2015/16 Community Incentive Scheme (CIS) narrative for practices
August 2015
The CIS is changing name from the Community Incentive Scheme to GP plus – GP+. The scheme
will be referred to as GP+ in the remainder of this document.
1. Clinical
1.1 Quarterly reviews
INCENTIVE PAYMENT: £100 PER REVIEW
Appropriate for GP+ patients and to be performed with the support of Living Well Network
(LWN) Hub.
A quarterly review will be held at the GP surgery every 3 months between the individual, the
GP, and anyone else the person would like to be there with them. A GP+ practitioner may
attend this review, but this will be on a case by case basis, depending on need. If the GP has
queries about the support being offered, or would liken the GP+ worker to attend where
they have concerns, this can be arranged by contacting [email protected].
The GP+ team will prompt, and where needed, assist the person to make the quarterly
review appointment with the surgery. This should be with a named GP that the person
knows, and not carried out on emergency or on the day duty appointment.
At each review, the GP+ template will need to be completed on EMIS. This contains a
number of prompts around physical and mental health checks to be carried out. The areas
covered include; review of mental health and medication, review of the mental health
Recovery & Support Plan, blood pressure, general health check.
1.2 Annual reviews
INCENTIVE PAYMENT: £225 PER REVIEW
Appropriate for GP+ patients and to be performed with the support of the LWN Hub.
The annual review will include a more thorough physical health screen. This will mirror the
current QOF indicators, and will be an extra physical health check in addition to the annual
QOF requirement, targeting areas of need for each particular patient such as smoking
cessation or cervical cancer screening.
If the GP has any concerns about the person’s mental wellbeing, functioning, coping or
social stressors as a result of the review, they should contact the GP+ team to discuss and
jointly agree a plan. The GP+ team will aim to meet with the person promptly, and feedback
any outcome to the GP.
Should the person DNA, the GP+ team need to be informed so that they can check in with
the person and re-schedule, accompanying them if needed.
1.3 Physical health assessments
INCENTIVE PAYMENT: £50 PER ASSESSMENT
Applies to people on the SMI register but excludes people supported via GP+. Advanced
physical health checks for GP+ patients are included as part of the quarterly and annual
reviews.
The number on the SMI register for each practice is based on the information returned from
the reconciliation of the practice-based SMI register that was part of the 2014/15 scheme.
Physical health assessments will be informed by the baseline audits. For example, where the
audit highlights that someone on the SMI register has diabetes and their BP is more than
130/80, the practice will take steps to bring the BP in down in line with clinical guidance. MH
Locality leads are available for support.
2. Information and data quality
INCENTIVE PAYMENT: £525 ON COMPLETION OF ALL AUDITS, CODING AND ACCESS TO
RECORDS
2.1 Baseline audits
To be performed on the whole SMI register. The baseline audit performed in 2014/15
produced results that were variable and included unexpected anomalies which were due to
inconsistencies in coding. Therefore, the audits will be re-run using more specific
parameters and codes. EMIS templates will be provided shortly for audits to be completed
and data submitted by
Your locality lead will support each practice to analyse the results and formulate a plan to
perform the consequent health assessments (see item 1.3 above).
2.2 Repeat audit
Identical audits will be run at the end of the year in April with the expectation that
improvements in the physical health and healthcare of people on SMI registers will be
gained.
2.3 Depression coding
This element aims to improve the quality of coding for depression and to enable accurate
recording for the recurrent depression pilot which will start later this year.
2.4 Access to records
Patient access to records is already in process. The aim of including it in the GP+ scheme is
to ensure that individuals will be able to access their primary care record to support
recovery. It can also facilitate aspects of the recovery and support plan. It is preferable that
practices offer access to everything except free text.
The LWN Hub will be able to offer support to people to register for online services, where
required.
3 Training and education
3.1 All practice education event
INCENTIVE: £220 PER STAFF MEMBER, MAX OF 2 PER PRACTICE
All practice staff are invited to attend 2 all practice mental health educational events.
3.2 Mental Health First Aid Lite training
INCENTIVE: £175 PER STAFF MEMBER, MAX OF 2 PER PRACTICE
Training will be delivered by the Lambeth Early Intervention and Prevention Service (LEIPS)
mental health promotion team. Sessions are available from September 2015 through to
April 2016 in venues throughout the borough. There is no charge to the practice for this
training.
The scheme incentivises a maximum of 2 staff from each practice to attend the training.
Whilst non-clinical front line staff are prioritised, practices may be able to identify other
staff who could benefit e.g. HCAs, apprentices, newly qualified clinical personnel etc.
THIS TRAINING IS NOT SUITABLE FOR GPs
Dates and venues for the training are found in the document embedded below
MHFA Lite flyer
A4_CCG dates.pdf
4 Contacts




GP+ facilitator: [email protected]
South West Mental health clinical locality lead: [email protected]
South East Mental Health Clinical Locality Lead: [email protected]
North Mental Health Clinical Locality Lead: [email protected]