analysis. Lancet.
2012;379 (9823):136-142. doi:10.1016/S0140-6736(11)61817- 5.

Elliott RA, Putman KD, Franklin M, Annemans L, Verhaeghe N, Eden M,
Hayre J, Rodgers S, Sheikh A, Avery AJ. Cost effectiveness of a
pharmacist-led information technology intervention for reducing rates of
clinically important errors in Medicines Optimisation in general practices
(PINCER)
PharmacoEconomics
2014;
32(6):
573-590.
DOI:
10.1007/s40273-014-0148-8.
Salford Standard – Quality Standards for Primary Care
Standard 2.2 Drug Monitoring
Rationale
Shared Care Guidance is available for drugs designated Amber, where initiation
of therapy occurs in the specialist setting but, at an agreed time, prescribing and
drug monitoring is taken over by primary care.
Hospital specialists should request a sharing of care and provide guidance on the
arrangements for sharing of care between GP and hospital specialist. Greater
Manchester agreements are available on the GMMMG website.
Patients on these drugs need regular but infrequent consultant follow up but
frequent monitoring of side effects which may be more appropriately carried out in
primary care.
Delivery
To deliver this standard practices will be expected to:
Monitor Listed drugs in accordance to monitoring specified in the Salford standard,
produced by Medicines Optimisation Team:
DMARDS (rheumatology, dermatology, gastroenterology)
Azathioprine
Ciclosporin
Hydroxychloroquine
Leflunomide
Methotrexate
Mycophenolate
Sodium Aurothiomalate (Mycocrisin)
Sulfasalazine
Others
Mercaptopurine
Riluzole
Apomorphine (Parkinsons)
Hydroxycarbamide
Co-trimoxazole
Terbinafine
Azithromycin
Monitoring schedule given below:
58
Salford Standard – Quality Standards for Primary Care
Specialty and
condition being treated
Drug
IBD: Gastro SRFT
Azathioprine
Monitoring requirements




IBD: Gastro SRFT
Methotrexate



FBC: Monthly from three months to six
months, 3 monthly thereafter
U & E: Every 6 months (more frequently
if there is any reason to suspect
deteriorating renal function).
LFTs: Monthly from three months to six
months, 3 monthly thereafter
Parkinsons disease: SRFT
Apomorphine

6 monthly FBCs
MND: SRFT
Riluzole

First three month monitoring by
secondary care and then continue to
monitor the
LFTs (serum transmaines) at 3 monthly
intervals for the first year and
periodically thereafter, and report any
abnormalities to
the patient's Consultant.
Rheumatology: SRFT
Azathioprine

Monitoring varies according to
condition.
FBC weekly for 6 weeks, then fortnightly
until stable then monthly.
LFTs: Weekly for 6 weeks, then every
2 weeks, until dose stable then monthly
U&E’s – 6 monthly.
TPMT pre-treatment (done by SRFT)




Rheumatology: SRFT
Ciclosporin





59
Monitoring varies according to
condition.
FBC, U&E, LFTs
Primary care will be responsible for
blood monitoring from eight weeks
onwards. Monitoring should be
completed:Monthly from weeks 12 to 26, three
monthly thereafter.
FBC: Monthly until dose and results
Stable for 3 months. Thereafter 3
monthly
U and Es: 2 weekly until dose or bloods
stable for 3 months, then monthly
LFTs: Monthly until dose and results
stable for 3 months. Thereafter 3
monthly
Serum lipids: 6 monthly
Blood pressure monitoring each
attendance. BP > 140/90 on 2
consecutive readings 2/52 apart – treat
hypertension before stopping ciclosporin
(note possible drug interactions). If BP
cannot be controlled, stop ciclosporin
and obtain BP control before restarting
Salford Standard – Quality Standards for Primary Care
ciclosporin.
Rheumatology: SRFT
Leflunomide





Rheumatology: SRFT
Methotrexate



FBC: Every 2 weeks until dose and
monitoring stable for 6 weeks.
Thereafter monthly for 1 year. Then
based on clinical judgement.
U and Es: Every 2 weeks until dose and
monitoring stable for 6 weeks.
Thereafter monthly for 1 year. Then
based on clinical judgement.
LFTs: Every 2 weeks until dose and
monitoring stable for 6 weeks.
Thereafter monthly for 1 year. Then
based on clinical judgement.
Rheumatology: SRFT
Mycophenolat
e mofetil

FBC weekly until dose stable for 4
weeks, then every 2 weeks for 2 months
& thereafter, monthly
Rheumatology: SRFT
Sodium
aurothiomalate
(myocrisin)

FBC (including WBC and Platelets) and
urinalysis at the time of each injection.
The results of the FBC need not be
available before the injection is given but
must be available before the next
injection i.e. it is permissible to work one
FBC in arrears. Patient should be asked
about the presence of rash or oral
ulceration before each injection.
Rheumatology: SRFT
Sulfasalazine

FBC: Monthly for 3 months. If bloods
and dose stable, then 3 monthly
LFTs: Monthly for 3 months. If bloods
and dose stable, then 3 monthly.
Patient should be asked about the
presence of rash or oral ulceration


Schizophrenia
Amisulpride



60
FBC: Monthly for 6 months, if stable, 2
monthly thereafter.
U and Es: Monthly for 6 months, if
stable,
2 monthly thereafter
LFTs: Monthly for 6 months, if stable, 2
monthly thereafter
BP: At each attendance. If BP >
140/90,
treat in line with NICE guidance. If BP
remains elevated stop Leflunomide,
consider washout
Weight: Weigh at each visit, if >10% loss
reduce dose or stop. consider washout
At 3 months: BP, BMI, waist
measurement
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
At 6 months: BP, BMI, waist
Salford Standard – Quality Standards for Primary Care



Schizophrenia, Bipolar
illness and prevention of
new manic episodes in
respondent patients
Aripiprazole






Schizophrenia,
combination therapy for
mania, preventing
recurrence in bipolar
disorder
Olanzapine





Mania (monotherapy)

Schizophrenia, Mania,
depressive symptoms in
bipolar disorder
Preventing relapse in
bipolar disorder
Add on treatment of major
depressive episodes in
patients with major
depressive disorder (MDD)
who have had sub-optimal
response to antidepressant
monotherapy
61
Quetiapine






measurement
Fasting lipid profile
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
Perform FBC if unexplained infection or
fever
At 3 months: BP, BMI, waist
measurement
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
At 6 months: BP, BMI, waist
measurement
Fasting lipid profile
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
Perform FBC if unexplained infection or
fever
At 3 months: BP, BMI, waist
measurement
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
At 6 months: BP, BMI, waist
measurement
Fasting lipid profile
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
Perform FBC if unexplained infection or
fever
At 3 months: BP, BMI, waist
measurement
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
At 6 months: BP, BMI, waist
measurement
Fasting lipid profile
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
Perform FBC if unexplained infection or
fever
Salford Standard – Quality Standards for Primary Care
Schizophrenia, manic
episodes associated with
bipolar disorder
Risperidone


Short term treatment of
persistent aggression
Alzheimers dementia
unresponsive to other
approaches





At 3 months: BP, BMI, waist
measurement
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
At 6 months: BP, BMI, waist
measurement
Fasting lipid profile
Fasting blood glucose (random blood
glucose acceptable where fasting not
possible)
Perform FBC if unexplained infection or
fever
Renal SRFT and CMFT:
Cotrimoxazole
Respiratory SRFT and
UHSM
azithromycin
LFTs Should be carried out at baseline before
starting treatment

Every 6 months if within normal
parameters at baseline

Every 3 months in patients with
significant co-morbidities and/or over
65 years of age

Every month in Patients with severe
CKD (GFR <10 ml/min) along with urea
and electrolytes.

Liver function test must be carried out
immediately if the patient demonstrates
signs and symptoms of liver dysfunction
such as rapid developing asthenia
associated with jaundice, dark urine,
bleeding tendency or hepatic
encephalopathy.
Haematology:
Hydroxycarbamide
Every 8-12 weeks

Serum creatinine

Neutrophils

Haemoglobin

Reticulocytes

Platelets

U and Es.

LFTs
Full blood count (FBC) and urea and
electrolyte (U+E) is performed within 710 days and a monthly FBC from then
onward.
Every three months

Haemoglobin F% (Sickle cell disease
only)
Primary Care
62
terbinafine

Ensure LFTs are monitored before
treatment and then every 4–6 weeks
during treatment.
Salford Standard – Quality Standards for Primary Care
Dermatology
Azathioprine



Dermatology
Ciclosporin





Dermatology
Hydroxychloroquine


Dermatology
Key
Performance
Indicators
CCG Support
Contacts
References

U&Es and BP every 2 weeks until dose
stable for 3 months then monthly
thereafter (*).
FBC and LFT monthly until dose stable
and then 3 monthly thereafter.
Fasting lipids every 6 months.
BP > 140/90 on 2 consecutive readings
2 weeks apart – treat hypertension
before stopping ciclosporin (note
possible drug interactions). If BP cannot
be controlled, stop ciclosporin and
obtain BP control before restarting
ciclosporin.
(*Treatment generally limited to a
maximum of 6 months duration where
possible.)
Annual review either by an optometrist
or enquiring about visual symptoms,
re-checking visual acuity and assessing
for blurred vision using the reading chart
provided by The Royal College of
Ophthalmologists. Discuss with
ophthalmologist if on treatment for >5
years.
LFT every 6 months
FBC weekly for 4 weeks, every 2 weeks
for 2 months and then monthly
thereafter.
MO01_P: Drugs to be monitored in line with shared care protocol or local
monitoring guidance for each drug
Monitoring: Quarterly audit
Threshold: 100% achieved
<100% = not achieved

It is the responsibility of the GP to deliver this standard. Appropriate support
will be provided by the Medicines Optimisation Team
Clinical Lead: Dr Peter Budden; [email protected]
CCG Contact: Claire Vaughan, Head of Medicines
[email protected]


63
Mycophenolat
e mofetil
FBC weekly for 4 weeks, every 2 weeks
for 1 month and then monthly thereafter.
LFTs monthly until dose stable, then 3
monthly thereafter.
U&E’s should also be monitored 3
monthly
Optimisation;
Greater Manchester Medicines Optimisation Group (GMMMG) RAG list,
available here: http://gmmmg.nhs.uk/html/rag_adult.php
Relevant
Shared
Care
Protocols
as
available
here:
http://gmmmg.nhs.uk/html/local_scg.php
Salford Standard – Quality Standards for Primary Care
Domain 3
64
Salford Standard – Quality Standards for Primary Care
Standard 3.1
Childhood Asthma - Improving outcomes in childhood asthma
(informed by the Strategic Clinical Senate for Childhood Asthma)

Aims
Rationale
To offer a more proactive approach to the assessment and
management of asthma in children whilst empowering children and
their families to self-care. It intends to promote the management of
asthma in primary care and avoid families choosing to go straight to
A&E rather than being seen by the GP.
In the UK, 5.4 million people are currently receiving treatment for asthma, 1.1
million of whom are children. Asthma is the most common long-term medical
condition, and 1 in 11 children has it. There are around 1000 deaths a year
from asthma, about 90% of which are associated with preventable factors.
Asthma UK highlight that asthma is the most common long-term condition
among children, and the UK has one of the highest prevalence of asthma
symptoms among children worldwide. An estimated 1.1 million children in the
UK have asthma (around one in 11 children, or two children in every
classroom). More young boys than young girls have asthma, however, this
pattern changes with age and asthma is more common in girls after puberty.
Asthma UK estimates that one child is admitted to hospital in the UK every 17
minutes because of their asthma. In addition, the estimated annual cost of
treating a child with asthma is higher than the cost per adult with asthma.
Asthma is responsible for large numbers of accident and emergency
department attendances and hospital admissions. Most admissions are
emergencies and 70% may have been preventable with appropriate early
interventions, (NICE, 2013).
Asthma is a long-term condition that affects the airways in the lungs in children,
young people and adults. Classic symptoms include breathlessness, tightness
in the chest, coughing and wheezing. The goal of management is for people to
be free from symptoms and able to lead a normal, active life. This is achieved
partly through treatment, tailored to the person, and partly by people getting to
know what provokes their symptoms and avoiding these triggers as much as
possible.
Asthma admissions (0-19 years) in Greater Manchester, Lancashire and
Cumbria are above the national average (except Trafford, Wigan and
Cumbria). An audit undertaken by the Children and Young People Strategic
Clinical Network in 2014 showed that despite such high levels of hospital
admissions due to asthma the zero day length of stay is above 50% in all areas
(82% in one area).
65
Salford Standard – Quality Standards for Primary Care
Delivery
Key
Performance
Indicators
Practices will be expected to:
 Have a named clinical lead responsible for asthma;
 Establish a specific paediatric asthma register (0-19years) to aid audit of
their asthma service;
 Children with asthma receive a structured review at least annually
(recommended every 3 months dependent on severity);
 All children diagnosed with asthma are provided with an age appropriate
personalised asthma action plan, (PAPP) including self-care advice and
management. Provision and review of the PAPP should be recorded on
the clinical system;
 Provide adequate clinic time for assessment and management of asthma
in children (NICE recommends 20-30 minutes);
 Children diagnosed with asthma are given specific training and
assessment of inhaler technique by appropriately qualified healthcare
professional;
 Appropriate clinician to follow up those children who have received
treatment in hospital or by the Out of Hours service for an acute
exacerbation within 1 week, ideally within 2 working days;
 Achieve at least 80% uptake of flu immunisations of children aged 2 – 4
years;
 Implement a programme of audit and on-going improvements including
asthma diagnosis, safe prescribing monitoring, emergency admissions
and regular asthma reviews.

C04:
Increase uptake of flu immunisations of children aged 2 – 4 years

Annual audit/Read codes to identify:
 CYP01_P: named clinical lead;
 % who received treatment in hospital (as an emergency) or by
out of hours for an acute exacerbation (threshold 95%);
 C01: number of 0-19 year olds on paediatric asthma register;
 C05: % that received an annual structured review (threshold
95%);
 C06: % that received medication review (threshold 95%);
 C07: % that received an age appropriate personalised asthma
action plan (threshold 95%);
 C08: % that received specific training and assessment of inhaler
technique (threshold 95%).
Monitoring: via the Seasonal Influenza Vaccine Uptake.
Threshold: 80% for uptake of flu immunisation of children aged 2-4yrs;
100% of practices to undertake an annual audit.
In subsequent years audit will include:
an audit of 20% of age appropriate personalised asthma action plans for quality
Section to identify on-going improvements made as a result of the audit.
66
Salford Standard – Quality Standards for Primary Care
Contacts
Clinical Contact: Dr Shahid Munshi, [email protected]
CCG Contact: Eejay Whitehead ; Senior Service Improvement Manager;
[email protected]
References
67

Asthma UK, News Centre Facts: www.asthma.org.uk

Asthma UK figures: www.asthma.org.uk

Asthma UK (2011). Improving quality, innovation, productivity and
prevention of asthma services in local health settings. How Asthma UK
can help to transform services and save expenditure. Available at:
www.northwest.nhs.uk

NHS Choices: www.nhs.uk/Conditions/Asthma-inchildren/Pages/Introduction.aspx
Salford Standard – Quality Standards for Primary Care
Domain 4
68
Salford Standard – Quality Standards for Primary Care
Standard 4.1 Safeguarding

Aims






Rationale
To continue to improve the quality of safeguarding arrangements for
Children, Young People and Vulnerable Adults across Primary Medical
Care.
To promote and further develop GP safeguarding lead role within General
Practice.
To maintain mandatory safeguarding training with Primary Care and improve
the uptake of safeguarding training for safeguarding children, adults and
identified key areas of safeguarding practice.
To increase the performance and quality of GP’s engagement with the
provision of Initial Child Protection Case Conference reports and the Child
Protection process within Primary Care.
To increase the knowledge and skills of domestic violence and abuse in
General Practice.
To increase the engagement of GP’s with the Multi Agency Risk
Assessment (MARAC) process within Primary Care.
To Increase the knowledge and skills of MCA/DoLs within Primary Care
incorporating training for practice staff the monitoring of cases at a practice
level.
General Practitioners (GPs) are an integral part of the multiagency response to
safeguarding children, young people and adults at risk in Salford. The current
statutory guidance on Working Together to Safeguard Children (2015) supports
the role and responsibilities for GPs in relation to safeguarding children.
Additionally, The Care Act (2014) and corresponding statutory guidance replaces
the previous ‘No Secret’s’ guidance (2000) and provides a legal framework for
key individuals and organisations with responsibilities for safeguarding adults at
risk of abuse.
In terms of domestic violence and abuse (DVA) the NHS is often the first point of
contact for victims who have experienced violence. The health service especially
Primary Care plays an essential role in responding to helping prevent further DVA
by intervening early, providing treatment and information and referring patients to
specialist services. DVA is linked to a host of different health outcomes and is a
risk factor for a wide range of both immediate and long-term conditions.
General practice, as part of the wider NHS, has a duty to respond to survivors of
DVA and to safeguard vulnerable adults and their children. This response can
improve public health, improve health outcomes and support a patient-centred
service and addresses not only the contemporary health burden but also that of
future generations.
The NHS England Accountability and Assurance Framework (2015) states that,
CCGs have a duty to support improvements in the quality of primary medical
care. Safeguarding is core element of quality in primary care which will continue
to be endorsed by the CCG Safeguarding Team.
69
Salford Standard – Quality Standards for Primary Care
The NHS Salford CCG Safeguarding Team has worked closely with General
Practices enabling focused work to be undertaken in relation to improving the
quality of safeguarding arrangements. The Salford Standard will enable the
continued development of this work throughout Primary Care.
Delivery
Practices will be expected to:






