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Transcript of Federating for Innovation - Primary Care Commissioning · Uroflowmetry - Dantec-Danflow...
Federating for Innovation: The experience
of ‘GP Care’
Dr Phil Yates July 2014
Biography
• GP in Bristol, 30 years;
• Senior Partner large general practice, 14 years;
• PEC Chair South Gloucestershire PCT, 6 years;
• National Clinical Advisor to Modernisation Agency, 2 years;
• APMS contract for 8-8 services, 5 years;
• Chairman of GP Care, 8 years;
• Council Member of South West Clinical Senate, 1 year;
• Council member of National Association of Primary Care, <1 year.
Agenda
1. Why Federate?
2. The provider environment & the birth of GP Care;
3. Innovative Services: a. Near patient testing
i. Ultrasound;
ii. DVT & Anticoagulation;
iii. Urology diagnostics;
b. Patient Record Network ‘PRN’ for Clinical Records;
c. Screening for referral value: i. Sleep Apnoea screening;
ii. Cardiac Arrhythmia screening;
d. Consultant Link Service – advice and guidance
4. Practice development & transformation
5. Accountable Care and re-modelling provision
6. Summary
1. Why Federate?
Support
• New income streams for primary care;
• Preventing ‘cherry picking’ by the commercial sector;
• Ensuring integration with general practices;
• Back office support;
Bidding & Risk Sharing
• Bidding at scale for contracts;
• Quality Assurance of service delivery;
Remodelling Care
• “Think like a patient: Act like a taxpayer”;
• Reform of General Practice and patient access;
• Linking in-hours and OOH care.
Supporting efficiency and financial NHS restructuring
• Prime Contractor → Accountable Care.
Why Federate?
Re-modelling ‘Out-of-hospital’ Care
10 Care 20 & 30 Care
GP led
Consultant led
All undifferentiated illness
Little cross referral
Limited long-term conditions (LTCs)
Most access to diagnostics
Acute management major conditions
Long-term follow up of many LTCs
Pre-primary 10 & Community delivered 20 & 30
SSD / Pharmacist / Nurse GP Consultants
Web-based
advice; self-help
tel, email & SMS;
expert patient;
community & 3rd
sector support
Assessing risk
Minor illness & injury
Specialist nurses
LTCs & social care
Telemedicine
Telehealth
Diagnostic uncertainty
1st diagnosis
Complex problems
Follow ups
Sub-specialisation
Multiprofessional teams
Major surgery
High-tech
interventions
True ‘consultancy’
Teaching &
support
2. The provider environment and the birth of GP Care
Commissioner / Provider environment
CCGs (& CSUs)
DH
Provider CICs / SEs Various FTs
Independent Sector
Mental Health
NHS England & LATs
Optometrists Dentists
Pharmacists
Policy
Co
mm
ission
er In
de
pe
nd
ent P
rovid
ers
GPs
Local Authorities
& PH England
Need for larger medically-based community providers
CCGs (& CSUs)
Provider CICs / SEs Various FTs
Independent Sector
Mental Health
NHS England & LATs
Optometrists Dentists
Pharmacists
Policy
Co
mm
ission
er In
de
pe
nd
ent P
rovid
ers
GP Care
Local Authorities
& PH England
DH
Independent Sector
Independent Sector
Independent Sector
About us
• Ltd Co:
• 100 GP practices;
• 700 GPs;
• 850,000 population coverage;
• Provider of community-based care to the NHS;
• Articles of Association similar to a CIC or SE;
• Strict regulations controlling conflict of interests.
Our objective
• To facilitate the shift of NHS healthcare services into primary care/community;
• To deliver innovation that benefits patients and the public purse;
• To support existing NHS Clinicians.
Our operational model
• A bidding and contract holding entity;
• Subcontract clinical care to existing local teams (both 10 & 20 care);
• Redesign admin pathways and manage patients.
GP Care – Who are we?
We are about collaboration & integration not fragmentation
GP Care’s Principles
• Focus on the patients’ experience;
• Reunite clinicians to improve care – each service is consultant and GP led;
• ‘Hide’ all patient-facing bureaucracy & governance: – Hassle free, dependable, speedy;
– Services where they’re needed;
• Exemplary clinical governance and quality;
• Prioritise relationship to the Commissioner;
• Ensure every ‘performer’ is incentivised.
