The following support article summaries the requirements for the Network DES contract for 2020/21 and offers guidance around how Ardens can help you achieve these requirements. Please see NHS England guidance here.


Enhanced Health in Care Homes

For PCN's patients who are living in the PCN Aligned Care Home(s), its suggested clinicians to deliver a weekly 'home round'. Please see pages 46 and 47 of the NHS England guidance for further information.


Ardens have provided searches to help practices monitor care home activity. To locate the searches, navigate to the Population Reporting module > Ardens Searches > Ardens Main Searches > Ardens Manager National Cntract Reports > Care Home folder.


The Clinical Activity folder (once run) will report on encounter, care planning, review, death and vaccination activity.


The Register folder will provide practices with detailed practice care registers, including patients currently living in a nursing/care/residential home and those patients who have passed away in a care home in the past year.


The Work to do folder identifies work to be done, for example, patients that have not got a record of preferred place of death or care in the past 3 years. To complete the work to do, record the relevant information for the patients displaying in the Population Reporting tab. Please note - the Ardens Care Home template can be used to record the required information.



The Care home data quality search folder identifies patients who have a 'care home' code in their record which is not recognised by the PCN DES business rules. You may wish to re-code these with 'Lives in residential home' or 'Lives in nursing home' ((or living temporarily in care home') as these are the recognised codes.


To support practices with capturing  consistent ward round data for care home patients, the Ardens Care Home template is available, please see further details of this template here along with other supporting templates.



Early Cancer Diagnosis 

Our understanding of the service specification is that practices should work together to achieve the QOF QI Early Cancer diagnosis. 


The Quality Improvement for Early Cancer Diagnosis requires practices to improve participation in the national cancer screening programme, and also improve referral and safety-netting practices for patients suspected of having cancer.


Ardens have a number of resources to support these requirements.


The Ardens Cancer screening searches (which can be located in Population Reporting > Ardens Searches > Ardens Main Searches > Cancer screening searches folder), identifies uptake for bowel and breast screening for those patients eligible. 



The Cervical screening uptake and call/recall folder contains searches to identify eligible patients that are yet to have cervical screening and due either a 1st, 2nd or 3rd invitation.


The Ardens Fast Track Safety Netting Tools allows practices to keep track of patients referred for a 2WW fast track referral. The tools include alerts to warn clinicians if a patient is yet to be seen within 3 weeks. Further information of the Ardens Fast Track Safety Netting tools can be found here.



To monitor achievement of cancer activity and identifying work that still needs to be done relating to PCN DES. Access the Population Reporting module > Ardens Searches > Ardens Manager National Cntract Reports > Cancer folder.


The Clinical Activity folder (once run) will report on the diagnosis, referral and screening activity recorded for this fiscal year.


The Work to do folder identifies work to be done. This is mainly patients that have not had screening advice recorded in this fiscal year. The practice also have the option to narrow down to specific groups of patients, such as Learning Disability, Transgender and BAME. 


To complete the work to do, access the patients displaying in the Population Reporting tab, check if a patient has been given advice and code appropriately.


The Ardens Cancer Template includes a Cancer Care Review page to complete the review for the patient.


Additional Roles Reimbursement Scheme (ARRS)

Each PCN may employ Allied Health Professionals to work with GP Practices. 


Social Prescribers and Clinical Pharmacists may wish to use the Ardens Social Prescribing and Signposting Template to record activity. This template can be located in the Ardens > Other templates > Social folder



Please note - there is now an available social prescribing referral code which is reflected both in the template and associated searches. 


Physiotherapists may wish to use the Ardens Musculoskeletal Template to record activity. This template can be located in the Ardens > Other Templates > Musculoskeletal folder.


Ardens have created a suite of searches to help practices and PCNs to monitor the activity of the Allied Health Professionals. To access the searches, navigate to the Population Reporting module > Ardens Searches > Ardens Manager National Cntract Reports > Team Activity folder.


The Team Activity folder contains searches broken down by role:



Run the searches individually or by entire folder to view the results.


Structured Medication Reviews (SMR)

PCNs should identify specific groups of patients who need a SMR. To support practices to identify target populations, Ardens have created a suite of searches.


To access the searches, navigate to the Population Reporting module > Ardens Searches > Ardens Main Searches > Ardens Manager National Cntract Reports > SMR folder.


The Clinical Activity folder outlines the SMR activity done in this fiscal year, broken down by the types of review recorded.


