| Reference | FOI 2025/1231 |
|---|---|
| Description | Enhanced services NHS GM commission through primary care for LTC management (including Diabetes, Cardiovascular Disease, Chronic Kidney Disease, Respiratory conditions, etc.), |
| Date Requested | 19/05/2025 |
| Date Replied | 28/05/2025 |
| Category | Contract Management |
1. List of Enhances Services/Incentivisation schemes: Please provide a list of the services (specifications if possible) you commission through primary care specifically for LTC management – Please also include prescribing incentive schemes from your Medicines Optimisation team.
2. Delivery Level:Are these services delivered at a practice level, PCN level, or another level?
3. Commissioning Method: Are these services commissioned in bulk or individually
a. Contracting Details:How are primary care providers contracted to deliver these services? For example, is a percentage paid upfront with the remainder upon delivery?
b. Measurement Criteria: Are primary care providers measured based on activity outputs or outcomes?
4. Review Schedule:When are these services due for review?
5. Support Interest:Would you be interested in any support in designing, delivering, or evaluating the impact of these enhanced services for your population?
1. 2024/25 locally commissioned services through general practice, supporting the long-term conditions referenced above:
| Locality | Summary | Specification |
| Bolton | High risk Cardiovascular disease (CVD) reviews
High risk of type 2 diabetes screening Screening / ongoing reviews for Atrial Fibrillation, Asthma, Chronic obstructive pulmonary disease (COPD), Heart Failure, Chronic Kidney Disease, Diabetes. |
** |
| Bury | GM standards around Cardiovascular Disease, Diabetes and Medicines Optimisation are being used to support early detection of CVD and Type 2 Diabetes, including prevention. | ** |
| Heywood, Middleton & Rochdale (HMR) | Establishment of a neighbourhood plan of which CVD is included to improve population health outcomes.
Health checks undertaken with the aim of prevention for heart disease, strokes, type 2 diabetes and kidney disease, including prevention by monitoring blood pressure, cholesterol, smoking status, HbA1c levels and Body mass index (BMI). |
** |
| Manchester | Type 2 diabetic service to provide enhanced support within primary care, supporting a reduced need to be referred into secondary care, and improving patient experience.
Prescribing of Disease-modifying antirheumatic drugs (DMARDS) and associated patient testing for rheumatic disease. |
** |
| Oldham | Diabetes early detection / screening service to promote early identification of type 2 diabetes to try and reduce their CVD and mortality risks proactively.
Early detection and diagnosis of COPD – identify and ongoing review. |
** |
| Salford | Holistic care of patients with known CVD and Type 2 Diabetes. Long-term-condition reviews of patients with diabetes, frailty, asthma. Population health checks to prevent and detect early signs of heart disease, stroke, diabetes and kidney disease. | ** |
| Stockport | Falls reduction through frailty assessments for frail population, including patients identified with dementia. Assessments and care plans to be completed. Chronic disease management to be undertaken and structured medication reviews.
Early detection of heart failure including performing Electrocardiogram (ECG’s) as clinically required. Complete 6-monthly reviews for patients diagnosed with heart failure, including ECG’s and blood tests as required. Optimise patients with known CVD and Type 2 Diabetes undertaking frequent reviews of high-risk patients. |
** |
| Tameside | Neighbourhood health plan in place covering six areas: CVD (Inc. Stroke and Type 2 Diabetes), Musculoskeletal disorders, Mental I’ll health, Dementia, and Chronic Respiratory Disease. Focus on high-risk patients using a digital risk stratification tool to prioritise patients known with CVD and/or Type 2 Diabetes who are of highest risk and require reviews. | ** |
| Trafford | GM standards around Cardiovascular Disease, Diabetes and Medicines Optimisation are being used to support early detection of CVD and Type 2 Diabetes, including prevention by monitoring blood pressure, cholesterol, smoking status, HbA1c levels and BMI. | ** |
| Wigan | GM standards around Cardiovascular Disease, Diabetes and Medicines Optimisation are being used to support early detection of CVD and Type 2 Diabetes, including prevention by monitoring blood pressure, cholesterol, smoking status, HbA1c levels and BMI. | ** |
**Service Specifications were sent to the requester with this response. If you require a copy of the full response, together with the Service Specifications, please contact NHS GM’s FOI team – nhsgm.foi@nhs.net.**
2. Delivery in HMR locality is through sub-contracting arrangements via local Trust and GP Federation. These arrangements are under review in 2025/26.Tameside locality delivery is at PCN level. Locally commissioned services across all 8 other localities are delivered at GP Practices.
3. Services to support CVD and Diabetes are now being commissioned at a Greater Manchester level (specifications attached) to reduce variation of service delivery and funding, whilst improving equity of access and standardisation of provision and care for our patients.
**A word document was sent to the requester with this response. If you require a copy of the full response, together with the attachments, please contact NHS GM’s FOI team – nhsgm.foi@nhs.net.**
Other GM level commissioned services and schemes also include:
**Word documents were sent to the requester with this response. If you require a copy of the full response, together with the attachments, please contact NHS GM’s FOI team – nhsgm.foi@nhs.net.**
3a. There is currently a variance of partial payments paid upfront and remainder towards the end of the year dependent upon activity/achievement of outcomes delivered, or percentage payments staggered throughout the year based upon what is achieved in year.
3b. Primary care providers are measured utilising a combination of activity data and health outcomes data.
4. GP locally commissioned services are reviewed on a rolling annual basis.
5. We acknowledge your offer.
NHS Greater Manchester (NHS GM) is already progressing comprehensive review and evaluation of these services and how they are commissioned to understand the needs of the GM patient population and how best to improve their patient experience and access of these services. This also includes addressing Clinical Commissioning Group’s legacy variation in funding arrangements, supporting the ‘left shift’ from hospital to community as outlined by Lord Darzi, and targeting on contribution to improving patient outcomes and the impact on overall healthcare system costs.