Key
Performance
Indicators
Ensure that the GP Safeguarding Lead role is embedded into practice with
regular attendance at GP Safeguarding Lead Forum meetings and
dissemination of safeguarding information at practice level as standard;
Ensure that GP Safeguarding Leads to have completed training in Adult
Safeguarding, Childrens’ Safeguarding Level 2 & 3, CSE, Domestic
Abuse, Prevent and MCA/ DoLs (as minimum);
Demonstrate Domestic Abuse awareness in relation to high risk identified
cases is managed appropriately at practice level through staff training,
information sharing, contribution to Salford MARAC and standard Read
coding application;
Demonstrate that all initial child protection case conference reports are
provided as requested for each child (and parent if applicable) by their
registered GP in the appropriate timescale on the agreed proforma;
Ensure that all children subject to child protection plans are identified on
GP systems using standard Read coding application;
Ensure that Mental Capacity Act and Deprivation of Liberty safeguards are
identified to ensure appropriate safeguards are in place for those lacking
capacity and practitioners are compliant with this legislation.
Part 1- Developing the GP Safeguarding Lead Role
 SG01:
Attendance of the GP Safeguarding Lead at a minimum of 4/6
safeguarding lead meetings (from May 2016 to March 2017);

SG02:
Dissemination of information from the GP Safeguarding Lead meeting;

SG03:
GP Safeguarding Lead monthly meeting with Practice Health Visitor;

SG04:
GP Safeguarding Lead attendance at and completion of training.
Part 2 – Domestic Abuse
Part 2 of the safeguarding component is based on an achievement of all the
elements which includes:
 SG05:
Application of domestic abuse Read codes to 100% of patient records for
notified cases heard at MARAC;
70
Salford Standard – Quality Standards for Primary Care


SG06:
50% of clinical and 50% non-clinical practice staff to attend the domestic
abuse training;
SG07:
Completion of 100% MARAC requests.
Part 3 – MCA/DoLs
Part 3 of the safeguarding component is based on an achievement of all elements
which includes:
 SG08:
50% of clinical staff (GP’s and Practice Nurses) are expected to undertake
MCA/ DoLs training in addition to GP safeguarding leads;

SG09:
The MCA/DoLs Read code application to be used within individual
practices to flag patients records. This will be audited on a quarterly basis.
Part 4 – Case Conference Reports
Part 4 of the safeguarding component is based on an achievement of all elements
which includes:
 SG10:
Completion of 100% of requested case conference reports;

SG11:
100% of forms should be submitted within the requested timescale;

SG12:
100% should be submitted on the GP initial case conference report
proforma;

SG13:
Application of Read codes of children placed on a Child Protection Plan.
All submissions should be emailed to: [email protected]
CCG Support
71
The CCG will:
 Ensure new and/or revised case conference/MARAC proformas are loaded
onto GP clinical systems in a timely manner;
 Ensure that bi-monthly GP Safeguarding Leads meetings have been
arranged for 2016/17 & 2017/18;
 Ensure attendance lists are collected at each meeting and individual
practice attendance is monitored by the Safeguarding Team;
 The Safeguarding Team will ensure that the relevant training seminars are
on offer for completion as specified within the standard and will record and
monitor attendance at all training events. (see Section 4 for details);
 The Safeguarding Team will ensure that there is correspondence with
individual practices regarding Initial Child protection case conferences,
Salford Standard – Quality Standards for Primary Care
MARAC and MCA/DoLs;
CCG Safeguarding Lead to review and approve submitted plan of action;
CCG Safeguarding Lead and CCG designated nurses to review evidence
of actions completed within the agreed timeframe or evidence of effort;
Safeguarding Practice Profiles will be available to all practices to review
their safeguarding data and performance.



Contacts
References
72
Clinical Lead:
Andrea Patel, Designated Nurse Safeguarding Children and LAC;
[email protected]
Liz Walton, Designated Nurse Adult Safeguarding; [email protected]

Department of Education (March, 2015) Working Together to Safeguard
Children. A guide to inter-agency working to safeguard and promote the
welfare of children, London: Department for Education.

General Medical Council (2012) Protecting Children and Young People
within Medical Practice. General Medical Council.

Safeguarding Children and Young People; roles and competences for
health care staff, intercollegiate document 2014. Royal College of
Paediatrics and Child Health 2010.

National Health Service England (July 2015) Safeguarding Vulnerable
People in the Reformed NHS – Accountability and Assurance
Framework, London: NHS England.
Salford Standard – Quality Standards for Primary Care
Domain 5
73
Salford Standard – Quality Standards for Primary Care
Standard 5.1 Dementia and Mild Cognitive Impairment

Aims


Rationale
To reduce the gap between expected and actual dementia prevalence and
the variance between practices.
To improve the assessment of all patients presenting with memory
problems by standardly using a validated assessment tool.
To improve the physical and mental health of patients with dementia and
their carers by ensuring that they receive a comprehensive annual health
check.
In 2012, the Department of Health prioritised dementia through the Prime
Minister’s Dementia Challenge (Department of Health (DH), 2012). The challenge
was to diagnose earlier, drive improvement in care, create dementia friendly
communities and improve research.
It was recently estimated that there were 850,000 people living with dementia in
the UK today, including 700 000 people in England and approximately 2500 in
Salford. This number is forecast to rise rapidly as the population ages, reaching
over one million by 2025 (Alzheimer’s Society, 2014b). The current cost to the UK
economy for dementia is over £24 billion a year, through a combination of health
and care costs and carer contributions.
In recent years there has been a national drive to improve the prevalence rate for
dementia. NHS Salford CCG has a current prevalence rate of 82%, which is the
highest in Greater Manchester. Moreover, NHS Salford CCG is committed to year
on year improvement to reduce the gap between expected and actual prevalence
rates.
Presently, there is insufficient evidence of benefit to justify population screening
(Lafortune, 2013, cited in Alzheimer’s Society, 2104c). However, several
documents highlight the significant role which primary care can play to increase
diagnosis rates, by recognising early signs and symptoms and screening at risk
groups. (Royal College General Practitioners, 2012; DH, 2014a). A key
recommendation from UK dementia policy is the fact that everyone who works in
primary care has an important part to play, including receptionists. This will mean
all staff having access to dementia education, which is consistent with their roles
and responsibilities (DH, 2014b).
Current guidelines require GPs to annually review both the physical and mental
health needs of patients with dementia who are registered with their practice.
(NICE, 2007). Evidence suggests that although the number of people in the UK
recorded as having a review is high, the quality of these reviews is, on the whole
variable. This standard seeks to address this variation in quality of care.
Patients diagnosed with mild cognitive impairment are at increased risk of
developing dementia with an annual conversion rate of 10% (Petersen et al,
2001; DeCarli, 2003; Bruscoli & Lovestone, 2004; Petersen, 2004a; Panza et al,
2005). Currently, this cohort is actively followed up by the Salford Memory and
74
Salford Standard – Quality Standards for Primary Care
Assessment Service (MATS) for a 2 year period following diagnosis. Practices
are required to develop MCI registers prospectively from 1st April 2016 so that in
future years, the register may be used to organise structured follow up of such
cases once discharged from the MATS service.
Delivery
Practices will be expected to:
Primary Care dementia assessment
The assessment for dementia will be undertaken using one of: the General
Practitioner assessment of Cognition (GPCOG); Six Item Cognitive Impairment
Test (6CIT), Mini-Cog Assessment Instrument or the Salford Learning Disability
Dementia Screen Questions in primary care, by a healthcare professional with
knowledge of the patient’s current medical history and social circumstances.
If as a result of the completed assessment the patient is suspected as having
dementia the practice should follow the local Dementia Referral Pathway.
Annual health check
Patients diagnosed as having dementia will be offered an annual general health
review that will cover the following areas:
 an appropriate physical, mental health and social review for the patient;
 a record of the patients’ wishes for the future (document pending);
 communication and co-ordination arrangements with secondary health (if
applicable);
 identification of the patients’ carer(s); and
 obtain appropriate permission to authorise the practice to speak
directly to the nominated carer(s) and provide more detail of the
support services available to the patient and their family, if
applicable, the carer’s needs for information commensurate with
the stage of the illness and his or her patient’s health and social
care needs,
 as appropriate, the carers should be included in the care plan or
advanced care plan discussions,
 as appropriate, the impact of caring on the care-giver, offer the
carer a health check to address any physical and mental health
impacts, including signposting to any other relevant service to
support their health and wellbeing.
If the carer is registered with a different practice, the patient's practice will inform
the carer that they can seek advice from their own practice.
Practice leadership and workforce development
The practice will identify a dementia champion within the practice who might be
a receptionist, manager or a clinician – acting as an advocate for dementia
through the practice with a focus on supporting front facing staff, attending any
relevant training commissioned by NHS Salford CCG and cascading learning
as appropriate throughout the practice.
75
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
CCG Support

VG01_P:
Have a Dementia register in place (100%).

VG02_P:
Have a Mild Cognitive Impairment register in place (100%).

Assess the effectiveness of the practice to refer patients for
diagnosis
 D2: Dementia diagnosis rate (number of patients with a dementia
diagnosis as a percentage of the expected prevalence for the
practice) for the preceding 12 months.
Threshold
≥ 70%* = achieved;
< 70%* - ≥ 60% = acceptable;
< 60% - ≥ 50% = Improvement Plan;
< 50% = trigger.
*this will rise to 80% in 2017/18

Improve the care plans for dementia patients
 D4: Percentage patients with dementia whose care plan has been
reviewed with a face-to-face review within the preceding 12
months.
Threshold
≥90% = achieved;
<90% - ≥80% = acceptable;
< 80% - ≥ 60% = Improvement Plan;
<60% = trigger.

Improve provision of giving appropriate information to patients
 D5: Percentage of patients with a newly diagnosed dementia being
given information about local services.
Threshold
≥ 90% = achieved;
< 90% - ≥ 80% = acceptable;
< 80% - ≥ 60% = Improvement Plan;
< 60% = trigger.

Dementia Champion to attend training and cascade information
to practice staff
 VG03_P: Annual declaration of the practice’s dementia champion
attendance at training events and how this learning is then
cascaded throughout the practice.
Measures: Practice to supply declaration of attending training event if
requested by the CCG.
Monitoring: Annual audit.
The CCG will:
 Ensure sufficient commissioned capacity in the MATs clinic to receive
referrals.
76
Salford Standard – Quality Standards for Primary Care
 Provide information about local resources that patients and carers can be
sign-posted to commission dementia training for practice staff.
Contacts
References
77
Clinical Lead: Dr Jenny Walton; [email protected]
CCG
Contact:
Integrated
Commissioning
[email protected]
Manager,
Paul
Walsh;

Alzheimer’s Society, (2014a) Prime Minister's Challenge on dementia

Alzheimer’s Society (2014b), Dementia 2014: Opportunity for change

Alzheimer’s Society (2014c) Lafortune, L., Martin,S., Fox, C., Cullum, S.,
Dening, T., Rait, G., Katona, C., Brayne, C., (2013) There is no evidence
supporting population screening for dementia – Reporting on a systematic
review of costs and benefits

Connolly, A., Iliffe, S., Gaehl, E., Campbell, S., Drake, R., Morris, J.,
Martin, H., Purandare, N. (2012a,b) Quality of care provided to people with
dementia: utilisation and quality of the annual dementia review in general
practice

British Journal General Practice 62 (595)

Department of Health (2009) Report. Living well with dementia. A national
dementia strategy

Department of Health (2012) Prime Minister’s Challenge on Dementia.

Department of Health (2013) Improving care for people with dementia

Department of Health (2014a,b) Dementia Revealed What Primary Care
needs to know London

NICE clinical guideline 42

Robertson, J., Roberts, H., Emerson E. (2010) Health Checks for People
with Learning Disabilities: A Systematic Review of Evidence Learning
Disabilities Observatory

Royal College of General Practitioner (2012) Dementia: diagnosis and
early intervention in primary care London

Royal College of Psychiatrists (RCP), (2013) The financial case for
reinvesting in mental health

The Health Foundation (2011) Highlight: Dementia Care London
Salford Standard – Quality Standards for Primary Care
78

2015/16 General Medical Services (GMS) contract Quality and Outcomes
Framework (QOF)

Enhanced Service Specification Facilitating timely diagnosis and support
for people with dementia 2015/16
Salford Standard – Quality Standards for Primary Care
Standard 5.2 Severe Mental Illness

Aims


Rationale
Improve physical health in patients with psychosis, schizophrenia or bipolar
disorder – conditions collectively known as serious mental illness (SMI).
To ensure that all SMI patients in Salford receive their annual review in line
with NICE guidance/principles.
To improve engagement and empower SMI patients through education to
help them address their physical health issues.
Patients with SMI are at increased risk of the same physical health conditions as
the general population and consequently have significantly shorter life
expectancies than the general population. Recent data from NHS England
suggests these discrepancies in life expectancy are as much as 10 years for
people with bipolar disorder, eight years for those with schizoaffective disorder
and 14.6 years for people suffering from schizophrenia.
Since Salford is ranked as one of the most deprived local authority areas in
England with life expectancy significantly lower than the England average. Due to
poor physical health, the death rates from cancer, heart disease and stroke are
higher than the England average. Rates of schizophrenia and bipolar disorder are
set to rise nationally by around 10% between 2012 and 2022 and therefore this
needs to be an even greater priority for Salford.
The NICE guideline for psychosis and schizophrenia, and the NICE guideline for
bipolar disorder recommend primary care utilises registers to monitor the physical
health of patients with these disorders.
In addition to adverse lifestyle factors such as smoking, poor diet, obesity and
lack of exercise, antipsychotic drugs vary in their liability to cause metabolic side
effects such as weight gain, lipid abnormalities and disturbance of glucose
regulation. Specifically, they increase the risk of the metabolic syndrome, which is
a strong predictor of type 2 diabetes mellitus and ischaemic heart disease.
Other health issues that this disadvantaged group face include
hyperprolactinaemia secondary to antipsychotic use; health inequalities as they
are less likely to seek care either through screening programmes or when unwell
and respiratory disease and cancer secondary to lifestyle factors as listed above.
The focus in the Salford Standard is focusing on the physical health needs of this
cohort. QOF covers the provision of a psychiatry care plan in the GP records
(either a copy of their CPA or a plan written in conjunction with the patient +/- their
carer). Therefore it is appropriate for the standard to focus on those areas of care
that fall outside QOF requirements.
79
Salford Standard – Quality Standards for Primary Care
Delivery
Practices will be expected to:
Patients on the SMI Register:
Ensure patients on the SMI register attend for their annual physical health check,
which should include the following:
 Lifestyle review (smoking, diet, physical inactivity, drug and alcohol use);
 BMI and waist circumference;
 Pulse and BP;
 Glycaemic screening (HbA1c);
 Lipid profile (can be taken fasting or random);
 Renal, LFTs and FBC where clinically indicated e.g. U&Es in patients with
hypertension, diabetes etc. LFTs in those with a history of alcohol misuse
or a BMI > 30. FBC if patients have had a history of neutropenia or are on
other medication e.g. cytotoxics, antibiotics etc. which may add to the risk.
If a patient fails to attend the practice would be expected to assertively
follow up non-attendance
 Offer interventions for any abnormalities identified during the annual
physical health check in accordance with NICE guidelines for that
condition.
 Offer referral to combined healthy eating and physical activity programmes
and help to stop smoking where appropriate.
Patients on atypical antipsychotics:
 As per the shared care protocol, patients commenced on atypical
antipsychotics will, for the first 6 weeks of treatment, have their physical
health monitoring addressed by secondary care mental health services.
Thereafter this responsibility transfers to primary care and should be
delivered as below:
Timeframe
After first
treatment
Monitoring Required
3 months of atypical
Annually
Change in atypical;
After first
3 months of
atypical treatment
BMI/waist circumference
Pulse and BP
Glycaemic screening (HbA1c)
Lipid profile
As above for annual SMI check and Prolactin
level
NEW
BMI/waist circumference
Pulse and BP
Glycaemic screening (HbA1c)
Lipid profile
Then as per annual check
Children and adolescents (under the age of 18) on atypicals, if not assured
completed by specialist services
80
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
Time frame
Monitoring required
Every 6 months
BMI/waist circumference
Pulse and BP
Glycaemic screening (HbA1c)
Lipid profile
Prolactin

Practices should liaise with secondary care (ideally the patient’s care coordinator) if patients fail to attend for their physical health check, and if any
abnormalities are detected which mental health services should be made
aware of e.g. hyperprolactinaemia, diabetes, hypertension etc.

