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GP commissioning take home messages

GP commissioning take home messages, written by Dr David Jenner (GP and NHS Alliance PBC Lead), are included in all of the clinical features in Guidelines in Practice. The complete archive of these PBC messages is below, and the associated articles can be accessed by clicking on the titles.

Although of particular relevance to commissioners and those involved in GP commissioning, these key messages are also useful for other healthcare professionals in primary care, highlighting the costs of referral and the areas of care that can be provided locally.

Article	Area	Issue
SIGN should review its guidance on anticoagulants, Dr Alan Begg	Cardiovascular	16 (5)
Although SIGN guidance relates to Scotland, many of the issues also relate to clinical commissioning in England The recommendation from the European Society of Cardiology on the use of CHA2DS2-VASc over CHADS2 in non-valvular atrial fibrillation is yet to be reflected in the quality and outcomes framework, or indeed recommended for use by NICE CCGs may wish to consider local incentive schemes to encourage practices to follow CHA2DS2-VASc if they consider the evidence on reducing thrombotic events in atrial fibrillation to be robust, and pending further guidance from SIGN or NICE The place of NOACs in the prophylaxis of thrombotic events in non-valvular atrial fibrillation should be clarified by CCGs in local formularies as NICE does recommend them as an option to consider against warfarin within their licensed indications NOACS are considerably more expensive than warfarin, but do not require regular blood monitoring so CCGs could identify the circumstances where they may be advantageous over warfarin in their formularies (e.g. in poor control of international normalised ratio using warfarin, or difficulty performing regular blood tests in itinerant, or housebound, individuals) CCG formularies should be adapted to clearly define the local choices and licensed indications for antithrombotic agents in secondary prevention of coronary heart disease, peripheral arterial disease, transient ischaemic attack, and stroke.
Structured review is an essential part of asthma care, Dr Dermot Ryan	Respiratory	16 (5)
The NICE quality standard for asthma should be considered by CCGs as a standard against which to assess the current provision of asthma services, and then to aspire to To ensure a short, clear, effective pathway to meet this standard, CCGs need to engage with GPs and GP out-of-hours services to increase training in asthma for primary care clinicians, and ensure that people with uncontrolled asthma can be referred directly to a specialist respiratory unit.NHS England, as commissioners of difficult asthma services, need to give priority to those patients most in need of these services CCGs should aim to ensure that patients with asthma attending hospital, out-of-hours or ambulance services, receive a prompt review of their asthma in hospital from a suitably qualified individual, or at their GP practice after discharge: this extra work needs to be paid for Practices are currently incentivised through QOF to undertake asthma reviews. New incentives are needed for GPs to carry out opportunistic reviews of people with asthma who do not attend reviews, to help reduce the number of emergency admissions; these patients often have psycho-social or emotional problems which hinder their asthma management As part of its central role of improving healthcare, the NHS has a responsibility to establish sustainable educational schemes to meet the education and skills requirements of healthcare professionals.
Training GPs in allergy testing would reduce referrals for rhinitis, Dr Matthew Doyle	Eye, Ear, Nose & Throat	16 (5)
The BSACI guideline recommends a far greater role for allergy testing than is currently provided in the majority of clinical practice In the current resource-restricted environment, CCGs will need to balance these recommendations against other commissioning priorities CCGs should investigate the availability of serum-specific IgE testing at local laboratories, as this is likely to be a more realistic and cost-efficient method of ensuring allergy testing than training busy GPs in skin prick testing CCGs should ensure they have access to a specialist allergy service for complex or more severe cases Once allergy services are commissioned, CCGs should ensure clear local care pathways are available to primary care to make the most efficient use of these services The link between allergic rhinitis and asthma is significant; CCGs could encourage practices to specifically address rhinitis symptoms in annual asthma reviews, as effective rhinitis treatment could improve asthma control for patients and reduce expenditure on asthma medication and emergency admissions.
Patients with asthma need to be able to use their inhaler effectively, Henry Chrystyn	Respiratory	16 (4)
Correct inhaler use is vital for the proper control of asthma, yet most adults do not use pMDIs effectively The QOF incentivises practices to check and record inhaler use at least annually for patients with asthma or chronic obstructive pulmonary disease CCGs could look to reduce avoidable emergency admissions and improve patient care by offering training for practice nurses as, with the abolition of PCTs, little primary care support is available from NHS England (formerly the NHS Commissioning Board) Although inhaler devices vary in price, NICE guidance says that patients should be offered an inhaler of their own choice, which, if used correctly, is likely to be cost effective and reduce the likelihood of exacerbations Local formularies for inhaler devices with cost comparisons, summaries of licensed indications, and dosing regimens are likely to help improve prescribing and help patients receive appropriate and effective treatments.
Support and advice is key in treating people with Crohn's disease, Sarah Cripps	Gastrointestinal	16 (4)
Crohn's disease is relatively uncommon, but is associated with considerable ongoing morbidity and healthcare costs For CCGs, the biggest costs will relate to hospital care and TNF-a inhibitors (the latter are excluded from the PbR tariff and impose costs as pass-through drugs) CCGs could; agree formularies for TNF-a inhibitors with secondary care to help reduce these costs, look to improve and streamline care by agreeing a local care pathway with specialists that allows the majority of care to be undertaken in the community