Delivery of Planned Care Local Enhanced Service Pre Contract Support Project

Please refer to full specification in Appendix A.

[Planned Care LES Pre Contract Support] Overview The overall aims of this Planned Care Local Enhanced Service (PC LES) agreement are: • To improve the clinical and lifestyle outcomes for people who are frail or living with long term conditions or a serious mental illness • To improve the quality and consistency with which people with a range of long term conditions are identified and proactively managed in general practices in Camden. The objectives of the agreement are to embed: • Accurate identification of long term conditions and their complications • Best practice management of these conditions • Collective action across practices to establish the capacity to deliver this contract and achieve outcomes for patients ( and associated income rewards) through collaborative cross practice working at a locality level • Collaborative management with patients that empowers them (through the YOC care planning approach) to play an active role in their own care • Reflective practice that identifies problems and leads to improvements in delivery of care • Robust administrative and clinical systems to maximise access to the care specified • Targeted education and support to enable practices to maximise their impact on the cohort of patient captured by LES Key components LES The key components and outcomes of delivery of LES relate to: Identification/Prevalence and list reviews Care planning & clinical reviews RCAs Outcome: Increase register prevalence through active searching for eligible patients and list reviews to identify those at risk Outcome: Improve clinical outcomes and patient experience through the provision of enhanced care using a YOC care planning Outcome: Learning from review and reflection by conducting RCAs

Scope The Planned Care LES will build on the successful Long term Conditions LCS1 that has been running since October 2013. This LCS will extend both the scope and duration of the agreement and encourage collaborative working among GP practices. The scope will be extended from the existing 6 long term conditions: • Atrial fibrillation • Chronic Kidney disease • Chronic obstructive pulmonary disease • Diabetes • Heart Failure • Hypertension to include: • cancer and epilepsy; (two new long term conditions) • complex care (frailty); • serious mental illness (SMI) All Camden practices are eligible to apply for the LCS2 Programme and will be encouraged to do so through a collaborative / geographical / population approach to the specification, this could include the current locality approach i.e.: • North locality • South locality • West locality The provider is responsible for mobilising appropriate partnerships to ensure effective service delivery of the LCS2 Programme. Purpose To deliver LCS2 Programme support function during the development of delivery plans and service implementation January 2016 – 30th April 2016.