SMI1:
Ensure patients on the SMI register attend for their annual physical health
check of patients on the SMI register who have attended for their annual
physical health review.
Threshold: ≥75% = achieved;
<75% - ≥60% = acceptable;
< 60% - ≥ 50% = Improvement Plan;
<50% = trigger.

SMI2:
As per the shared care protocol, patients commenced on atypical
antipsychotics will, for the first 6 weeks of treatment, have their physical
health monitoring addressed by secondary care mental health services.
Thereafter, this responsibility transfers to primary care.
 Percentage of patients commenced on an atypical antipsychotic who
have been monitored as per the standard for their physical health
monitoring.
Threshold: ≥ 75% = achieved;
< 75%- ≥ 60% = acceptable;
< 60% - ≥ 50% = Improvement Plan;
< 50% = trigger.
CCG Support
The CCG will ensure that:
 Appropriate services are commissioned to ensure that patients can be
referred into combined healthy eating and physical activity programmes and
smoking cessation services.
 It actively promotes and emphasises the importance of physical health
checks with the mental health services it commissions, either via contracting
or CQINs (Commissioning for Quality and Innovation).
Contacts
Clinical Lead: Dr Jenny Walton; [email protected]
Head of Integrated Commissioning, Judd Skelton; [email protected]
Mental Health Commissioning Manager, Tony Marlow; [email protected]
References
81

NHS England (NHSE) (2014b) NHS England pledge to help patients with
Salford Standard – Quality Standards for Primary Care
serious mental illness.
82

NICE CG 178. Psychosis and schizophrenia in adults: treatment and
management. 2014

NICE CG 185. Bipolar disorder. The assessment and management of
bipolar disorder in adults, children and young people in primary and
secondary care. 2014

Atypical
antipsychotics
shared
care
protocol
http://nww.salfordccg.nhs.uk/MedicinesManagement/documents/SharedCa
reProtocolAtypicalAntipsychotics2.pdf
Salford Standard – Quality Standards for Primary Care
Standard 5.3 Military Veterans


Aims
Rationale
To improve the recording of Military Veteran and Reservist status
To ensure Military Veterans receive appropriate and timely NHS Hospital
Care when required
The Armed Forces Covenant (HM Government, 2011) sets out the relationship
between the nation, the government and the Armed Forces. This document
explains about removing disadvantage, so that the Armed Forces can get the
same outcomes as the civilian community.
The Armed Forces community, (including Reservists), should enjoy the same
access and standard of healthcare as received by any other UK citizen. Veterans
and Reservists should receive routine healthcare from their local NHS andthey
should receive priority treatment whenever it relates to a condition resulting from
their service in the Armed Forces; subject to clinical need.
To enable Primary Care to adhere to the requirements of The Armed Forces
Covenant, the status of ‘Military Veteran’ or ‘Reservist’ should be recorded in the
Practice system. A Veteran is classed as someone who has served at least one
full day in the armed forces (HM Government, 2011).
Delivery
Key
Performance
Indicators
Practices will be expected to:
 Record Armed Forces Veteran and Reservist status on the practice
system;
 Include a statement in referral letters when referring a veteran for NHS
Hospital Care for a health condition which may be related to the patient’s
military service so that they may receive priority access dependent on
clinical need;
 Comply with the requirements of the Armed Forces Covenant and ensure
high Quality responsive services for Veterans, Reservists and their families.


MV01:
Record the status of Military Veterans and Reservists using the Read Code
13Ji% or 13JY
MV02:
Report numbers of patients with history of military service to the CCG
CCG Support
The CCG will:
Provide an audit template.
Contacts
Clinical Lead: Dr Jenny Walton; [email protected]
CCG Contact: Neil Cudby, Senior Service
[email protected]
References
83

Improvement
Manager;
H M Government, (2011) The Armed Forces Covenant Available at:
www.gov.uk/government/uploads/system/uploads/attachment_data/file/49
Salford Standard – Quality Standards for Primary Care
469/the_armed_forces_covenant.pdf

84
Meeting the Healthcare Needs of Veterans – A Guide for General Practice
http://www.salfordccg.nhs.uk/download.cfm?doc=docm93jijm4n1387.pdf&
ver=1548
Salford Standard – Quality Standards for Primary Care
Standard 5.4 Learning Disabilities and Autistic Spectrum Conditions




Aims
Rationale
Improve identification & recording of patients with LD / ASC.
Improve uptake/quality/experience of annual LD health check.
Improve screening rates for people with LD/ASC.
Improve access for people with LD/ASC.
People with learning disabilities (LD) and/or ASC have a range of complex health
needs but national reports show significant delays in diagnosis / treatment. For
people with LD, these delays have been identified as one of the main contributory
factors to premature deaths (CIPOLD Report 2013). People with LD also have a
shorter life expectancy and a higher incidence of mental illness, sensory
impairments, communication difficulties & behavioural concerns.
The interaction of physical, behavioural and mental health issues can be difficult to
interpret, causing illness to be overlooked. This diagnostic overshadowing is
another known contributory factor to late diagnosis of treatable conditions.
The abusive treatment of adults with LD at Winterbourne View Hospital (exposed
by the Panorama Programme in 2011) has led to a national program
(Transforming Care) to stop individuals with LD / Challenging Behaviours being
placed ‘out of area’ and returning people from long stay hospital placements.
Salford has been identified as an area of good practice in that it has a range of
services to support people to remain in Salford. To maintain this we need to
ensure that this group can readily access primary care support when health
problems occur, with access to specialist multi-disciplinary community-based
expertise as appropriate.
In Salford there are over 4000 adults with a learning disability. About 1000 have a
moderate or severe LD and are registered with GP practices (10% of these are
65yrs+). The other 3000 have a mild learning disability and are not actively known /
supported by specialist teams – as they use mainstream health & social care
services.
In 2013/14:
 There were 108 children registered as LD with GP Practices.
 There were 55 adults recorded as having LD and autism (5.7%) by GP
Practices.
 Cancer screening rates: cervical screening 20%, breast screening 19%
bowel screening 37% (the figures for cervical screening was less than in
2012/13).
 Uptake of annual health checks was 53%.
Delivery
85
To qualify, practices will be expected to:
 Sign up to the LD DES
 Have accurate QOF LD registers– constructed in liaison with LEA/SCC
Salford Standard – Quality Standards for Primary Care







Key
Performance
Indicators
86
(includes LD register and Downs syndrome register) (QOF requirement)
Have accurate Cross-reference their register of patients with ASC –
constructed in liaison with LEA/SCC. with SCC.
Offer the LD health check to patients aged 14yrs+ on LD register, and
provide a Health Action Plan (HAP) where appropriate. (DES NHS
England).
Provide information in a range of accessible formats (Equality Act 2010).
Identify & record the ‘information & communication’ requirements for
patients with LD /ASC. (Accessible Information Standard SCCI1605 and
Section 250 of Health & Social Care Act 2012).
Identify & record any ‘reasonable adjustments’ required for patients with
LD /ASC. (Equality Act 2010).
Offer access to screening initiatives to all eligible patients with LD/ASC.
Participate in the ‘LD Health & Wellbeing Self-Assessment Framework’
(LD SAF).

VG04_P:
Sign up to the LD DES.
Threshold: 100%

LD1:
Have accurate LD Registers (includes Down’s Syndrome Register)
Measure: LD registers reflect prevalence data & align with councils
register.
Monitoring: Clinical system.
Threshold: ≥ 90% = achieved;
< 90% - ≥ 80% = acceptable;
< 80% - ≥ 60% = improvement plan;
< 60% = Trigger.

VG08_P:
Practices to cross reference learning disability register with the councils
(CTLD) and share autism register
Measure: Practice to maintain record of contact made with CTLD to share
autism register and cross reference LD register
Monitoring: Practices to submit record of contact made with LD team
Threshold: ≥ 90% = achieved;
< 90% - ≥ 80% = acceptable;
< 80% - ≥ 60% = improvement plan;
< 60% = Trigger.

LD3:
Increase the uptake of cancer screening for patients with LD
Measure: Percentage of eligible patients with LD to be up to date with
cancer screening (presently 19% breast, 20% cervical & 37% bowel).
Monitoring: Number who have had cancer screening out of total number
of eligible (for breast/cervical/bowel) taking the combined average as the
achievement (threshold) score.
Salford Standard – Quality Standards for Primary Care
Threshold: ≥ 50% = achieved;
< 50% - ≥ 40% = acceptable;
< 40% - ≥ 20% = improvement plan;
< 20% = Trigger.
(NB: To extend this target by 20% in 2017/18)

LD4:
Comply with Accessible Information Standard SCCI-1605 and provide
information in a range of accessible formats.
Measure: Identify & record ‘information & communication requirements’ for
patients with LD.
Monitoring: Clinical system.
Threshold: ≥ 50% = achieved;
< 50% - ≥ 40% = acceptable;
< 40% - ≥ 20% = improvement plan;
< 20% = Trigger.
(NB: To extend targets to include people with ASC in 2017/18)
CCG Support
The CCG will:
 Provide a process/guidance that practices can use to check the accuracy of
their LD Registers (process presently being developed – which will cover
how to check names on both LD registers).
 Provide training to Practices that supports the delivery of the DES LD
annual health check scheme, and meets min training requirements in this
contract.
 Provide information on accessible materials/resources.
 Support Practices to run/extract data for LD SAF.
Contacts
Clinical Lead: Dr Jeremy Tankel; [email protected]
Kerry Thornley, Integrated Commissioning Manager:
[email protected]
87
Salford Standard – Quality Standards for Primary Care
References
88

Michael J (2008) Healthcare for all: report of the independent inquiry into
access to healthcare for people with learning disabilities. Available from
www.iahpld.org.uk (Internet).

Department of Health (2009) Valuing People Now: a new three-year
strategy for people with learning disabilities. DH: London.

Department of Health (2012) Transforming care: A national response to
Winterbourne View Hospital, DH: London.

Improving Health and Lives Learning Disabilities Observatory (2012)
Confidential Inquiry into premature death of people with learning
disabilities, IHAL: Bristol.

Department of Health (2014) Premature Deaths of People with Learning
Disabilities: Progress Update. DH: London.

Hoghton, M. And the RCGP Learning Disabilities Group. (2010) A Step by
Step Guide for GP Practices: Annual Health Checks for People with a
Learning Disability. The Royal College of General Practitioners: London.

Improving Health and Lives Learning Disabilities Observatory (2015) Health
checks for people with learning disabilities: including young people aged 14
and over, and producing health action plans IHAL: Bristol.

NHS England (NHSE), (2014) Directors of Adult Social Services (ADASS)
An Introduction to the Joint Health and Social Care Learning Disability SelfAssessment Framework (LD SAF) Available at:
https://www.improvinghealthandlives.org.uk/securefiles/150804_1232//LD_
SAF%20launch%20letter_Final_V1.0.pdf

Public Health England (2014) Making reasonable adjustments to primary
care services – supporting the implementation of annual health checks for
people with learning disabilities PHE: London.

HM Government (2014) Think Autism Fulfilling and Rewarding Lives,
the strategy for adults with autism in England: an update DH:
London.
Salford Standard – Quality Standards for Primary Care
Standard 5.5
Asylum Seekers

Aims

Rationale
Special arrangements for providing care and management of Asylum
Seeker Patients.
To ensure Asylum Seeker Patients receive appropriate and timely NHS
Hospital Care/ Mental Health Specialist Service when required.
People claiming asylum are an extremely diverse group originating from
countries all over the World. They present numerous challenges in terms of
disease processes; many suffer from mental health disorders HIV and other
blood borne and tropical diseases can occur.
Adults and children at increased risk of infection by M tuberculosis complex (M
tuberculosis, M africanum, M bovis), specifically if they:
 Have arrived or returned from high- prevalence country within the past 5
years;
 Were born in high prevalence countries;
 Live with people with active TB.
The incidence of the Post-Traumatic Stress Disorder is particularly high in this
group; many have experienced torture rape and other forms of abuse. Salford
PCT commissioned the Horizon Centre, a dedicated asylum seeker general
practice, between 2004 and 2012 and the wealth of experience accrued by the
employed staff in that service has been used to inform this standard.
in August 2015, there were 167 patients Read coded as asylum seeker
registered in the previous 15 months across 19 practices in Salford; only 68 of
these patients were allocated to practices signed up to deliver the Asylum
Seeker Locally Commissioned Service.
In view of the fact that less than half of the asylum seekers we are aware of are
registered with practices that have signed up to the Asylum Seeker LCS it has
been decided to decommission that service and instead devise an equitable
provision to address the needs of asylum seekers registered with all the
practices in Salford.
The Gateway Protection Service is not within the scope of the Salford Standard
for Asylum Seeker Patients.
Delivery
Practices will be expected to:





89
Have systems in place to record asylum status by Read code.
Accommodate the cultural requirements of patients; be able to offer a
choice of gender of GP’s.
Use the appropriate translation services to meet the needs of the patient,
preferably face to face.
For the first 12 months only following registration practices will be
expected to provide longer appointment times for asylum seeker
patients, ideally 20 minutes, but not less than 15 minutes.
Refer to the specialist Mental Health of Asylum Seekers Service patients
Salford Standard – Quality Standards for Primary Care


Key
Performance
Indicators
with mental health issues not responding to standard treatments.
Utilise the Asylum Seeker Guideline to ensure all relevant data including
country of origin, first language and whether the patient needs an
interpreter or not
Is available to Specialist Mental Health of Asylum Seekers Service when
patients are seen.

AS05:
Practice to develop an Asylum Seeker Register
 Asylum Seeker Patients to be coded 13ZN

AS04:
Practice to avoid using telephone translation services.
 Audit* the use of translation services, using 9NQ0.00 with 13ZN
for the 1st year of registration.

AS3:
Practices must record country of origin, first language and whether the
asylum seeking patients need an interpreter or not, utilising the agreed
read codes.
 Threshold for the 3 areas above
≥ 80% = Achieved;
< 80% - 50% = Acceptable;
< 50% = Improvement Plan.

VG07_P:
Practices must provide longer appointment times ideally 20 minutes, but
not less than 15 minutes.
 Evidence in the form of an audit made available to the
commissioner, if requested* showing the number of patients with
a read code of 13ZN with average length of appointments for the
1st year of registration.
Threshold: ≥ 80% = Achieved;
< 80% - 50% = Acceptable;
< 50% = Improvement Plan.

VG05_P:
Practices to ensure where Asylum Seeker patients with mental health
issues who are not responding to standard treatments a referral is made
to the Specialist Mental Health Asylum Seekers Service.
 Evidence in the form of an audit* to be made available to the
commissioner, if requested showing the number of patients with a
read code of 13ZN referred to a specialist mental health service.
*NB. Audits will not routinely be required, but when requested should be made available to the
commissioner within 20 working days following the request
90
Salford Standard – Quality Standards for Primary Care
CCG Support




Contacts
References
91
Continue to commission and review Specialist Mental Health of Asylum
Seekers Service.
Loading of Asylum Seeker Guideline/Template to facilitate patient review
and support the collection of required data to assist referral to specialised
service.
Provision of details of voluntary organisations offering support.
Provision of appropriate training, either as optional or mandated
dependent upon the education calendar.
Clinical Lead: Dr Steven Elliot [email protected]
CCG Contact: Natalie McInerney, Service
[email protected]
Improvement
Manager;

http://migrationobservatory.ox.ac.uk/briefings/migration-uk-asylum

https://www.gov.uk/government/publications/immigration-statisticsjanuary-to-march-2015/immigration-statistics-january-to-march2015#summary-points-january-to-march-2015

The Immigration Act A briefing by Doctors of the World UK for local
Healthwatch November 2014 www.healthwatchenfield.co.uk
Salford Standard – Quality Standards for Primary Care
Standard 5.6 Carers


Aims
To improve the Number of carers identified within GP practices in Salford.
To ensure that carers who are identified have access to the health care
they need including access to health checks.
To ensure that all carers identified are referred effectively for the provision
of ongoing advice, information and support.