Services and our operational relationships
Chambers of Consultants
GP Surgeries & OOH bases
Acute and Foundation Trusts
Hand surgery
Minor Surgery
Urology
Cardiology
Anticoagulation
Ultrasonography & Dexa
Audiology
Nurses, Physios & HCAs
Urology
General Medicine
Radiology
Respiratory / sleep
Third & Charity Sectors; SEs & CICs
Urodynamics
Audiology
Commissioner
Support functions: •HR & legal •Finance & payroll •Trouble shooting •Practice merger & development
Support functions: Consultant Link Service – advice & guidance Patient record network
Service Locations
Deliberately
diffuse – use
bases where
people live
Counters
inequalities &
the ‘inverse care
law’ of health
provision
Network of 90+
premises – from
which we select
& operate
GP Care provides
1. the critical mass
for commissioning
of different services
in the community
2. Quality
Assurance
Places specialists
where patients
need specialist
care
Mobile ‘kit’ means
anachronistic
institutional care
outmoded
Nature of GP Care and other GP Provider Companies
• Established as a Ltd Co but loose network with member practices;
• Working with Nuffield Trust on a national network of GP Provider Companies:
– Need to recognise these entities as ‘Providers in contract with the NHS’;
– Need as much support as any other provider organisation to develop integrated community services
e.g. N3; PACS; IEP; EMIS; SUS; PAS.
3. Innovative services
a) Near patient testing
i. Ultrasound;
ii. DVT & Anticoagulation;
iii. Urology diagnostics;
Mobile Ultrasound
- Phillips CX50
i. Ultrasound
• DVT & urology support
• Non-obstetric, community-based delivery
• Pregnancy reassurance scans
• Linked to centre and hospitals with N3, PACS & Image Exchange Portal, SUS.
• Immediate advice available from Radiologist
• Uploadable to hospital so no repeat scans needed
Winner of ‘Community service redesign’ national
award for prison service
Winner of ‘Healthcare Outcomes’ national award
ii. DVT & Anticoagulation
• Point of care d-dimer tests
– Immediate results
– Reduced administration
– Reduced clinical risk
– Immediate treatment
• Point of care INR monitoring
– Less administration
– Face to face discussion with patients for clarity
– Reduced costs to NHS
A
C
C S u r g e r y
POC D-dimer - Clexane Ultrasound, b/test & Rx
Clexane (daily) & POC INR (or other anticoagulants)
Average 4.7 visits to local base
Never darken the hospital’s doors
Convenient - to patient: integration with own GP
72% reduction in cost to the NHS
DVT
2nd win (2014) in 3 years for ‘Community
Innovation’
• Now being asked to widen our inclusion criteria
• Local haematologist is our 2ndy care lead
Uroflowmetry - Dantec-Danflow
Flexi-cystoscopy – Dantec
& Endosheath system
iii. Urology diagnostics
• Remote electronic consultant triage reduces demand by 15%
• One stop shop
• Delivered in surgeries by our ultrasound team and the acute Trust’s consultants
• Innovative sheath technologies
• 60% patients managed entirely within primary care
• Seamless onward referral for 2WW and cancer care
3. Innovative services
b. Patient Record Network (PRN) for clinical records
Patient Record Network
• EMIS-Web based clinical record system
• 500,000 records available (Read only) in: - – Hospital Emergency Departments
– GP Out of hours bases
– St Peter’s Hospice
• Secure Information Governance
• Probably superseded now by other national developments
c. Screening for referral value
i. Obstructive Sleep Apnoea
ii. Cardiac Arrhythmia
3. Innovative services
i. Obstructive Sleep Apnoea
• High referral levels with high costs to 20 care sleep laboratories
• Screening process to identify snorers v. obstructive sleep apnoea
• Home based kit with downloads to respiratory consultant for interpretation
• Only OSA need referral
Konica Minolta Pulsox 300i
Hypnogram
ii. Cardiac Arrhythmia Monitoring
• Worn constantly
• Pre-programmed to record events
• Identifies heart irregularities
• Analysed remotely
• To reduce avoidable referrals
• Patient reassurance
• To refer appropriate patients with data on the arrhythmia already available
Broomwell
Healthwatch
d. Consultant Link Service - Advice & Guidance
3. Innovative services
10 Care 20 & 30 Care
GP led
Consultant led
All undifferentiated illness
Little cross referral
Limited ‘long-term conditions’ work
Most access to diagnostics
Acute management major conditions
