National Primary Care Development Team Phase III Penny Gates Lead Manager SW Peninsula NPDT Centre

1. National Primary Care Development TeamPhase IIIPenny GatesLead ManagerSW Peninsula NPDT Centre

2. Chronic Disease Management • Diabetes • COPD • National Programme commenced September 2003 • 20 PCTs & 100 practices including • Bath & NE Somerset • Bournemouth • Bristol North • Torbay • Refine the model and generate exemplars

3. Rollout • Available to all PCTs April 2004 • £20,000 for 2004/05 to provide project management support for participating PCTs • Help practices reach the required standards to secure the necessary points under the new contract • Application of generic improvement tools • Help to address other clinical areas within the QOF • Measures to demonstrate improvement

4. Aims • To ensure that a minimum of 60% of all people with Diabetes (both Type 1 and Type 2) within participating sites have an HBA1c<7.5 • To reduce the number of COPD hospital admissions by 40% in participating sites

5. How? • Creation of care pathways for diabetes and COPD between primary and secondary care • Delivering improvement at Practice level • Getting the whole Practice on board • Proactive secondary prevention • Patient involvement • Support from the PCT • Support from local NPDT Centre • Measurement

6. Improvement measuresDiabetes • % of people with diabetes with a last recorded HbA1c of <7.5 within the previous 12 months • % of people with diabetes with a last recorded cholesterol reading of <5 mmol within the previous 12 months • % of people with diabetes with a lst recorded BP reading of <140/80 within the previous 12 months • % of people with diabetes with a retinopathy screening recorded within the previous 15 months (such screening according to national approved technique

7. Improvement measuresCOPD • % of patients who have received spirometry to confirm diagnosis • % of COPD patients with smoking status recorded within previous 12 months • Number of acute admissions for respiratory illness in COPD patients in the previous 12 months

10. Other NPDT programmes…

11. QuISPQuality Improvement Skills for Primary Care • 4 national one day learning events on the QOF • 20 February - London • 25 February - Bristol • 27 February - Birmingham • 1 March - Manchester • 3 national "train the trainer events" • Local delivery of QuISP training programme • To multi-disciplinary practice teams in a third of PCTs • Deliver training and practical tools in improvement techniques to primary care professionals • Help practice teams and PCTs to implement the new contract

12. QuISP Programme • 3 one-day Workshops • Approximately 30 participants • 3-4 members from between 6-10 practices per programme • Commencing April this year • Devon & Cornwall

13. nGMS/PMS Collaborative • Help PCTs and practices teams to maximise the benefits achievable under nGMS and PMS • 28 sites, one in each SHA area based on 28 PCTs and their constituent practices • Drawing on expertise of others • Showcase examples of good practice and what is possible • Delivery through the NPDT Centres

14. Any questions?