Rationale
Over the past few years the significant contribution of the ‘carer’ role to health and
social care services has been highlighted (Carers UK, 2014a).
Nationally, there are 6.5 million unpaid carers, accounting for 1 in 8 adults and
estimates suggest they save the state £119 billion a year (Buckner & Yeandle,
2011; Carers UK, 2014a). Findings from a recent study highlight that 70% of carers
come into contact with health professionals, yet only 10% of these are identified as
carers. (Shoneguard 2013).
Healthcare staff are not proactive in signposting carers to relevant support or
information; when information is given, it comes from charities and support groups.
(NHS England & NHS Improving Quality, 2014).
Salford Carers strategy 2013-16 produced by the City Council and NHS Salford
CCG estimates that there are 23,400 adult carers in Salford, and currently only
5800 are known. 13% of Salford’s adult population are carers compared with 12%
across the rest of England (Salford Council 2013).
There has been a growing emphasis in recent years on the need to provide more
comprehensive support to carers, as they often face greater social deprivation,
isolation and ill health. They also have fewer opportunities to do the things other
people may take for granted, such as access to paid employment, learning
opportunities or having quality time to spend on their own, or with friends. For
young carers, it can often compromise their education and social life; limiting their
life chances (Carers UK, 2014a).
Carers UK (2014c) highlights that:
•
•
•
•
72% of carers are worse off financially, as a result of caring;
54% have given up employment to care;
21% have had to reduce their working hours due to caring responsibilities;
On average, carers retire 8 years earlier, thereby missing out on years of
income and pension contributions;
• Those caring for 50 hours a week or more are twice as likely to experience
poor health, particularly mental health problems.
The Royal College of General Practitioners (RCGP, 2014) highlights an urgent
need to further embed the identification and support of carers within general
practice. This will ensure carers are supported at an earlier stage, enabling real
benefits for both carers and patients alike.
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Salford Standard – Quality Standards for Primary Care
Delivery
Practices will be expected to:









Key
Performance
Indicators
Identify a Carers Lead (link) within the practice;
Have a carers register which is maintained and updated;
Ensure that all staff, including receptionists, are ‘carer aware’, and have a
basic understanding of support available;
Offer carers an annual health check (if otherwise eligible);
Display information in the waiting room to help carers identify themselves
and to highlight available support and information;
Offer annual flu vaccination;
Ensure the release of staff for attending GP links meetings and other
education and training events;
Have available an electronic referral form on the practice or other system
to refer to Salford Carers Centre;
Undertake a NICE screen for depression (NICE guidelines [CG90], pg.16).

CA01:
Increase numbers of carers registered within practices – achieve 2% of list
Size.

CA02:
Annual Health checks – Offer to 80% of carers on register in year 1 and
95% in year 2.
CCG Support
The CCG will:
 Commission a range of services to meet carers needs;
 Commission a specialist GP support / liaison service to support GP
practices that will make regular contact with the Practice carer lead;
 Commission a service to develop and deliver training for GP practice
based staff;
 Prove regular information to practices on Carers developments;
 Provide data and information on Practice achievement of this standard;
 Work with Data Quality Manager to develop an electronic Carers Health
Check template for the practice system;
 Develop electronic forms for practice systems for referral for Carers
support (or use of universal referral template);
 Provide a Practice toolkit involving guidance and information on carers.
Contacts
Clinical Lead: Dr Jenny Walton; [email protected]
Contact:
Glyn
Meacher,
Integrated
[email protected]
References
93
Commissioning
Manager;

Buckner, L and Yeandle, S (2011) Valuing Carers 2011, calculating the
value of carers’ support. Centre for International Research on Care, Labour
& Equalities. University of Leeds. London: Carers UK.

Carers UK (2014a) The State of Caring 2014 Available at
http://www.carersuk.org/for-professionals/policy/policy-library/state-of-
Salford Standard – Quality Standards for Primary Care
caring-2014
94

Carers UK (2014b) Carers at Breaking Point Available at:
http://www.carersuk.org/for-professionals/policy/policy-library/carers-atbreaking-point-report

Carers UK (2014c) Facts About Carers- Policy briefing. London.

NHS England (2014) Commitment to Carers Available at:
http://www.england.nhs.uk/wp-content/uploads/2014/05/commitment-tocarers-may14.pdf

NHS England & NHS Improving Quality. (2014) Commitment for Carers:
Report of the findings and outcomes. London. Office for National Statistics
(ONS) (2011) Carers data Available at:
http://www.ons.gov.uk/ons/guide-method/census/2011/index.html

Supporting Carers: An action guide for general practitioners and their
teams. Available at: http://www.rcgp.org.uk/clinical-and-research/clinical
resources/~/media/CB33FA45E03741A08E64F92A5F74DB07.ashx

Carers Week (2013) Prepared to Care? Exploring the impact of caring on
people’s lives, in: Schonegevel, L. (2013) Macmillan briefing on carers
issues. Available at
http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/MPs/Co
mmons2ndReadingBriefing.pdf

NICE Clinical Guideline 90 – Depression in Adults (October 2009) Available
at: guidance.nice.org.uk/cg90
http://www.salford.gov.uk/d/Salford_Carers_Strategy_2013-2016.pdf
Salford Carers Strategy 2013 – Salford City Council/NHS Salford CCG
Salford Standard – Quality Standards for Primary Care
Domain 6
95
Salford Standard – Quality Standards for Primary Care
Standard 6.1 Health Improvement
Rationale
6.1.1 NHS Health Checks (risk identification/early diagnosis of Stroke,
Diabetes, Kidney Disease, Cardiovascular Disease)
In England, over 4 million people are estimated to have cardiovascular disease
(CVD). This is recognised as the largest single cause of long-term ill health,
disability and death (DH, 2013). A steep rise in unhealthy behaviours – smoking,
physical inactivity, eating a poor diet and alcohol misuse - has led to increasing
levels of ill health across all sections of the population. This is magnifying the
burden of vascular conditions (Murray et al, 2013).
The main causes of Salford’s life expectancy gap are CVD, cancer and
respiratory disease. Whilst there are signs that early death rates from heart
disease, stroke and cancer are falling, Salford is still lagging behind England
averages (Salford Public Health, 2015). 88% of NHS Health Checks were
delivered by GPs in 2014/15 – and there was a great improvement in uptake
from 30% in 2013/14 to 60% in 2014/15.
It is estimated that an effective vascular check programme can prevent 1,600
cases of myocardial infarction (MI) and stroke, 650 premature deaths and
identify over 4,000 new cases of diabetes each year (PHE, 2013). The Salford
Health and Wellbeing Strategy (Salford City Council, 2013) identifies that finding
people with risk factors early and helping them to get support to modify their
lifestyles or get early treatment is one way we can support our population to be
healthier.
6.1.2 Pulse Checks (aged 65 years and over)
Atrial Fibrillation (AF) is the most common sustained dysrhythmia, affecting at
least 600,000 people in England. It is a major cause of stroke. Every year there
are approximately 152,000 strokes in the UK. Most people affected are over 65
and identifying AF early could prevent 4,500 strokes and 3,000 deaths per year
in the UK (Stroke Association, 2014). Estimates suggest that one stroke would
be prevented for every 37 people screened.
6.1.3 Alcohol – AUDIT C, FAST, AUDIT 10 & Brief Intervention
Alcohol misuse creates a huge burden on health, in terms of treating alcohol
related disease and premature mortality. About 26% of all adults in England,
equating to 10.5 million people, are drinking at hazardous and harmful levels
(British Society of Gastroenterology (BSG), 2010).
Salford is well above the national average for the prevalence of problem
drinking. Digestive diseases, which include cirrhosis of the liver, are amongst the
top 5 causes of the life expectancy gap for both sexes in Salford, when
compared to the England average (PHE, 2015a).
Connor et al. (2015) recommended in the Lancet that: “Screening and brief
interventions could encourage people with alcohol use disorders to receive
treatment early. Patients scoring 0–7 in the AUDIT in primary care (100) should
96
Salford Standard – Quality Standards for Primary Care
be given basic alcohol education, those scoring 8–15 given straightforward
advice on reduction of hazardous drinking, those scoring 16–19 given straight
forward advice in addition to brief counselling and continued monitoring, and
those scoring 20–40 referred for specialist assessment.”
6.1.4 Smoking Cessation
Smoking is still the leading cause of premature death and preventable ill health
with Salford having a particularly high rate of smoking - attributable hospital
admissions (PHE, 2015b).
Smoking prevalence among adults in Salford has reduced from 30.4% in 2010 to
an estimated 22.9% in 2015, but it is still 4.5% higher than the England average
with the most deprived wards having the highest smoking rates. Smoking in
pregnancy contributes to low birth weight and rates locally are higher than the
England average (15% compared to 12%).
Evidence shows that smokers who are asked if they still smoke are more likely
to quit (NICE, 2006). Level 1 services are routine opportunistic screening and
signposting / referral to Stop Smoking Service (within the practice or to level 3
providers). This level of care is therefore included in the Salford Standard as
part of normal care and identification of smokers; it also contributes to GP QoF
points. A Level 2 service delivers a comprehensive stop smoking service for
patients / clients aimed at reducing smoking prevalence with ongoing
motivational support for up to one year (see service description). GPs can opt in
to be a Level 2 service provider.
6.1.5 Blood Pressure Checks
High blood pressure accounts for approximately 12% of all GP consultations in
England (Public Health England, 2015c). People from the most deprived areas
are 30% more likely than the least-deprived to have high blood pressure.
High blood pressure is preventable, and risk of cardiovascular disease is
reduced down to a threshold of 115/75mmHg. Over ten years, an estimated
45,000 quality adjusted life years could be saved, and £850m not spent on
related health and social care, if England achieved a 5mmHg reduction in the
average population systolic blood pressure. Testing is advisable at least every
five years, more frequent re-testing for those with high-normal blood pressure.
Delivery
Practices will be expected to:
6.1.1 NHS Health Checks (risk identification/early diagnosis of Stroke,
Diabetes, Kidney Disease, Cardiovascular Disease)
 Attend relevant training for NHS Health Checks and BMJ Informatica.

97
Offer a Salford NHS Health Check to everyone aged 40-74 years, without
existing cardiovascular disease or diabetes. Elements or metrics may be
added, to or removed from, the above list, as per guidance from the
Department of Health (DH). Point of Care testing can be used if desired
Salford Standard – Quality Standards for Primary Care
(currently not funded by the CCG).
 Age
 Gender
 Ethnicity
 Family history of CHD (first degree relative)
 BP (record systolic and diastolic measurement)
 Height (actual measurement, not patient report)
 Weight (actual measurement, not patient report)
 Body Mass Index (BMI)
 Smoking (record status)
 Bloods (lipids, HbA1c, U&Es, LFTs, (as a minimum))
 Alcohol (AUDIT C or FAST. If a patients scores 5, complete
AUDIT 10 at the same time)
 Pulse (check rate and rhythm – to detect AF)
 Physical Activity (record current levels)
 Dementia (over 65s – use the screening question on the
template)

Ensure all staff undertaking health checks are competent to deliver in line
with guidance issued by PHE.

Ensure referrals to other lifestyle services are recorded on BMJI.

Submit data via BMJ Informatica template.
6.1.2 Pulse Checks (aged 65 years and over)

Offer opportunistic pulse checks to patients aged 65 years and over e.g.
when patients are attending for another reason such as the flu jab.
6.1.3 Alcohol – AUDIT C, FAST, AUDIT 10 & Brief Intervention
98

Undertake AUDIT C or FAST on any patient who is 16 years or over, who
has not been screened in the last 2 years.

Offer AUDIT 10 to any patient who scores positive on AUDIT C or FAST
(5 or more).

Offer a brief intervention to all patients who score positive on AUDIT C or
FAST, at the same time as undertaking AUDIT 10.

Signpost patients scoring between 8 and 19 on the AUDIT 10 to the
relevant support, i.e. the locally commissioned organisation that offers
brief interventions (currently Being Well).

Signpost patients scoring over 20 on AUDIT 10 to Salford Integrated
Drug & Alcohol Service, and offer the opportunity to make the
appointment from the Surgery.
Salford Standard – Quality Standards for Primary Care
6.1.4 Smoking Cessation:

As part of Level 1 smoking cessation interventions, routinely (once every
2 years) ask, review and record the smoking status of all patients aged
16 or over.

Signpost individuals who smoke to Level 2 smoking cessation services
and information and advice as appropriate; record this on the GP record
and local database (currently Quit with Us).
6.1.5 Blood Pressure Checks
Key
Performance
Indicators

As per PHE recommendations, take and record blood pressure once
every 5 years.

For those identified as having hypertension, refer to section 1.5.
6.1.1 NHS Health Checks (risk identification/early diagnosis of Stroke,
Diabetes, Kidney Disease, Cardiovascular Disease)
All patients aged 40-74 to receive/be offered a health Check.
Measure PH22: Number of initial NHS Health Checks completed (aged 40-74
years)
Monitor: Read code.
Threshold: Achieve 60% uptake of the NHS Health Check from the eligible
population.
6.1.2 Pulse Checks (aged 65 years and over)
All patients over 65 years to have a pulse check.
Measure PH10: Number of pulses checked (aged 65 years and over).
Monitor: Read code.
Threshold: Achieve 80% uptake annually.
6.1.3 Alcohol – AUDIT C and FAST
All patients over 16 years to have been offered an AUDIT C or FAST within the
last 2 years.
Measure PH07: Number of patients over 16 years offered an AUDIT C or FAST
within the last 2 years.
Monitor: Read code.
Threshold: 50% offer over 2 years (i.e. 25% per annum) = achieved;
<50% - 30% offer over 2 years (i.e. 15-25% per annum) =
acceptable;
<30% - trigger alert.
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Salford Standard – Quality Standards for Primary Care
6.1.4 Smoking Cessation
All patients over 16 years to have their smoking status recorded and offered
advice within the last 2 years.
Measure PH03: Number of patients offered advice and have their smoking
status recorded.
Monitor: Read code.
Threshold: Achieve 50% uptake.
6.1.5 Blood pressure check
PH11: All patients over 30 to have their blood pressure recorded within the last 5
years
Threshold: Achieve 75% of target group.
Support
The CCG/Public Health will:
 Support practices to identify patients eligible for Health Checks using
BMJ Informatica;
 Provide an estimate of the annual eligible population;
 Signpost to Haelo support pack for improving Health Check uptake;
 Support practices with training and detailed guides to NHS Health
Checks;
 Provide information for signposting to other community services
commissioned by public health/CCG for brief interventions and lifestyle
advice;
 Support the wider agenda by commissioning population based
approaches to risk reduction.
Contacts
Siobhan Farmer, Consultant in Public Health; [email protected]
References
100

British Society of Gastroenterology (BSG), (2010) Alcohol related
disease: Meeting the challenge of improved quality of care and better use
of resources London.

Connor, JP, Haber, PS, Hall, WD: Alcohol use disorders. The Lancet,
Vol.386, No. 9997, Sep 5, 2015.

Department of Health DH, (2013) CVD Outcomes Strategy: Improving
outcomes for people with or at risk of cardiovascular disease London.

Murray C.J. et al., (2013) UK Health Performance: findings of the Global
Burden of Disease Study 2010 The Lancet Vol: 381 pp. 997-1020.

NICE (2006) PH Intervention Guidance 1: Brief interventions and referral
for smoking cessation in primary care and other settings.

Public Health England (PHE), (2013) NHS Health Check implementation
review and action plan London.

Public Health England (PHE), (2015a) Local Alcohol Profiles Available at:
www.lape.org.uk/
Salford Standard – Quality Standards for Primary Care

Public Health England (PHE), (2015b) Local
Profiles Available at: www.tobaccoprofiles.info

Public Health England (PHE), (2015c) Tackling high blood pressure From
evidence into action. Available at:
www.gov.uk/government/publications/high-blood-pressure-action-plan

Salford City Council (2013). Salford Health and Wellbeing Strategy 2013
– 2016. Available at:
https://www.salford.gov.uk/jointhealthwellbeingstrategy.htm

Salford Public Health Mortality Report 2015
(http://www.salford.gov.uk/d/Salford_Mortality_Report_2015.pdf,
Accessed 14.10.15)

Stroke
Association,
(2014)
www.stroke.org.uk/about-stroke
About
Stroke
Tobacco
Control
Available
at:
We acknowledge the Bolton Quality Contract for some of the text and
references for this section.
Standard 6.2 Screening
101
Salford Standard – Quality Standards for Primary Care
Rationale
National screening programmes are effective at targeting and inviting the right
people to identify diseases early, but there are still large numbers of patients
who decline the opportunity to be screened. The NHS Cancer Screening
Programme (NHSCSP, 2015) suggests that more could be done on a local
level to improve uptake. Pignone (2001), suggests that staff in a Primary Care
setting, can encourage patients who are faced with screening decisions, to
make informed choices, by providing up-to-date information about the options
available.
On a local level, there are approximately 1,237 new cases of cancer diagnosed
each year (2011-2013 average). The most plausible drivers for improved
survival appear to be diagnosis at an early stage, through effective screening
programmes, and access to early treatment (Foot and Harrison, 2011).
6.2.1 Breast Screening
Salford’s breast screening uptake rate is 68.7% (April 14 to March 15), which is
higher than the England average, of 57.8%. Uptake is variable across
Practices, with particularly low uptake in the most deprived communities
(Salford Public Health, 2014). The NHS Breast Screening Programme offers
screening every 3 years to all women aged 50 to 70 years.
6.2.2 Bowel Screening
The Bowel Cancer Screening Programme (BCSP) aims to reduce bowel
cancer mortality by detecting and treating bowel cancer, or pre-cancerous
growths early. Currently, Salford’s screening uptake rate is 52% (April 14 to
March 15), which is lower than the England average, of 57.8%. Uptake is
variable across practices, with particularly low uptake in the most deprived
communities (Salford Public Health, 2014). The NHS Bowel Cancer Screening
Programme offers screening every 2 years to all men and women aged 60 to
74 years.
6.2.3 Cervical Screening
This programme aims to reduce the incidence, and associated mortality, of
invasive cervical cancer. If an overall coverage of 80% can be achieved, a
reduction in death rates of around 95% is possible in the long term (NHSCSP,
2015). Screening is currently offered at different intervals depending on age,
allowing the process to be targeted effectively (Sasieni et al, 2003). Those
aged 25 to 49 are offered cervical screening on a 3 yearly basis and those
women age 50 to 64 are offered every 5 years. Salford’s uptake is currently
74%. (QOF target is 80%).
6.2.4 Abdominal Aortic Aneurysm (AAA) Screening
The incidence of AAA is increasing, and the prognosis of ruptured AAA
remains dismal (PHE, 2014). AAA causes about 2% of all deaths in men over
the age of 65 years. A major improvement in operative mortality would have
little impact on total mortality, so screening for AAA has been recommended as
a solution. Uptake in Salford in 2014/15 was 68.7% compared to an England
102
Salford Standard – Quality Standards for Primary Care
figure of 79.5% (HM Government, 2015).
6.2.5 Diabetic Eye Disease
All people with type 1 and type 2 diabetes aged 12 or over are eligible for an
annual diabetic eye screen but those patients already under the care of an
ophthalmology specialist for the condition are not invited for screening.
Pregnant women with Type 1 or 2 diabetes are also offered screening. The
programme offers pregnant women with type 1 or type 2 diabetes additional
tests because of the risk of developing retinopathy. Uptake in 2013 in Salford
was just 75.6 compared to 79.1% in England (PHE 2015).
Delivery
Practices will be expected to:
Breast, Bowel, Cervical, Diabetic Eye Disease, AAA
 Work with the Area Team to support the programme and increase the
uptake of screening in the practice target population.
 Practices to follow up individual patients who have not attended their
screening appointments and provide information and support to
encourage uptake; this should improve screening figures across
Salford.
Follow up of DNAs can be undertaken in a variety of ways e.g. Text,
phone call, email or letter
Key
Performance
Indicators

Practices to Read code DNAs and follow up with advice and
support to promote the uptake of cervical screening (25 - 49 yrs =
3-yearly, 50 - 64yrs = 5-yearly) by following up DNAs:
Measure PH13:
No. of Women aged 25 - 49yrs recorded as DNA Cervical screening
given advice re screening or coded as declined screening following
recording of DNA in the last 3 yrs.
Total no. of Women aged 25 - 49yrs recorded as DNA
Cervical screening in last 3 yrs.
Measure PH13:
No. of Women aged 50 - 64yrs recorded as DNA Cervical screening
given advice re screening or coded as declined screening following
recording of DNA in the last 5 yrs.
Total no. of Women aged 50 - 64yrs recorded as DNA
Cervical screening in last 5 yrs.
Monitor: Read Code.
Threshold: 1% above the current practice baseline.

