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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
A multidisciplinary team is vital in the care of hip fracture patients, Dr Sally Hope	Musculoskeletal & Joints	15 (1)
Commissioners should be fully aware of the best-practice tariffs operating for people aged over 60 years who have a fragility hip fracture The tariff is payable when all of the following clinical characteristics are met by the provider: time to surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia; admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon; admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery, and anaesthesia; assessed by a geriatrician in the perioperative period (within 72 hours of admission); post-operative geriatrician-directed multiprofessional rehabilitation team; fracture prevention assessments (falls and bone health) The best practice tariff offers a premium of £890 over the base tariff (c.£5000–£8500).
NICE updates its ACD algorithm on antihypertensive drugs, Dr Terry McCormack	Cardiovascular	15 (1)
The main issue for commissioners from the updated guideline on hypertension is the use and funding of ABPM for the diagnosis of hypertension The cost of this equipment tends to fall to the providers (GPs), whereas any savings from reduced prescription costs will be allocated to the prescribing element of the commissioning budget Commissioners might therefore consider funding ABPM monitors from a top slice of the prescribing budget to ensure uptake of the guideline All groups of antihypertensive drugs discussed in the guidance are now available generically and at low cost and should be identified in local formularies Candesartan is a popular angiotensin-receptor blocker that is expected to come off patent in May 2012 so generic prescribing should be encouraged now.
People with CKD have a higher risk of cardiovascular events, Dr Ivan Benett	Cardiovascular	15 (1)
Commissioners could begin their review of CKD by examining the QOF practice prevalence to ensure that patients are being identified The QOF indicators for CKD (CKD1–CKD6) also provide information on the basic management of patients, particularly in relation to blood pressure control Commissioners will need to secure, through contracts, best practice tariffs for effective care, including dialysis, for people with end-stage CKD The quality standard for CKD is likely to form part of the national outcomes framework, which will judge the performance of commissioners and clinical commissioning groups and direct payments for quality premiums (subject to legislation) Any focus on CKD is likely to increase detection and referral to secondary care—commissioners would be wise to agree local referral care pathways to prevent overwhelming secondary care and excessive tariff costs Tariff prices for nephrology outpatient = £198 (new), £128 (follow up)
Early recognition of lung cancer will help to improve outcomes, Dr David Baldwin	Malignant Disease	14 (12)
Commissioners should ensure that primary care has access to radiology and smoking cessation services as prevention and early diagnosis of lung cancer are key responsibilities for GP practices Commissioners will need to work with their local cancer network to ensure that NICE-recommended specialist services are available locally or at a tertiary centre Specialist chemotherapy regimens should be agreed between commissioners and providers through cancer networks, and the costs specified in contracts It is recommended that patients have access to a specialist lung cancer nurse and commissioners should ensure that such a post is complementary to primary and community services, including palliative care Contracts should specify how chemotherapy and specialist nurse contacts are paid; here will be a new mandatory tariff for chemotherapy and external beam radiotherapy in 2012.
CHD indicators provide more detail on treatment of MI, Dr Alan Begg	Cardiovascular	14 (11)
GP commissioners should be aware that the QOF CHD markers do not match NICE and SIGN guidance in all areas The diagnosis and investigation of possible CHD is a key point for agreement of a local care pathway that follows NICE/SIGN guidance and which matches the availability of specialist investigations GP commissioners could work with colleagues in primary care commissioning to agree local-exception reporting to cover CHD13 and CHD8 (if target cholesterol levels cannot be met using NICE-approved lipid lowering agents) GP commissioners could specify that acute hospital contracts include a requirement for NICE-approved medication and interventions following acute admissions for ACS and angina NICE has released new guidance on the use of ticagrelor in ACS (Technology Appraisal 236), which will need to be funded and built into local antiplatelet protocols for management post-ACS Costs of antiplatelet treatment per month: - Aspirin 75 mg (28) = £0.82 - Clopidogrel 75 mg (30) = £1.94 - Ticagrelor 90 mg (56) = £54.60.