The Register folder will provide practices with a list of target population for SMR. 


The SMR - target populations folder breaks the target population by groups (care home residents, patients recorded as having a fall or admission in last 6 months, housebound, medication associated with errors, severe frailty patients and those patients on 10 repeats or more.


The SMR Data quality search folder identifies patients who have had a 'medication review' since 1st October 2020 and have more than one element of SMR done and may need a SMR coded added to their record.


The Work to do folder identifies work to be done and patients requiring a structured medication review. Click on the Population Included tab to identify the patients. Please note - the Ardens Structured Medication Review includes standardise coding of this activity.



To standardise coding of this activity, Ardens have provided a Structured Medication Review template and Pharmacist Review Template, both can be searched for via the Run Template option in the consultation screen.


Please see the following support article, for further information on the Structure Medication Review template - click here.


Investment Impact Fund (IIF)

PCNs have already been allocated 27p/weighted patient through the PCN support funding stream and this covers Apr-Sep 2020. The remaining £24.5m funding will be available for PCNs to earn through the new IIF, which will operate in a similar way to QOF (with each indicator allocated a certain number of points). There are six indicators:


  • PR01: Percentage of patients aged 65+ on 31 Mar 2021 who have received a seasonal flu vaccination. 72 points, minimum achievement 70%, target full payment 77%. All activity between 1 Sep 2020 and 31 Mar 2021 included.
  • HI01: Percentage of LD patients who have received a LD health check. 47 points, minimum achievement 49%, target for full payment 80%. All patients on LD register as of 31 Mar 2021 are included. All activity between 1 Apr 2020 and 31 Mar 2021 included.
  • PC01: Percentage of patients referred to social prescribing. 25 points, minimum achievement 0.4%, target for full payment 0.8%. All activity between 1 Apr 2020 and 31 Mar 2021 included.
  • MS01: Percentage of patients aged 65+ prescribed NSAID without gastro-protection. 32 points, minimum achievement 43%, target for full payment 30%.
  • MS02: Percentage of patients aged 18+ prescribed oral anti-coagulant and anti-platelet without gastro-protective. 6 points, minimum achievement 40%, target for full payment 25%.
  • MS03: Percentage of patients aged 18+ prescribed aspirin and another anti-platelet without gastro-protective. 12 points, minimum achievement 42%, target for full payment 25%.
     

Please note - the "MS" indicators are "inverse indicators" and the target is as few patients as possible. Only prescribing between 1 Oct 2020 and 31 Mar 2021 is included.


For 2020/21 each IIF point will be worth £111 and there will be 194 points available to each PCN. Payments are linked to prevalence and unweighted list size on 1 Jan 2021. This means that PCNs with a higher prevalence and/or larger list-size than the national average will receive more funding.


Ardens have created a suite of IIF searches to support practices monitor achievement and a summary of work still to do. To access the searches, navigate to the Population Reporting module > Ardens Searches > Ardens Main Searches > Ardens Manager National Cntract Reports > IIF folder.


The Clinical Activity folder is broken down by sub folders relating to the 6 indicators.


The Summary of work to do folder will identify work still to be done to achieve the relevant indicator.



The following indicators work on a downwards scale, and the target is a few patients as possible:

  • IIF: Prescribing  - No gastroprotection if dual antiplatelet + >18y
  • IIF: Prescribing - No gastroprotection if on NSAID + >65y 
  • IIF: Prescribing - No gastroprotection if on OAC/AP + >18y 


For each patient displaying in the Population Included tab for the searches above, review the patient record and add the appropriate information.


The following indicators work on a upwards scale, and the target is as many patients as possible.

  • IIF: Review - Not had LD Health Check 
  • IIF: Vaccinations - Not had seasonal flu vaccination if > 65y


The Ardens Learning Disability template includes the relevant codes needed to complete the LD Health Check. To achieve this indicator, the patient must be recorded appropriately with a Learning Disabilities health assessment, Learning Disabilities health action plan reviewed or a completion of Learning Disabilities health action plan in the current financial year. 


Practices may also find the LD housekeeping searches will be useful to identify potentially missing from their LD register:



The above searches can be found within the Ardens Searches > Ardens Main Searches > Learning Disability >  NHSE Guidance ref 001030 folder.


For patients needing a flu vaccination, Ardens have a number of resources to support practices with this, please see here.


If you require any further assistance on the process above, please contact Ardens support on: suport-emis@ardens.org.uk