103
Practices to promote the uptake of diabetic eye checks annually to
Salford Standard – Quality Standards for Primary Care
all diabetic patients over 12 years old by following up DNAs
Measure PH15:
No. of diabetic patients aged 12yrs and over recorded as DNA DRS
given advice re DRS or coded as declined DRS following recording of
DNA in the last 12 months
Total no. of diabetic patients and 12 and over recorded as DNA DRS
in the last 12 months (exclude pts who decline)
Monitor: Read codes.
Threshold: 1% above the current practice baseline
Support
104

Practices to promote the uptake of breast screening checks every
3 years to all women aged 50-70yrs by following up DNAs
Measure PH16:
No. of women aged 50 - 70yrs recorded as DNA Breast
Screening with advice re breast screening offered or coded
as declined breast screening following recording of DNA in
the last 3 yrs.
Total no. of women aged 50 - 70yrs recorded as DNA Breast
Screening in the last 3 yrs.
Monitor: Read code.
Threshold: 1% above the current practice baseline

Practices to promote the uptake of bowel screening every 2 years
to all patients aged 60 - 74yrs by following up DNAs
Measure PH17:
No. of patients aged 60-74yrs who have been offered bowel screening
No. of patients aged 60-74 yrs recorded as ‘no response to bowel
screening’ with advice given re bowel screening or coded as declined
screening following the recoding of no response in the last 2yrs
Total no. of patients aged 60 - 74 yrs recorded as DNA
Bowel Screening.
Monitor: Read code.
Threshold: 1% above the current practice baseline

Practices to promote the uptake of AAA screening to all men over
65yrs of age by following up DNAs & offering advice
Measure PH18:
No. of men aged over 65 DNA AAA Screening with
information provided re AAA screening or coded as declined AAA
screening following the recording of DNA in the last 2 yrs.
Total no. of men aged over 65 DNA AAA Screening coded as declined
AAA screening in the last 2 yrs.
Monitor: Read code.
Threshold: 1% above the current practice baseline
The CCG/Public Health Team will:
 Provide cancer profiles and data to GP practices;
 Signposting to community/public health services for prevention or
Salford Standard – Quality Standards for Primary Care


ongoing support;
Create a list of appropriate read codes to record follow up;
Signpost to appropriate PHE /NHSE Area Team Support including
resource packs for practices.
Contacts
References

Foot, C, Harrison, T, (2011) How to improve cancer survival London:
The King’s Fund.

Health & Social Care Information Centre (HSCIC), (2014) [Online]
Available at: www.hscic.gov.uk/catalogue/PUB10339/bres-scre-prog-eng2011-12-rep.pdf

Her Majesty’s Government (2015). AAA Screening 2014 to 2015 data
tables. Available at: https://www.gov.uk/government/publications/abdominalaortic-aneurysm-screening-2014-to-2015-data

NHS Cancer Screening Programmes (NHSCSP, 2015).
Online at
https://www.gov.uk/topic/population-screening-programmes

Public Health England (PHE), (2014) NHS Cancer Screening
Programmes [Online] Available at: www.cancerscreening.nhs.uk/

Public Health England (PHE), (2015) Public Health Outcomes Framework
[Online] Available at: http://www.phoutcomes.info/

Pignone, M., (2001) Cancer Screening in Primary Care Are we
communicating? Journal of General Intern Medicine Vol: 10 p.867.

Sasieni, P., Adams, J., Cuzick, J. (2003) Benefits of cervical screening
at different ages: evidence from the UK audit of screening histories,
British Journal of Cance.r

Salford City Council Public Health (2014). Salford GP Cancer Profiles,
Available on request.
We acknowledge the Bolton Quality Contract for some of the text and references
for this section.
Standard 6.3 Health Protection
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Salford Standard – Quality Standards for Primary Care
Rationale
The Public Health Outcomes Framework highlights health protection as one of 3
main pillars for improving and protecting the nation’s health (PHE, 2014).
Immunisation is also the most important way of protecting people from vaccine
preventable diseases (DH, 2014).
6.3.1 Influenza
The best way to improve the prevention and management of ‘flu is to increase the
uptake of vaccination, especially amongst those in clinical risk groups, and health
and social care workers with direct patient contact.
GP’s will be responsible for the vaccination of the following groups: People aged 65 years or over (including registered patients living in longstay residential care homes);
 People aged from six months to less than 65 years of age with a serious
medical condition such as:
 chronic (long-term) respiratory disease, such as severe asthma,
chronic obstructive pulmonary disease (COPD) or bronchitis
 chronic heart disease, such as heart failure
 chronic kidney disease at stage three, four or five
 chronic liver disease
 chronic neurological disease, such as Parkinson’s disease or motor
neurone disease, or learning disability
 diabetes
 splenic dysfunction
 a weakened immune system due to disease (such as HIV/AIDS) or
treatment (such as cancer treatment);
 All pregnant women (including those women who become pregnant during
the flu season);
 All those aged two, three, and four years (but not five years or older) on
31 August;
 Registered carers.
Frontline health and social care workers to be offered flu vaccination by their
employer. This includes general practice staff. Collection of this data is
mandatory.
Children in school years 1 and 2 will be offered the vaccination in a school based
programme (GP’s are not commissioned to provide this programme).
The Joint Committee on Vaccination and Immunisation has also advised that
morbidly obese people (defined as BMI 40+) could also benefit from a flu
vaccination. This is funded by the DES but it is expected that all practices will set
out to achieve this.
6.3.2 Pneumonia
Pneumococcal disease is caused by the bacterium Streptococcus Pneumoniae
(pneumococcus). It is a major cause of disease and death globally, and in the UK.
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Salford Standard – Quality Standards for Primary Care
It particularly affects:
 The elderly;
 People with no spleen or a non-functioning spleen;
 People with other causes of impaired immunity and certain chronic
medical conditions.
There are more than 90 different pneumococcal types (serotypes) that can cause
disease in humans. More than 5,000 cases are diagnosed each year in England,
with the number of cases peaking in December and January (DH, 2014).
2014/15 uptake rate for PPV in Salford 67.0%.
There is no target for PPV but it is expected the offer is 100% and WHO uptake is
95%.
Delivery
Practices will be expected to:






Key
Performance
Indicators
Provide access to flu vaccination for people aged 65 years and over;
Provide access to flu vaccination for people less than 65 years old who
are in an at risk group;
Provide access to pneumococcal vaccination for people aged 65 years
and over;
Provide the flu vaccine for children aged 2 to 4 years old;
Have a system in place to follow up DNA;
Ensure data of those immunised is reported promptly on IMMform.
Influenza
 PH01_P:
Sign up to the Influenza DES.
Threshold = 100%.
Flu

Support
The CCG/Public Health Team will:
 Provide GP Practices with monthly data for flu vaccination uptake during
the season October to March;


Contacts
References
107
FV01:
Achieve 75% of target group.
Pneumococcal vaccination uptake date will be provided once reporting
arrangements have been confirmed from Department of Health;
Carry out audits of the cold change as part of the infection control audit
process.
Public Health Lead: Beverley Wasp, Health Protection Strategic Manager;
[email protected]

Department of Health (DH), (2014) [Online] Available at:
www.gov.uk/government/uploads/system/uploads/attachment_data/file/31
Salford Standard – Quality Standards for Primary Care
6007/FluImmunisationLetter2014_accessible.pdf

Public Health England (PHE), (2014) Public Health Outcomes Framework
for England 2013-2016 Available at: www.phoutcomes.info/
We acknowledge the Bolton Quality Contract for some of the text and
references for this section.
Standard 6.4 Sexual Health
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Rationale
The Government has an ambition to improve the sexual health of the population.
This will require:
 A reduction in inequalities and improvement in sexual health outcomes;
 The development of an honest and open culture where everyone is able
to make informed and responsible choices about relationships and sex;
 Recognition that sexual ill health can affect all parts of society – often
when it is least expected (Department of Health (DH), 2013).
6.4.1 Chlamydia
Chlamydia is the most commonly diagnosed sexually transmitted infection (STI)
in the UK, affecting both men and women. From April 2003 to September 2013,
the National Chlamydia Screening Programme (NCSP) delivered over 8,155,500
tests with 535,255 diagnoses made (15-24 year olds) (NCSP, 2014). Untreated
chlamydia can lead to pelvic inflammatory disease, ectopic pregnancy and
infertility. Young people, aged between 15-24 years, should be tested for
chlamydia annually, or when they change sexual partner. Any form of
unprotected sex can put a person at risk of catching chlamydia, including oral
sex (DH), 2013).
Opportunistic screening should be established as a fundamental part of sexual
health services for young adults (NCSP, 2014). The National Chlamydia
Screening Programme offers screening to young people aged 15-24 years.
Delivery
Key
Performance
Indicators
Support
109
Practices will be expected to:

Offer opportunistic or targeted chlamydia screening to all 15- 24 years
olds using the reporting and recording systems of the commissioned
Greater Manchester STI screening support service;

Improve chlamydia screening rates within the Practice;

Offer/signpost patients to a full range of contraception and sexual health
services (for example, refer to other practices offering Long Acting
Reversible Contraception services, or local integrated sexual health
services).

PH02_P:
All practices to register as a chlamydia screening centre.
Threshold: 100% registration.

PH12:
Practices to establish a baseline of % of young people aged 15 - 24 who
are offered a test.
Threshold: Establish a % baseline of offer and uptake in Year 1.
The CCG/Public Health Team will:
Salford Standard – Quality Standards for Primary Care




Contacts
References
Provide details of local epidemiology and expected rates locally;
Provide details for practices to register with the GM STI Screening
Programme;
Provide feedback on positivity rates;
Provide details of relevant integrated Sexual Health services and
websites for signposting purposes.
Public Health Lead: Peter Varey, Public Health Commissioning Manager;
[email protected]

Department of Health (DH), (2013) A Framework for Sexual Health
Improvement in England London.

National Chlamydia Screening Programme (NCSP), (2014), [Online]
Available at: www.chlamydiascreening.nhs.uk/ps/

Public Health England (PHE), (2014) Chlamydia: surveillance, data,
screening and management.
Available at: www.gov.uk/government/collections/chlamydia-surveillancedata-screening-and-management
Standard 6.5 TB Screening
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Rationale
Tuberculosis (TB) rates in England remain high and are associated with
significant morbidity, mortality and costs (PHE, 2015). The onset of TB can be
insidious and difficult to detect with significant diagnostic delays. Late diagnoses
are associated with worse outcomes for the individual and in the case of
pulmonary TB, with a transmission risk to the public. It is likely that the majority
of TB cases in England are the result of ‘reactivation’ of latent TB infection
(LTBI), an asymptomatic phase of TB, which can last for years.
LTBI can be diagnosed by a single, validated blood test (interferon gamma
release assay (IGRA)), and is usually treated with antibiotics, preventing active
TB disease in the future. LTBI testing and treatment (‘LTBI screening’) of new
entrants to England is supported by the National Institute of Health and Care
Excellence (NICE, 2011). In spite of evidence supporting clinical and cost
effectiveness of LTBI screening, implementation in England has been
inconsistent.
The Collaborative TB Strategy for England 2015−2020 (PHE, 2015)
recommends LTBI testing and treatment for 16 to 35 year olds who recently
arrived in England from high incidence countries, where TB incidence is
150/100,000 population or over.
Salford’s average annual rate of incidence of TB (2012-2014) is 11.1 cases per
100,000 people which classify the City as “low incidence” (i.e. has a rate of
incidence of TB less than 20 per 100,000). However, we have an increasing
BME population who can be at higher risk of the disease and need to ensure
care for these individuals including LTBI screening is offered. PHE (2015)
recommend that “individuals should be tested for LTBI if they are aged 16 to 35
years, entered the UK from a high incidence country (≥150/100,000 or SSA)
within the last five years and been previously living in that high incidence country
for six months or longer”.
LTBI testing should be performed through a single IGRA test carried out in
primary care. It is best to start with prospective LTBI testing (identifying eligible
recipients when they first register with a GP practice) before planning
retrospective LTBI testing exercises.
Delivery
Practices will be expected to:

Key
Offer LBTI screening to new registrants aged 16 to 35 years who have
entered the UK from a high incidence country (≥150/100,000 or SSA)
within the last five years and been previously living in that high incidence
country for six months or longer. GPs should also use this opportunity to
test for HIV, if appropriate (see standard 5.5).
Measure PH21:
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Salford Standard – Quality Standards for Primary Care
Performance
Indicators
Practices to record patients from high incidence countries.
Monitor: Read code.
Threshold: 100% recorded.
CCG Support
Provide the link to the list of high incidence countries:
http://www.health.nsw.gov.au/Infectious/tuberculosis/Documents/countriesincidence.pdf
Contacts
Siobhan Farmer, Consultant in Public Health; [email protected]
References
112

NICE (2011). Tuberculosis: clinical diagnosis and management of
tuberculosis, and measures for its prevention and control. Available at:
http://www.nice.org.uk/guidance/CG117

Public Health England (2015). Collaborative Tuberculosis Strategy for
England:
2015
to
2020.
Available
at:
https://www.gov.uk/government/publications/collaborative-tuberculosisstrategy-for-england
Salford Standard – Quality Standards for Primary Care
Domain 7
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Salford Standard – Quality Standards for Primary Care
Standard 7.1 Proactive Care