Long-term follow up of many conditions
10 Care 20 & 30 Care
GP led
Consultant led
All undifferentiated illness
Little cross referral
Limited ‘long-term conditions’ work
Most access to diagnostics
Acute management major conditions
Long-term follow up of many conditions
Clinical split
Reunite clinical advice
Objective: Supporting GPs managing more patients in primary care
Concept: Immediate, telephone access – to consultant Advice &
Guidance
Key points: Use of consultant mobile phones
Voice recording calls making the service paperless
Consultant Team(s) GPs
Call routing
Service Model
GP Practice Set-Up: - Unique tel # for each practice - GP Care sets up each practice with their preferred source of
advice for each specialty (can use up to 3 hospitals for each specialty)
Tel Call - Consultant Provides Advice - Consultants available 8am-6pm via mobile phone Hunt Group - GP and consultant conversation digitally recorded
Outcome Monitoring - Consultants stay on line and log the outcome of the call (during
trial period only
Digital sound file: • Sent to GP practice team and
attached to practice/team records
• Sent to hospital teams for records
and medico-legal purposes
Hospital Team Set-Up: - ‘Hunt Group’ of consultants set up for each specialty team at
each hospital - GP Care manages the Hunt Groups on a daily basis to ensure
that all and only available consultants are logged in
Set up:
Call routing:
Outcome Reporting - Reporting full performance metrics by practice, CCG, hospital
Call features: • GPs can call from practice or
mobile
• Paperless for consultants so no
extra clinical sessions
• Consultants can accept or reject
calls
GP makes the call - GP dials unique tel #
- Selects specialty - Keys in patient NHS number
- Call loops through consultant Hunt Group until one answers (15 seconds/different ring tones)
- If no answer then GP Care manages call overflow and arranges call-back
© GP Care UK Limited, registered number 0651 7384
Access 16 months to 30 January 2013 Average call answering time = 68 seconds Average call duration = 3 minutes
Outcomes (logged by consultants) • 63% referral avoided; • 2% admission avoided; • 9% GP requested diagnostics; • 24% referral recommended; • 2% admission recommended.
Benefits • Reduction in avoidable referrals
• Better for patients • Reduced cost to the ‘system’
• Reduced referral/admission rates support reduction in bed capacity • Improves flow of referrals when they are appropriate • Improves communication and integration between primary and secondary care • Provides case based learning for primary care • Improves overall NHS ‘system’ efficiency (using existing Consultant Resource)
Feedback • Consistently positive feedback - GPs “It’s good to be able to talk to consultants again”
Outcomes – Cardiology
Referral avoided Admission avoided GP requested diagnostics
Referral recommended Admission recommended
63%
2%
24%
9%
2%
4. Practice Development & Transformation
GPs’ challenge – the case for a ‘scaled up’ organisation
Individualised care
Person
al d
octo
ring C
on
tin
uit
y o
f ca
re
Practice specificity
Patient Choice
Contracting unit size has been progressively
rising
Performance management & quality variation
Duplication of procedures & protocols e.g.
CQC, registration, summarisation, audits, contract
monitoring.
Prohibitive contracting
costs for small organisations
Restricted primary care expertise e.g. finance, legal, HR, strategic.
Competition & Procurement Law
Links between GP Care & local GP OOH Provider
GP Care
Elective / mainly
scheduled focus
Need for housebound
transport access
OOH provider
Out of Hours / mainly
unscheduled focus
Transport system used
at nights/weekends
Head Office,
Board. IT &
Commercial
functions
Scheduling &
call-centre
Urgent care
functionality
Commissioners want higher critical mass for robustness & contract bids;
Links allow differentiation of Management team functions;
Move towards an Accountable Care Organisation;
PMCF
Practices Practices Practices Practices Practices
EMIS-web Shared support
for template & IT
utilisation
Shared Telephony – real or virtual centre Integrated appointment booking capability
Own
GP
OOH
options
& links to
community
providers
Booked
w/e review
for high risk
pts
Patient record
available
wherever they
present
Care
plans
What are the PMCF deliverables?