Aims




Rationale
Safer care delivery with a more robust proactive approach to identifying,
monitoring and managing the most vulnerable people.
Reduce unplanned hospital admissions/readmissions/A&E Attendances.
Deliver right care, at the right time in the right place – ensuring that
patients’ needs are addressed by the most appropriate professional.
Support and enable people to continue to live independently for as long as
possible.
Improve health outcomes by reducing the variation of community care
provision.
The purpose of the Proactive Care domain is to ensure that practices in Salford
work collaboratively with partners across health and social care to systematically
identify individuals who would benefit from proactive, multi-disciplinary
assessment, review and care planning.
This aligns with national guidance and local strategy to enable general practice
to play an even stronger role at the heart of integrated community services that
deliver better health outcomes, more personalised care, excellent patient
experience and efficient use of NHS resources.
Neighbourhood multidisciplinary groups (MDG) are in place to provide a forum
for multi-specialty professionals to proactively discuss those people identified as
most at risk, as well as providing a broader focus on prevention and signposting
to community services.
All practices in Salford are invited and have opportunity to attend an MDG
meeting. There are currently two MDG’s per neighbourhood, per month.
All practices in Salford are invited and have opportunity to attend an MDG
meeting. There are currently two MDG’s per neighbourhood, per month.
Delivery
This standard should be read in conjunction with the MDG Operational
Plan_Sept 2015
Practices will be expected to:
Proactive Care Programme – Avoiding Unplanned Admissions (National
Direct Enhanced Service).
 Practices will sign up to and deliver the National Enhanced Service
Proactive Care Programme - Avoiding Unplanned Admissions and
consider the identified 2% population identified for discussion at the
neighbourhood MDG meeting.
Prepare for the MDG meeting
 In preparation for contribution at the MDG ensure that any preparatory
work is undertaken to ensure that all relevant information held on the
patient is ready for presentation at the MDG meeting.
 Proactive Planning: Use appropriate risk stratification to identify patients
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Salford Standard – Quality Standards for Primary Care

for discussion (page 118).
Reactive Planning: Review any patients that have had >2 admissions in 3
months/consider for wider discussion at the MDG.
 Log onto Allscripts/Sunrise EPR site to review the generated list for
discussion, prepare summary information of care plan.
 For those flagged for discussion on the list, ensure that the shared
care record is populated with any additional information which will
facilitate discussions at the MDG. This needs to be complete at least
the week prior to the MDG so that MDG colleagues have sufficient
time to review the information.
Attend the MDG meeting
 Practice to have representation (GP, ANP or any other relevant
practitioner) at the neighbourhood MDG meeting every 2 weeks.
(Meetings take place every 2 weeks which allows for timely review of any
previous admissions).
 Arrange alternative cover at the meeting to ensure that the practice is
represented.
 Proactively contribute to discussions on your patients.
 Where a referral is required into a service – the attending representative
from the service will accept this as a formal referral within the meeting.
Where the service is not represented in the meeting – it will be the
responsibility of the care coordinator to make the onward referral.
Post MDG actions:
 Undertake post work to complete any actions allocated in the MDG
meeting;
 Review and update Allscript / Sunrise list;
 Complete any actions assigned to you;
 Reflect updates in own professional care record;
 For patients identified for discussion ensure that:
 A patient held care record and shared care plan is produced and
given to the patient
 Inform any new patients added discussed of the named care coordinator
 An electronic care record and shared care plan is produced;
 Appropriately update read codes for any improvements/declines in the
level of Sally.
Care Coordination & Informing the Patient:
 If assigned the role of Care Coordinator – you will be responsible for
overseeing the delivery of the agreed care plan. This will require on-going
work with patient/service users and their carer/family and other
professionals involved in care to ensure that the plan is delivered;
 Where there is an update to the care plan – as care coordinator you are
responsible for sharing the updated plan with the individual and other
people involved in care and support and ensuring the patient’s views are
considered in advance of Shared Care Plan being agreed at the MDG.
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Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators
Proactive Care Programme – Avoiding Unplanned Admissions.
PC01_P:
Sign up to and deliver the requirements for the avoiding unplanned
admissions enhanced service. Threshold = 100%.
Attendance at the meeting.
PC02:
Evidence & Threshold.
Compliance will be monitored through review of:
 Sign in sheets at meetings - 75 % compliance.
Care-Co-coordination & Informing the Patient
PC04_P:
Evidence.
The compliance of this standard will be monitored through an annual audit. The
MDG Administrator will initiate the process and responsibility for the audit will lie
with the Integrated Care Programme Office. The audit will include a review of the
following:
1.
The name of the care co-ordinator in the individual’s shared care
record – 75% Compliance;
2.
Number of Shared Care Plans handed back to the individual – 75%
Compliance;
3.
Patient awareness of the care co-ordinator through the annual patient
satisfaction survey* – 75% Compliance.
*refer to 11.2 of the MDG Operational procedure.
Training
Evidence & Threshold.
See Section 4 for training requirements.
Support
SRFT will:
 Provide information to support practices to risk stratify their
population for identification for discussion at the MDG;
116

Provide an MDG Administrator to support MDG meetings to
coordinate and facilitate the MDG meetings for all localities – this
will include organisation of the meetings, sharing of information
to practices in a timely manner allowing for pre work to be
completed, tracking of patients progress through MDG
discussions, monitor review dates for patients to be discussed;

Ensure that practices have access to the appropriate software to
facilitate management of patients through the MDG process, e.g.
Electronic Shared Care Record, Allscript/Sunrise;

Ensure that appropriate skill mix of professionals are invited to
the MDG in order that the meeting is effective and efficient;

Ensure that the MDG Operational Procedure is updated.
Salford Standard – Quality Standards for Primary Care
The CCG will:
 Ensure that data quality will extract the appropriate read codes
from practice systems on monthly;

Contacts
References
117
Prepare and initiate the annual evaluation questionnaire.
Clinical Contact: Dr Jenny Walton; [email protected]
CCG
Contact:
Senior
Service
Improvement
[email protected]
Manager
Integration

Improving General Practice: A Call to Action, NHS England.

Salford Together, (2014) Operational Procedure–Integrated Care
Programme (ICP) Multi-Disciplinary Groups (MDGs) & Care
Coordination.

Salford Together (2014) Salford Integrated Care Programme for Older
People Service and Financial Plan (2014/15 – 2017/18.

MDG Operational Plan _September 2015
Salford Standard – Quality Standards for Primary Care
Risk Stratification and Review process for Vulnerable people at risk
Level of
Sally
Criteria
Level of Shared Care Plan
Triggers for review
Able Sally
(1)
 Active and self-managing
 Emergency admission escalated following
provisional screen
 2 or more attendances to A&E within 3 month
period escalated following provisional screen
 Newly diagnosed long term condition
 At risk of isolation/ recent bereavement
Needs
Some
Help Sally
(2)




Needs
Some
More Help
Sally (3)
 Newly diagnosed with moderate/severe
dementia
 Receives home care (substantial risk)
 Diagnosed with multiple long terms
conditions/co morbidities ( including
polypharmacy) requiring continuous support
from services
 Receive regular visits from district nursing
(those seen over W/E )
 Requires co-ordinated multi-professional
support
 Requires 24/7 care (includes anyone in
permanent residential or nursing care)
 High level care at home (critical risk)
Wellbeing planOwned and completed by individual with support if
required.
Includes 5 Ways to Wellbeing & personal
preferences/things that are important in their life.
May include Independence plan ( following Needs
Some Help Sally episode- but now able to selfmanage)
Independence plan –
Care plan with input from Health/Social Care
Professional (HSCP) who provides direct support to
the individual such as GP, practice, nurse, specialist
nurse, social worker or therapist.
Named key worker- most likely to be HSCP in most
regular contact- could be GP.
Contact number- in & out of hours
Anticipatory care plan- what to be aware of and do
should condition appear to deteriorate.
Supported Independence PlanAs above but shared care plan will be MDG care
plan.
Needs a
Lot of
Help Sally
(4)
Diagnosed with early/mild dementia
Co-dependent couple
Carer ( informal)
Newly diagnosed long term condition requiring
short term input till able to self- manage
 Lives Alone/Socially inactive
 On the Avoiding Unplanned Admissions Case
Management Register
Initiates discussion with individual for consideration
of ‘advance care’ planning
As above OR
 Have an unstable long term condition




Emergency admission escalated following
provisional screen for MDG REVIEW.
2 or more attendances to A&E within 3
month period - escalated following
provisional screen.
Escalated by HSCP due to concerns represent management plan
Is at risk of becoming de-stabilised due to
other factors
MDG Reviews-Excludes individuals on GSF
Care PlanShared care plan includes EOLC plan.
May be discussed within MDG or with community
team & care home.

Under regular review
119
Salford Standard – Quality Standards for Primary Care
120
Salford Standard – Quality Standards for Primary Care
Domain 8
121
Salford Standard – Quality Standards for Primary Care
Standard 8.1
Access to Primary Care Medical Services

Aims

Rationale
To improve access to primary care medical services.
To improve the patient experience of accessing primary care medical
services.
A patient’s ease of access to their practice, and preferred GP, can affect their
quality of care and health outcomes (Bottle et al., 2012; King’s Fund, 2012).
Similarly it is acknowledged that continuity of care has a positive impact on
emergency admissions. Research suggests that high levels of patient
satisfaction with access to primary care correlates with higher QOF scores,
and also with lower rates of emergency hospital admission (Kontopantelis et
al., 2010). On the other hand, poor access to a GP has been linked to a
higher proportion of patients with a first diagnosis of cancer being admitted to
hospital as an emergency (Bottle et al., 2012).
In terms of appointment availability, there is evidence that practices offering
less than 70 appointments per 1000 registered patients struggle to meet
demand, leading to access problems within core hours. Following recent
studies in order to optimise care in Salford, practices will be asked to offer
appointments that equate to 9% per registered population.
This standard is about having sufficient capacity to deal with demand and
avoid patients attending A&E, which is not an effective use of resource.
The denominator is the list size at the beginning of the quarter.
The numerator needs to be calculated as follows:
1. Take any week from the present quarter.
2. Calculate the total number of all face to face appointments carried out by
GP’s including training grades in that week.
3. Add the total number of appointments by advanced nurse practitioners
(ANP) who see acute undifferentiated illness
4. Add all telephone consultations undertaken by Doctors and ANP.
Delivery
122
Practices will be expected to:
 Provide bookable sessions morning and afternoon Monday to Friday;
 Offer access to both male and female clinical members of staff. (NB:
This does not have to cover all sessions and can be agreed locally);
 Open 8.00 am – 6.30pm, Monday to Friday (in their own practice);
 The minimum number of appointments should be 9% of the registered
practice list size per week (this can include face to face, telephone or
video consultations);
 Offer pre-bookable appointments up to 4 weeks in advance ;
 Offer several different methods of making appointments so no group is
disadvantaged e.g. patient online booking;
 Provide appropriate appointments for all deflections (e.g. NHS111 &
Salford Standard – Quality Standards for Primary Care



Key
Performance
Indicators









A&E);
Provide same day access where required (based on clinical need) for
all registered patients, both adults and children;
To facilitate and ensure continuity of care for patients registered with
the practice in order for them to access out of core hours primary care
services, practices are asked to complete (in line with CCG IG
protocols) a data sharing agreement to allow providers to access their
patient’s medical records;
To have a practice plan in place to achieve all of the above standards
and to give consent to share with all CCG member practices.
A01_P: Bookable appointment sessions Monday to Friday (am & pm)
A02_P: Access to both male and female clinical members of staff
A03_P: Practice is open between the hours of 8.00 am – 6.30 pm
A04_P: Provide appointments for 9% of the registered population per
week
A05_P: Appointments are bookable up to 4 weeks in advance
A06_P: Patients are able to access same day appointments (where
there is a clinical need identified)
A07_P: Practices are able to provide appropriate appointments for all
deflections (e.g. NHS111 & A&E)
A08_P: Signed Data Sharing Agreement in place
A09_P: Practice Access Plan (to be available)
Monitoring:
 A Mystery Shopper Audit of 10% of practices will be undertaken every
six months;
 An appointment list to be available on request;
 A data sharing agreement is in place;
 A practice access plan is developed.
Threshold: 100% for all.
Exclusions:
 Appointments initiated by the surgery for the purposes of undertaking
reviews for Long Term Condition patients
 QOF related appointments
 Blood tests
 Cervical smears
 Work carried out by a HCA
 Practice nurse appointments.
CCG Support
123
The CCG will:
 Provide a Data Sharing Agreement Template for practices to
complete;
Salford Standard – Quality Standards for Primary Care

Contacts
References
124
Provide data as appropriate to support submissions.
Clinical Leads: Dr Jeremy Tankel; [email protected] & Dr Annette
Johnson, Clinical Lead for Quality; [email protected]
CCG Contact:
Sam Glynn-Atkins, Service Improvement Manager;
[email protected]

Ipsos MORI, (2013) The Ipsos MORI Almanac 2013 Available at:
www.ipsos-mori.com/researchpublications/publications/1632/The-IpsosMORI- Almanac-2013.aspx

Kontopantelis, E., Roland, M., Reeves, D., (2010 Patient experience of
access to Primary Care: identification of predictors in a national patient
survey BMC Family Practice Vol: 11 p.61

NHS England (NHSE), (2014) National GP Survey Results Available at:
www.england.nhs.uk/statistics/category/statistics/gp-patient-survey/

Rosen R., (2014) Meeting need or fuelling demand? London: Nuffield
Trust & NHS England The King’s Fund, (2011) Improving the quality of
care in general practice London.

The King’s Fund, (2012) Exploring the association between quality of
care and the experience of patients London.

The Greater Manchester Association of CCGs (2015) Delivery of 7 day
access across Greater Manchester; 2 June, Agenda Item 4 p.5.
Salford Standard – Quality Standards for Primary Care
Domain 9
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Salford Standard – Quality Standards for Primary Care
Standard 9.1
Aims
Rationale
Patient Safety – learning from events / incidents

To improve patient safety by learning from incident reporting.
The National Patient Safety Agency (NPSA) defines significant event
analysis as:
‘A process in which individual episodes (when there has been a significant
occurrence either beneficial or deleterious) are analysed in a systematic
and detailed way to ascertain what can be learnt about the overall quality
of care, and to indicate any changes that might lead to future
improvements’.
The terms “significant event analysis” and “significant event audit” are used
interchangeably in a general practice context and mean the same thing. It
is a technique to reflect on, and learn from, individual cases to improve
quality of care overall.
All types of events / incidents offer an important opportunity for reflection
and learning. More often than not events / incidents highlight areas which
when appropriate actions are put in place, can improve the quality, safety
and experience for patients, carers and staff; however it needs to be
remembered that events / incidents can also demonstrate good practice.
By reporting incidents and near misses, GP practices can look at these and
link them with other information e.g. complaints, audit, to identify any
trends, reflect and disseminate learning in an appropriate way within the
practice, neighbourhood and across all GP practices in Salford.
Most incidents relate to system failure rather than an individual’s mistake.
Event / Incident reporting needs an open and fair culture so staff feel able
to report problems without fear of reprisal.
Practices should be able to demonstrate a team-based learning
environment.
As part of the revalidation process both medical and nursing staff are
expected to demonstrate they have reflected on events / incidents as
outlined within the professionals revalidation requirements. This is
measured by the employer and the NMC (Nursing staff) and the GMC
(GPs)
It is expected that practices will report those incidents which result in the
126
Salford Standard – Quality Standards for Primary Care
death of the patient, specifically the following:
Delivery

Suicides;


Requests for coroners statement;
Death on practice premises.
Practices will be expected to:

Abide by the ‘Duty of Candour’, as specified in the Joint statement
from the Chief Executives of statutory regulators of healthcare
professionals. See here;

Use the Insight web-based software system to report, manage and
handle events / incidents;

All staff should be aware of and be able to prioritise an event /
incident;

Information gathering. There should be evidence of information
gathering, including factual information on the event / incident such
as personal testimonies, written records and other health care
documentation. For more complex events, more in-depth analysis
will be required by using RCA methodology;

The event / incident should be shared with all members of the
practice (if appropriate) at team meetings to discuss, investigate and
analyse these events;

Analysis of the event / incident should include: what happened and
why, how could things have been different, what can we learn from
what happened, is change required; if so, what needs to change?;

Agree, implement and monitor change. There are no fixed endpoints; outcomes should be revisited and the implementation and
success of any agreed changes monitored at pre-set intervals;

It is expected that the following will always be reported:
 Suicides;
 Requests for coroners statement;
 Death on practice premises.
Key
Performance
Indicators
127
The following will be measured:

SE01_P:
That the Insight web based software system has been used to
report and investigate at least six event / incidents, three of which
must be GP practice incidents / events (report will be taken from
the web based system);
Salford Standard – Quality Standards for Primary Care

SE02_P:
GP practice events / Incidents have been reported and managed
within the timescales outlined within the CCG guidance documents
(report will be taken from the system);

SE03_P:
GP practice events / Incidents (identified via the system incident
number), actions to be taken and lessons learnt have been
discussed within a month of completion of the investigation, at
practice meetings (report will be taken from the system and minutes
of practice meetings);

SE04_P:
At least one incident per annum (identified via the incident
number), actions taken and the lessons learnt have been discussed
at the Neighbourhood meeting to enable learning across GP
member practices (minutes of Neighbourhood meetings);

SE05_P:
At the end of Quarter 4, each GP practice must submit a year-end
report outlining the number of incidents reported, how the learning
from incidents has been embedded within the practice, and the
impact this has had on the quality, safety and experience of patients,
carers and staff.
Submit to [email protected]
The threshold for all KPIs is 100%.
CCG Support



Contacts
128
The Midlands and Lancashire Shared Services, who ‘host’ the system
on behalf of the CCG, will provide on-going support / advice and
training to GP practices relating to the web based system.
The CCG GP Quality and Safety Clinical Leads will provide advice
and support for more complex issues as appropriate.
The Quality Assurance Team will provide quarterly reports to each
practice covering events / incidents reported at practice,
neighbourhood and CCG level.
Clinical Lead: Dr Jeremy Tankel; [email protected]
CCG Contact: Sue Harris, Lead Nurse Quality Assurance and
Improvement; [email protected]
Salford Standard – Quality Standards for Primary Care
Standard 9.2
Patient Experience
Rationale
When patients are ignored they are most at risk. This was one of the main
conclusions of the Francis Report (2013). In the same year, Don Berwick
presented his report on patient safety at The King’s fund. He suggested the
NHS should be engaging, empowering and hearing the views of patients,
and their carer’s, all the time. The Government Care Act (2014) strongly
advocates that patients are involved in decisions about their care, and
services that may affect them.
It is well documented that feedback from patients is vital in order to
transform NHS services, and support patient choice. The learning from
patient surveys, or patient forums, can be used to stimulate local
improvement, and also empower NHS staff to carry out the sort of changes
that make a real difference to patients and their care.
Patient Experience is a fundamental component of the quality of healthcare
and NHS Salford CCG is fully committed to seeking feedback and listening
to the views of patients- (Quality & Safety Strategy 15/16).
(a) From 1 April 2015, Patient Participation Groups are a mandatory
part of the GP contract, and practices will be expected to have an
effective group within the practice which meets at regular intervals,
empowers patients; assists and supports GP’s; and informs and
enhances the work of the CCG.
(b) A patient experience component was introduced into the Quality
Scheme during Q4 14/15, and practices have been expected to
develop a service improvement action plan which for 15/16 is based
on feedback from the last three GP national surveys.
Delivery
129
Practices will be expected to:
 Establish and organise effective patient participation group within the
practice which meets at regular intervals, empowers patients; assists
and supports GP’s; this informs and enhances the work of the CCG.
 Ensure that the group’s voice is heard and feedback and comments
used to make service improvements;
 Develop continuous improvement action plans using the themes arising
from local intelligence and patient feedback from Family & Friends test,
comments box, PPG feedback, and submit end of Q1 & Q3.
Salford Standard – Quality Standards for Primary Care
Key
Performance
Indicators

SE06_P:
At the end of Q2 and Q4 each GP practice will be required to provide
evidence to demonstrate that their patient participation group is
active, and feedback and learning is being acted upon within the
practice, and where appropriate Neighbourhood wide.

SE07_P:
At the end of Q2 and Q4 practices will be required to submit:
 their improvement action plans demonstrating how feedback
has been acted upon and used to make improvements;
 the minutes from PPG meetings using the template provided by
the CCG.
Plans to be submitted to: [email protected]
CCG Support
Contacts
References
130
The CCG will:
 Keep practices up to date on CCG priorities in order that patients are
informed;
 The CCG Patient Experience Manager will provide advice and
support for the set up and running of PPG’s, and attend meetings on
an ad-hoc basis;
 Develop a template to enable feedback to the CCG concerning
improvements that have been made as a result of PPG feedback;
 Organise & host yearly PPG Salford wide event.
Clinical Lead: Dr Jeremy Tankel; [email protected]
CCG Contact: Sue Harris, Lead Nurse Quality Assurance and Improvement;
[email protected]

http://www.hsj.co.uk/news/acute-care/the-francis-reports-18recommendations/5011951.article

http://www.kingsfund.org.uk/press/press-releases/our-response-donberwicks-report-patient-safety

http://www.napp.org.uk/ppgcontract.html

NHS Salford CCG Quality Strategy 2014-2017.pdf.

www.nice.org.uk/Guidance/CG138
Salford Standard – Quality Standards for Primary Care
Domain 10
131
Salford Standard – Quality Standards for Primary Care
Standard 10.1
Aims
Rationale
Demand Management


To ensure Effective Utilisation of Resources.
To deliver the Government ’referral to treatment’ target of 18 weeks,
by ensuring demand is clinically appropriate.
The government's priorities for modernising the NHS are underpinned by
achieving careful management of overall NHS resources. The priorities are
designed to ensure that people, wherever they live, have access to high
quality services and care. Consequently, the commissioners of services in
Greater Manchester are working to improve the cost effectiveness of
services.
The intention is to secure the greatest health gain from the resources
available by making decisions based on evidence about clinical effectiveness
balanced with known population needs, (Greater Manchester Effective Use of
Resources Operational Policy 2014).
Delivery
Practices will be expected to:
 Use NHS e-Referrals system when referring and offer a choice of
providers to patients;
 Ensure appropriate practice staff are aware of EUR Policies;
 Ensure EUR policies are easily accessible for all referrers within
practices;
 Comply with the EUR Policies; examples include:
 Benign skin lesions
 Grommets
 Tonsillectomy
For full list see link:
http://northwestcsu.nhs.uk/BrickwallResource/GetResource/292e42fc-c3944f97-b457-abc0a3799ba9
Key
Performance
Indicators
132
Submit a declaration of compliance with the following:

BM01_P:
Use of the NHS e-Referrals system (NHS e-Referrals booking
reports);

BM02_P:
Discussion of EUR policies with appropriate practice staff take place;

BM03_P:
Ensuring that EUR policies are easily accessible for all referrers within
Practices.
Salford Standard – Quality Standards for Primary Care
Submissions to: [email protected]
These will be monitored annually by audit.
CCG Support
The CCG will:
 Ensure EUR policies are up to date and available to practices on the
website;
 Work with Secondary Care to ensure services are published on NHS
e-Referrals, with availability to book appointments.
Contacts
Clinical Lead: Dr Jeremy Tankel; [email protected]
CCG Contact: Neil Cudby, Senior Service Improvement Manager Integration;
[email protected]
References
133

Greater Manchester Effective Use of Resources Operational Policy
http://northwestcsu.nhs.uk/BrickwallResource/GetResource/5f05623396fc-46bf-bc73-0b1d67f8e7e0

Salford CCG EUR Treatment Policies
http://northwestcsu.nhs.uk/BrickwallResource/GetResource/292e42fcc394-4f97-b457-abc0a3799ba9
Salford Standard – Quality Standards for Primary Care
Standard 10.2 Membership Engagement
Rationale
NHS Salford CCG is a membership organisation made up of all GPs from
across the 46 practices in Salford. The CCG aims to actively engage with its
members in order to ensure high quality services are commissioned to best
meet the needs of the population. Proactive and ongoing engagement
between GP’s and wider practice staff is fundamental to the CCG’s success.
This component outlines the core expectations of practices with regard to
membership engagement across the CCG (including inter-practice
engagement). The CCG recognises the importance of practice engagement
to:
 Enable shared learning and spreading of good practice;
 Identify and understand local challenges;
 Allowing for identification of common goals, as an integral part of the
community and neighbourhood;
 Establish a high level of shared purpose between practices and make
sure that contributes to planning care for patients;
 Understand the CCG vision, purpose, strategies and plans.
Delivery
134
Practices will be expected to:
 Identify a named commissioning lead in the practice to act as the main
conduit between the practice, neighbourhood and CCG;
 Attend the monthly Neighbourhood Clinical Commissioning Group
(NCCG) meeting - practice representation required (1x clinical and 1 x
non-clinical staff member);
 Attend the bi-monthly Salford Practice Managers Group meeting practice representation required (1 x practice manager attendance, or in
their absence non-clinical staff member);
 Attend the bi-monthly Salford Practice Nurse Forum – (1 x practice nurse
attendance);
 Attendance at two annual members events meetings – practice
representation required (at least 1x clinical and 1 x non-clinical staff
member);
 Practice completion and submission of the annual CCG questionnaire
(currently known as the baseline questionnaire as part of the Quality
Scheme);
 Read the members newsletters and other communications and ensure
that this is cascaded to wider practice staff, including those who don’t
have access to a computer;
 Invite wider practice staff (who wouldn’t normally attend the meetings
detailed in points 2 – 4 above) to attend twice annual neighbourhood
CCG engagement workshop). This will allow wider engagement with
those practice staff who wouldn’t usually attend CCG events / meetings.
Places will be allocated based on practice list size as follows:
Salford Standard – Quality Standards for Primary Care




Key
Performance
Indicators
List size;
0 – 4,999 = 2 staff (1 x clinical and 1 x non-clinical);
5,000 – 9,999 = 3 staff (2 x clinical and 1 x non-clinical);
10,000 + = 4 (2 x clinical and 2 x non-clinical).
It is recommended that this component sits outside of the monitoring and
financial payment as per the other domains so that engagement behaviour is
not jeopardised. On the whole membership engagement is good across
Salford and there is a risk that bundling payment up into other components may
cause risk to engagement. Payment will therefore be on based on attendance.
Members Engagement as monitored through the 2014/15 quality scheme
is as follows:
 BM04_P: Practice representation at NCCG meetings;
 BM05_P: Practice representation at Practice Managers meetings;
 BM06_P: Practice representation at practice nurse meetings.
Monitor: Annual audit.
Threshold: 100% representation = achieved;
75 - 100% = acceptable;
< 75% = trigger alert.
CCG Support
The CCG will:
 Ensure that CCG management support is allocated to each
neighbourhood in order to act as a key point of contact and to support
the operations of the neighbourhood meetings;
 That dates for meetings are scheduled and communicated in sufficient
time to allow for the practice to arrange for cover at the practice;
 Ensure that relevant information is provided ahead of meetings, in
sufficient time to allow members to understand the information provided;
 Ensure that engagement events are reflective of the CCG’s visions,
purpose, plans and strategies;
 Ensure that the CCG annual questionnaire is developed and sent out in
sufficient time for completion;
 Ensure that communication materials are relevant and provide up-todate and useful information;
 Ensure that any information raised by members is acted upon and
feedback to the appropriate team for action.
Contacts
Clinical Lead:
CCG Contact: Natalie McInerney, Service Improvement Manager;
[email protected]
135
Salford Standard – Quality Standards for Primary Care
Standard 10.3
Aims
Information Governance and IG Toolkit – including Business
Continuity Planning / Resilience


Rationale
To ensure GP practices have an adequate and up to date Business
Continuity Plan.
To ensure GP practices Business Continuity Plans include plans to
ensure they are effectively able to manage surges in activity i.e.
winter periods, around bank holiday weekends.
The NHS needs to be able to plan for and respond to a wide range of
incidents and emergencies that could affect health or patient care. These
could be anything from severe weather to an infectious disease outbreak or a
major incident.
Under the Civil Contingencies Act (2004), NHS organisations and providers of
NHS funded care must show that they can effectively respond to
emergencies and business continuity incidents while maintaining services to
patients.
In addition, CCG System Resilience Groups are required to provide
assurance to NHS England that robust arrangements are in place to
effectively manage surges in activity at both the start and the end of the
patients time in care, therefore, including primary care.
Delivery
Key
Performance
Indicators
Practices will be expected to:
 Have an adequate, up to date Business Continuity Plan;
 Within the Business Continuity plan Practices will be expected to have
outlined plans / processes to manage surges in activity;
 Examples of what these plans could include are below; plans may
involve federated working with other Practices:
 Extended hours / Weekend clinics;
 Additional capacity;
 Emergency only clinics post bank holiday;
 Drop-In clinics;
 Telephone consultations / Triage systems;
 Contingency staffing plans.

Complete IG Toolkit and achieve level 2 by 31 March each year,
including:
 BM07_P: Submission of a revised/updated Business
Continuity Plan to the CCG via IG Toolkit upload onto
website; to include an outline of plans/processes to manage
surges in activity
136
Salford Standard – Quality Standards for Primary Care
 BM08_P: Upload evidence onto the IG toolkit onto the online system
Monitor: Annual audit / random checks
Threshold = 100% for both.
Submit to [email protected]
CCG Support
Contacts
References
137
The CCG will:
 Provide a template for Business Continuity Planning to aid
submission.
Clinical Lead: TBC
CCG Contact: Caroline Rand, Head of Business Intelligence & Information
Technology; [email protected]

NHS England Core Standards for Emergency Preparedness,
Resilience
and
Response.
http://www.england.nhs.uk/wpcontent/uploads/2015/06/nhse-core-standards-150506.pdfponse 2015

Civil Contingencies Act 2004.
http://www.legislation.gov.uk/ukpga/2004/36/contents
Salford Standard – Quality Standards for Primary Care
Standard 10.4
Aims
Accessible Information

To establish a framework and set a clear direction such that patients
and service users (and where appropriate carers and parents) who
have information or communication needs relating to a disability,
impairment or sensory loss receive:
 ‘Accessible information’ (‘information which is able to be read
or received and understood by the individual or group for which
it is intended’);
 ‘Communication support’ (‘support which is needed to enable
effective, accurate dialogue between a professional and a
service user to take place’).

Such that they are not put “at a substantial disadvantage…in
comparison with persons who are not disabled” when accessing
NHS or adult social services. This includes accessible information and
communication support to enable individuals to:
 Make decisions about their health and wellbeing, and about
their care and treatment;
 Self-manage conditions;
 Access services appropriately and independently;
 Make choices about treatments and procedures including the
provision or withholding of consent;
 To be able to attend appointments, thereby reducing the
number of DNAs.

Rationale
The Equality Act became law in October 2010. It replaced, and aimed to
improve and strengthen, previous equalities legislation, including the
Disability Discrimination Act 1995. The Equality Act (the Act) covers all of
the groups that were protected by previous equality legislation, known as
Protected Characteristics, one of which is disability.
The Act places a legal duty on all service providers to take steps or make
“reasonable adjustments” in order to avoid putting a disabled person at a
substantial disadvantage when compared to a person who is not disabled.
Guidance produced by the Equality and Human Rights Commission (EHRC)
states that, “Anything which is more than minor or trivial is a substantial
disadvantage.” The Act is explicit in including the provision of information in
“an accessible format” as a ‘reasonable step’ to be taken.
Delivery
Practices will be expected to:
Provide information and support:
138

Make reasonable adjustments for those with protected characteristics;

Request information from the CCG where required e.g. BSL film;
Salford Standard – Quality Standards for Primary Care

Provide interpreters where required;

Request pictures & symbols where required;

Ensure that clinical systems include electronic flags or alerts to record
that the individual (and where appropriate, their carer) has a
communication need / requires information in a particular format and
mode of delivery, where such needs relate to disability, impairment or
sensory loss;
Enable patients to provide feedback about their experience of
receiving information in an appropriate format via PPGs, PALS, CCG
web page, questionnaires or engagement events;
Comply with Accessible Information Standard SCCI-1605.


Key
Performance
Indicators



CCG Support
139
BM09_P:
Comply with Accessible Information Standard SCCI-1605 by providing
information in a range of accessible formats which they can
understand.
Measure: submission of examples of information provided in an
alternative format to the CCG upon request.
Monitoring: annual audit.
Threshold: 100%.
BM12_P:
Practices must provide longer appointment times ideally 20 minutes,
but not less than 15 minutes where required.
 Evidence in the form of an audit made available to the
commissioner, if requested* showing the number of patients
with a read code of 13ZN with average length of appointments
for the 1st year of registration.
Threshold: ≥80% = Achieved;
<80% - 50% = Acceptable;
<50% = Improvement Plan.
BM13_P:
All eligible patients are able to access interpreters when required.
Measure: Practice to offer interpreters to all patients who require one
Monitoring: Practice to submit evidence in the form of proof of
signage or CQC report
Threshold: 100%.
The CCG will:
 Prepare and publish the communication and engagement strategy
which includes information on accessible communications;
 Ensure that their commissioning and procurement processes with
providers of health and / or adult social care reflect, enable and
Salford Standard – Quality Standards for Primary Care


Contacts
References
140
support implementation and compliance with this standard;
Seek assurance from provider organisations of their compliance with
this standard, including evidence of identifying, recording, flagging,
sharing and meeting of needs;
Ensure the Accessible Information Standard SCCI-1605 is available
on the website.
CCG Contact: Amanda Rafferty; [email protected]
For further information: www.england.nhs.uk/accessibleinfo-2/

SCCI1605 Accessible Information Specification (NHS England, 2015).


Access all Areas? (Action on Hearing Loss, 2013).
Action Plan on Hearing Loss (NHS England, 2015).

Equality Delivery System 2 (NHS England, 2013).

Final report of the Confidential Inquiry into premature deaths of people
with learning disabilities (CIPOLD) (University of Bristol CIPOLD
Team, 2013).

NHS Five Year Forward View (NHS England, 2014).

Patients First and Foremost: The Initial Government Response to the
Report of Mid Staffordshire NHS Foundation Trust Public Inquiry
(Department of Health, 2013).

‘Sick of It’ (SignHealth, 2014).

The Care Act 2014.

The Equality Act 2010.

The NHS Constitution (Department of Health, 2013).

The Power of Information (Department of Health, 2012).

Transforming care: A national response to Winterbourne View
Hospital, Department of Health Review: Final Report (Department of
Health, 2012).