Shared in-
hours
On-line repeat prescription service
Email consultations or support for
electronic self-help (e.g. Hurley group)
Clinical support to consortium members &
Professional A&G line
Modelling Practice Support
Provision to each hub of: • Practices’ business development – service development; private services, interface with
commissioners and other health & social care organisations, bidding agency for other community based healthcare activities;
• Operations – contract delivery, clinical governance / quality assurance, scheduling & access, infection control, staff deployment, results & document management;
• Human Resources – recruitment, skill mix, locum pool, in-house training, policies & procedures; • Relationship & liaison – patient participation groups, public involvement, complaints; • Clinical – professional behaviour, clinical training, mentorship and development, appraisal; • Centralised Home Visiting – All practice home, nursing & residential care visits and transportation
(from home to surgery and for home visiting / housebound care); • IT – hardware & software, template setup & management, training and clinician support; • Data – maximising effectiveness of IT, data quality & record summarisation, IT governance, audit &
reporting; • Finance - payroll, accounts, contracting & bidding, efficiency, remuneration, budgetary control; • Facilities - Practice premises, CQC & DDA compliance, rental & repairs, space & occupancy
planning; • * Future integration with community matrons / extended care practitioners / specialist nurse
• teams.
Practices A - G
Hub 1 Hub 2 Hub 6 Hub 4 Hub 5
Practices H - L Practices P - T Practices U - Z Practices i - v
Hub 3
Practices M - O
Each Hub 1 – 6
• Networked OOH & 7/7 working with base; • Diagnostics: USS & other near patient tests; • Links to End of Life care; • IT support [eg to clinicians on returns on clinical
services]; • Intermediate care / risk assessment & care
planning; • Private medical work; • Clinician training & mentorship / research; • Range of extended services; • * Future base for District Nurse & CNOP teams.
Practices A
Practices B
Practices C Practices D
Practices E
Practices F
Practices G
Standard General Practice
OOH
Standard General Practice
LTC / EoL
Standard General Practice Urology
Intermediate care
Standard General Practice
DVT Urgent care
Standard General Practice / USS Occupational
Health
Standard General Practice
Audiology Training
Standard General Practice Diabetes Research
Site managers Clinical leaders
IT network
Practice Support structures
Share
‘back office’
resource
Working with
local OOH
provider to
integrate
One OOH open
permanently per
hub area
Integrated
24 hour/day
7 day/week
provision
Could be foundation
for incorporation of
community health
staff
Initial findings suggest
resonance with GPs
& reminiscent of PCG
relationships
Virtual centre as central resource
Hub 1
Hub 3
Hub 4
Hub 2
Hub 5 Hub 6
5. Accountable Care & Remodelled provision
5. Accountable Care & Re-modelled provision
• Partnering with other provider organisations to provide the Business Intelligence functions to risk manage speciality budgets in their entirety;
• Link and operate all parts of the patient pathway from primary to tertiary care;
• Share savings across the provider network and with commissioners.
10 Care 20 & 30 Care
GP led
Consultant led
All undifferentiated illness
Little cross referral
Limited ‘long-term conditions’ work
Most access to diagnostics
Acute management major conditions
Long-term follow up of many conditions
10 20 and 30 Care
Model clinical speciality / care delivery around patient need
Manage whole pathway commissioned in its entirety from pre-primary to tertiary
Provider partnerships with risk-sharing / savings arrangements with commissioners
Clinical split
Commission whole pathways of care: accountable provider with a capitated budget
Summary
• The NHS financial & service challenge will only be met by radically changing how care is provided: – New localism;
– Using current & future technologies;
– Streamlining care & removing inefficiencies;
– Integration of care across organisational boundaries.
• The innovation of GP Provider Companies / Federations are key to realising the above.
Thank you
www.gpcare.org.uk