Valuing People: A New Strategy for Learning Disability for the 21st
Century (Department of Health, 2001).
Salford Standard – Quality Standards for Primary Care
Standard 10.5
Declarations of Conflicts of Interest
Rationale
Clinical Commissioning Groups (CCGs) manage conflict of interests as part
of their day-to-day activities. Effective handling of such conflict is crucial for
the maintenance of public trust in the commissioning system. This assures
patients, providers, the Government and tax payers, that CCG commissioning
decisions are robust, fair, and transparent and offer value for money (NHSE,
2014).
NHS Salford CCG has developed a Conflict of Interests Policy. This policy is
part of a suite of important CCG documents necessary to ensure effective
governance arrangements for the CCG. All CCG members, clinical directors,
clinical leads and senior managers are bound by the Policy and must
familiarise themselves with it. The Policy is available on the CCG website
here
Delivery
Practices have a duty to:
All members and staff of the CCG and all those contractors working on the
CCGs behalf in discharging their functions have agreed to NHS statutory
Guidance on the management of conflicts of interest. Specifically they must
declare and perceived or actual conflicts of interest within 28 days of joining
the CCG; on changing roles within the CCG; and in taking part in the
business of committees or subcommittees of the CCG.
The groups covered by the scope of this standard are also required to provide
any updates to declared conflicts of interest (or nil returns) on a quarterly
basis.
All groups within the scope of this standard are also required to review their
declarations on an annual basis and update accordingly (including completing
nil returns).
Salford GPs are required to complete a Declaration of Interest Form and send
to the CCG for inclusion in the register; forms can be found in the Conflicts of
Interest Policy on the CCGs website.
Key
Performance
Indicators
All members and staff of the CCG to complete declarations of interest forms
by all groups covered by the scope of this standard.
Measure BM10_P: Submission of declaration of interest forms 6 monthly
(including nil returns) to [email protected]
Monitoring: 6 monthly reviews.
Threshold: 100%.
141
Salford Standard – Quality Standards for Primary Care
CCG Support
The CCG will:
 Provide an electronic document for submission;
 The Board Secretary, on behalf of the CCG Chair, will maintain a
Register of Interests declared by all CCG members. The Register can
be accessed at:
www.salfordccg.nhs.uk/images/RegisterofInterestBoardClinLeadandStaffAug
14.pdf
 The Register will be refreshed every 3 months and will be checked
annually for accuracy. All interests declared in the Register will be
published in the CCG’s Annual Report.
Contacts
References
142
CCG Contact: Jenny
[email protected]

Noble,
Head
of
Governance
and
Policy;
National health Service Act 2006 (section 140), as amended by the
Health and Social Care Act 2012.
Salford Standard – Quality Standards for Primary Care
SECTION 4
Education &
Training
143
Salford Standard – Quality Standards for Primary Care
4.1
Education and training programmes
6.1.1
6.1.2
4.1.1
NHS Salford Clinical Commissioning Group (CCG) will provide a programme of
education and other training sessions to support delivery of the Standards, and a
selection of educational needs identified by local Primary Care staff.
4.1.2
Dedicated programmes will be developed for GPs, Practice Nurses (PN) and Practice
Managers (PM).
4.1.3
The CCG will develop a calendar of education and training (CCG Calendar). This will
include the dates and topics for all education and training sessions to be covered
throughout the year. A copy of the CCG Calendar will be provided for each Practice.
4.1.4
The CCG will organise additional events which practices are expected to attend eg
mandatory training, safeguarding and health improvement.
4.2
General principles for education and training
4.2.1
The CCG will organise training as specified within the individual standards.
4.2.2
There will be some flexibility within the education and training programmes to
deliver ‘hot topics’ as they arise.
4.2.3
6.1.1
Education and training sessions will take place at appropriate venues across Salford
e.g. AJ Bell Stadium, Neighbourhood hubs, Gateways.
4.2.4
6.1.1
Information will be circulated via the Salford CCG Newsletter, Practice Manager and
GP distribution lists.
4.2.5
An agenda for each session will be developed by the relevant Leads.
4.2.6
6.1.1
Certificates of attendance, where appropriate, will be provided.
4.2.7
6.1.2
Representatives are expected to feedback at practice team meetings where
appropriate.
6.1.3
4.2.8
144
There may be extenuating circumstances when education sessions may need to be
cancelled at short notice. The CCG will endeavour to let Practices know well in
advance, but circumstances may dictate otherwise.
Salford Standard – Quality Standards for Primary Care
4.3
GP Education
4.3.1
All sessions provided will be 2hrs in length unless otherwise stated.
4.3.2
6.1.1
Sessions can also be arranged to take place at individual Practices, for those who
cannot attend the dedicated sessions. However, these can only be arranged in the
event of extenuating circumstances, and by prior agreement with the CCG.
4.4
Practice Nurse Meetings
4.4.1
Practice Nurse Forum - the diary allows for 6 sessions per annum.
Practice Nurse Leads – the diary allows for 12 sessions per annum
These sessions may be half or full days dependent on the topic.
4.4.2
Practice Nurse Forum meetings will usually be delivered on the 3rd Thursday of each
month.
4.4.3
Practices will be expected to encourage Practice Nurses to attend dedicated education
sessions.
4.5
Practice Manager Meetings
6.1.1
4.5.1
6.1.2
The diary allows for 6 x CCG led sessions per year. Practice Managers may also
choose to attend peer led sessions. These are organised by the Practice Manager
Lead.
6.1.3
4.5.2
The PM discussion forum and peer led sessions will usually be delivered alternately, on
a monthly basis.
4.5.3
In the event that a PM cannot attend a session, it is expected that Practices will send a
deputy, who will provide feedback to the PM.
4.5.4
It is the responsibility of individual PMs or deputies to take notes at the meeting, to
enable feedback at Practice Team meetings.
4.5.5
Following the meeting, the CCG will send out contact details of any speakers, in case
further information is needed by individual Practices.
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Salford Standard – Quality Standards for Primary Care
Education, Training & Meeting Programme 2016-17
GP Education
Date
Neighbourhood
CCG Meetings
(Practices)
Date
Date
April 12
12.30-14.30
June 30
12.30-14.30
April 21
DNACPR & ICD, Eccles Gateway 1-3pm
April 26
Members Event
April
May 23
GP safeguarding leads forum 1-3pm
May
June
July 19
GP safeguarding leads forum 1-3pm
GP safeguarding leads forum 1-3pm
November
November 22
Members Event
GP safeguarding leads forum 1-3pm
January
GP safeguarding leads forum 1-3pm
August 23
October 27
December 13
1-3pm
July 21
1-3pm
September 15
1-3pm
November 17
1-3pm
January 19
1-3pm
March 16
1-3pm
12.30-14.30
November
December
May 19
12.30-14.30
September
October
Practice Managers
(St James’s House)
Date
July
August
Sept
Practice Nurse Forum
(Pendleton Gateway)
12.30-14.30
January
February
March
GP safeguarding leads forum 1-3pm
March
Further training and education will include:
Standard
Page
Training organised by CCG
1.3
Respiratory Disease
31
Spirometry
1.5
Chronic Kidney Disease
40
Consultant led (SRFT) training
1.6
Chronic Liver Disease
45
Provide and support delivery for relevant events
1.8
End Of Life
51
DNA CPR training and ICD awareness
2.1
Safeguarding
69
See page 146
5.4
Long Term Conditions & Autistic Spectrum Conditions
84
Training to provide support for delivery of the LD DES
6.1
Health Improvement
95
Health checks
10.2
Membership Engagement
132
Meetings as listed in table above + NCCG workshops per annum
146
Salford Standard – Quality Standards for Primary Care
Safeguarding training seminars 2016
Children’s Training Seminars
TRAINING / SEMINAR
Child Sexual Exploitation and Child Trafficking
Attendees
GP Leads, etc
DATE / TIME
VENUE
March, 1-3pm
Pendleton Gateway
Level 2 Safeguarding Children
April, 1-3pm
Walkden Gateway
Female Genital Mutilation
May, 1-3pm
St. James’s House
Domestic Abuse
June, 1-3pm
Pendleton Gateway
Neglect
July, 1-3pm
Eccles Gateway
Child Sexual Exploitation and Child Trafficking
September, 1-3pm
Walkden Gateway
Level 2 Safeguarding Children
October, 1-3pm
Broughton Hub
Domestic Abuse
November, 1-3pm
Walkden Gateway
Level 3 Safeguarding Children
December, 1-3pm
Pendleton Gateway
Adults Training Seminars
TRAINING / SEMINAR
Attendees
DATE / TIME
VENUE
Adult Safeguarding
January, 1-3pm
St. James’s House
Adult Safeguarding
February, 1-3pm
St. James’s House
MCA / DoLs
March, 1-3pm
Eccles Gateway
Adult Safeguarding
April, 1-3pm
Pendleton Gateway
MCA / DoLs
May, 1-3pm
Walkden Gateway
Adult Safeguarding
June, 1-3pm
St. James’s House
MCA / DoLs
July, 1-3pm
Eccles Gateway
Adult Safeguarding
September, 1-3pm
Pendleton Gateway
MCA / DoLs
October, 1-3pm
Walkden Gateway
Adult Safeguarding
November, 1-3pm
Broughton Hub
MCA / DoLs
December, 1-3pm
Eccles Gateway
147
Salford Standard – Quality Standards for Primary Care
SECTION 5
PRACTICE
IMPLEMENTATION PLANS
148
Salford Standard – Quality Standards for Primary Care
SALFORD STANDARD IMPLEMENTATION PLAN
Practice Name
Address
Telephone
Clinical Lead
Email Address
Non-clinical Lead
Email address
Overview of the Practice Plans to Implement the Salford Standard
Describe the Actions that the practice is taking to implement the Salford Standard.
This can include practice processes.
149
Salford Standard – Quality Standards for Primary Care
Risks & Issues to Delivery of the Salford Standard & Mitigating Actions
What risks is the practice facing in delivering all or any of the Salford Standard. Please
provide these under broad headings e.g. Equipment; Workforce (Staffing); IM&T;
Premise; Processes; Other Resources etc. and what actions the practice have taken or
are not taking to support delivery.
Federation or Sub-contracting any part of the Salford Standard
Please provide details of the areas of work as a practice you are either subcontracting
or any Neighbourhood Working / Federated arrangements agreed.
Education
If not already included in another section, please provide details how the practice will
release the appropriate clinical and non-clinical staff to attend mandated education
sessions and system training as well any optional sessions.
Consultation
Please advise what consultation and/or discussion has been undertaken as part of the
Implementation Planning Process with a) staff in the practice and b) Practice PPG’s.
Please give dates and those involved.
150
Salford Standard – Quality Standards for Primary Care
Other
Please use this space to advise of anything else you would like to tell us that isn’t
already covered in the above.
Name of person submitting plan on behalf of the practice
Signature:_______________________________________ Date: ___________________
Signed Implementation Plans to be submitted electronically no later than the 31 May 2016
Email plans to: [email protected]
151
Salford Standard – Quality Standards for Primary Care
SALFORD STANDARD
GUIDANCE ON COMPLETING THE IMPLEMENTATION PLAN
To complete use the Implementation Plan Template provided and ensure all sections are completed.
This plan must be submitted to the CCG electronically by 31 May 2016 and should include information
on how the practice plans to:1.
Work towards delivering the Salford Standard and how the funding associated
will be utilised to facilitate and support delivery.
2.
Ensure the plans cover all aspects of resources to deliver the Salford Standard which may include:





3.
Workforce; What additional workforce do the practice need and how will they recruit
Equipment; Does the practice need new or replacement equipment that will help
deliver the Salford Standard (e.g. new Spirometers)
IT; Although the CCG will provide the Reporting Tool is there any additional IT
requirements that the practice requires
Estates/Premises; Does the practice need to reorganise their clinic space / working
space or is there scope to improve the practice premises; leasing of other rooms etc.
Processes; Does the practice have the right processes in place; do new ones need
writing; are there changes of roles within the practice; what needs to be done to embed
changes for existing staff. Please explain how the practice will work with staff to deliver
the changes.
Neighbourhood Working / Federated Working:
What liaison has the practice had with neighbourhood practices. Are there any
agreements in place to collectively manage the delivery of the Salford Standard or
certain standards or domains e.g. of this may be:


Shared LTC Nurses across the Neighbourhood to undertake LTC Reviews.
Sharing female and male GP’s to ensure that patients have a choice to see female or male
GP’s within the access standard
4.
Consultation: Explain what meetings the practice have held with both staff
(especially those who will be working on delivering aspects of the Salford Standard)
and patients – how has the practice communicated this and have they sought views
of staff and patients.
5.
Education: Education plays a large part in keeping abreast of changes (especially
around the Long Term Conditions Standards for example). Explain how the practice
is going to be able to release nominated staff to attend mandatory and optional
training sessions and you can demonstrate that staff are encouraged to attend CPD
sessions.
Following approval of the submitted Implementation Plan the second upfront payment will be released
to the practice. If a practice is unable to submit their Implementation Plan by the date specified please
contact the Service Improvement Team / CCG immediately.
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Salford Standard – Quality Standards for Primary Care
SECTION 6
KPIs:
Measuring
Monitoring
Thresholds
Please see Salford Standard Business Case Appendix 2
153
Salford Standard – Quality Standards for Primary Care
SECTION 7
Read Code
Directory
Refer to Salford Standard Business Case
(not included in this document)
154
Salford Standard – Quality Standards for Primary Care
SECTION 8
GLOSSARY
155
Salford Standard – Quality Standards for Primary Care
6CIT
A&E
AAA
ABPM
ACE
ACR
AF
AIDS
ALD
6 Item Cognitive Impairment Test
Accident & Emergency
Abdominal Aortic Aneurysm
Ambulatory Blood Pressure Monitoring
Angiotensin-converting enzyme
Albumin to creatinine ratio
Atrial Fibrillation
Auto Immune Deficiency Syndrome
Alcoholic Liver Disease
IG
IGR
IGRA
IMM
KPIs
LCS
LD
LD
LDSAF
AKI
ANP
APMS
ASC
BCSP
BMI
BMJ
BP
BPM
BSG
BTS
CCG
CHD
CKD
CLD
COPD
CPA
CPR
CQINS
CSE
CVD
DES
DH
DMARDS
DNA
DNACPR
DoLS
ECG
eGFR
EHRC
EOL
EOLC
EPaCCS
EUR
EDHR
FBC
FFT
GI
GLP1
GM
GMC
GMMMG
GMS
GMSS
GP
GPCOG
GSF
HBA1C
Acute Kidney Injury
Advanced Nurse Practitioner
Alternative Provider Medical Services
Autistic Spectrum Conditions
Bowel Cancer Screening Programme
Body Mass Index
British Medical Journal
Blood Pressure
Blood Pressure Monitor
British Society of Gastroenterology
British Thoracic Society
Clinical Commissioning Group
Coronary Heart Disease
Chronic Kidney Disease
Chronic Liver Disease
Chronic Obstructive Pulmonary Disease
Care Plan Approach
Cardiopulmonary Resuscitation
Commissioning for Quality & Innovation
Child Sexual Exploitation
Cardiovascular Disease
Directed Enhanced Services
Department of Health
Disease Modifying Anti-Rheumatic Drugs
Did Not Attend
Do Not Attempt Cardiopulmonary Resuscitation
Deprivation of Liberties
Electro Cardiograph
Estimated Glomerular Filtration Rate
Equality and Human Rights Commission
End of Life
End of life care
Electronic Palliative Care Co-ordination Systems
Effective Use of Resources
Equality Diversity and Human Rights
Full Blood Count
Friends and Family Test
Gastrointestinal
Glucogen-type peptide 1
Greater Manchester
General Medical Council
Greater Manchester Medicines Management Group
General Medical Services
Greater Manchester Shared Services
General Practitioner
GP assessment of Cognition
Gold Standards Framework
Haemoglobin A1c (Glycated Haemoglobin)
LEA
LES
LFTs
LMC
LTC
LTBI
MARAC
MATS
MCA
MCI
MDG
MRC
MMT
MND
MPIG
NALD
NCCG
NCSP
NDLS
NHSCSP
NHSE
NMC
NOAC
NPSA
OOH
PALS
PHE
PIA
PM
PMS
PN
PPG
PPV
PR
QCIA
RCA
RCGP
SCC
SDG
SMI
SRFT
STI
TB
TPMT
U&Es
WBC
WHO
156
Information Governance
Impaired Glucose Regulation
Interferon gamma release assay
Immunisation
Key Performance Indicators
Locally Commissioned Services
Learning Disabilities
Learning Disabilities
Learning Disability Self-Assessment
Framework
Local Education Authority
Local Enhanced Schemes
Liver Function Tests
Local Medical Committee
Long Term Conditions
Latent Tuberculosis Infection
Multi Agency Risk Assessment
Memory Assessment Service
Mental Capacity Act
Mild Cognitive Impairment
Multi-Disciplinary Group
Medical Research Council
Medicines Management Team
Motor Neurone Disease
Minimum Practice Income Guarantee
Non- Alcoholic Fatty Liver Disease
Neighbourhood Clinical Commissioning Group
National Chlamydia Screening Programme
National Liver Disease Strategy
NHS Cancer Screening Programme
NHS England
Nursing and Midwifery Council
New Oral Anticoagulant
National Patient Safety Agency
Out of Hours
Patient Advice and Liaison Service
Public Health England
Privacy Impact Assessment
Practice Manager
Personal Medical Services
Practice Nurse
Patient Participation Group
Post Payment Verification
Pulmonary Rehabilitation
Quality Clinical Impact Assessment
Root Cause Analysis
Royal College of General Practitioners
Salford City Council
Sick Day Guidance
Severe Mental Illness
Salford Royal NHS foundation Trust
Sexually Transmitted Infection
Tuberculosis
Thiopurine methyltransferase
Urea and Electrolytes
White Blood Count
World Health Organisation
Salford Standard – Quality Standards for Primary Care