Community Integrated Healthcare –
An Approach by Whitstable Medical
Practice
Transforming General Practice – Unlocking the Potential
Nuffield Trust, London
Wednesday 15 May 2013
Dr J M Ribchester
Executive & Senior Partner, Whitstable Medical Practice
Whitstable Health Centre &
Chestfield Medical Centre
Estuary View Medical Centre
Estuary View Medical Centre
Estuary View Medical Centre
Whitstable
© J M Ribchester
Whitstable
© J M Ribchester
OUR POPULATION’S HEALTH
NEEDS
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Whitstable faces a growing health and social care challenge
associated with its ageing population.
The population of over 65s in East Kent will increase by
41% between 2005 and 2020.
Whitstable shows a greater proportion of over 65s in
comparison with the rest of the locality.
The probability of having a Long Term Condition (LTC)
increases from 17%, for people under the age of 40, to
60% for those aged 65 and over.
People with LTC’s use disproportionately more primary and
secondary care services, 52% of all GP appointments, 65%
of all outpatient appointments and 72% of all inpatient bed
days. This pattern will increase over time with an ageing
population.
WMP ranked 182 out of 287 GP practices in Kent & Medway
on the index of multiple deprivation
Long Term Conditions Registers
Disease Category
Number
% of Population
Hypertension
5052
15.14
Asthma
2105
6.31
Diabetes
1728
5.18
CHD
1323
3.96
COPD
579
1.74
Mental Health
208
0.62
Dementia
210
0.63
Heart Failure
313
0.94
Epilepsy
183
0.55
Obesity
2712
8.13
680
2.04
Depression
3817
11.44
CKD
1172
3.51
Thyroid
1263
3.78
Stroke
669
2.00
AF
35,000
31,63
4
31,19
0
30,96
3
1.4.08
1.4.09
33,41
4
33,13
2
32,37
0
1.4.01
32,41
5
29,69
1
1.4.00
30,08
0
29,72
9
30,000
29,51
9
31,000
29,71
0
32,000
30,73
6
33,000
31,99
8
34,000
32,71
4
Whitstable Medical Practice List sizes 1.4.1998 - 1.4.2013
33,81
2
WMP List Size Growth
Since 1998
29,000
28,000
27,000
1.4.98
1.4.99
1.4.02
1.4.03
1.4.04
1.4.05
1.4.06
1.4.07
1.4.10
1.4.11
1.4.12
1.4.13
QUESTION
What has Whitstable Medical Practice
been able to do differently?
ANSWER
Redesign the provision of healthcare in Whitstable
Better patient experience
Closer to home
Shorter waits
Less cost to the NHS
In short, the development of an economical model
of community integrated healthcare
Detailed
WISH
Workstreams
Long Term
Conditions
Community Elective Services
Diagnostics:
Screening Services:
Echocardiography
Ultrasound
Digital X-ray
Dermatoscopy Service for
Diagnosis of Malignant Melanoma
Mobile MRI Scanner
2006
2009
2010
2010
2012
Urgent Care
- Practice based
Level 3 Minor
Injury Unit
- Fracture clinic
- Co-located
ambulance
response
base
- co-located
community
pharmacy
Cardiology (tertiary)
Cardiology (secondary)
Gynaecology x2
Urology
2006
2010
2010
Orthopaedics x3
General Surgery
Colorectal Surgery
Pain Management
Dermatology
Care of the Elderly and Joint GP Care
Planning
Hand, Wrist & Forearm
2011
GPSI/Specialist Clinics:
Insulin Initiation
Rigid Sigmoidoscopy
Prostate Clinic
Warfarin Clinic
Cardiology OPD
Dermatology OPD
Epilepsy OPD
Cardiology
Surgery in Primary Care
(SIPC)
2009
2009
2011
Day Surgery:
Consultant-led outpatient clinics:
- Diabetes
- Cardiology
- COPD
- Dementia
AAA National Screening
Programme Centre
Guy’s Genetic Screening
Paula Carr Retinal Photography
Service for Diabetes
Carpal Tunnel Surgery and Injection Pathway
Dermatological Surgery
Local Steroid Injection Service
Upper Endoscopy Service (hosted by WMP and provided
by Prime Diagnostics Ltd)
Cataract Day Surgery Service (hosted by WMP and
provided by consultant ophthalmologists)
Therapists:
2011
Hearing Aid Clinic
Acupuncture
Chiropractic
Physiotherapy
2005
2006
2006
2008
2012
2005
2006
2007
2008
2008
2008
2010
2010
2010
Whitstable &
Tankerton
Hospital
Enhanced
Rehabilitation &
Intermediate Care
WISH Stakeholders
Kent
Community
Health NHS
Trust (EKHT)
Whitstable
Medical
Practice
(WMP)
18 GPs, 140 staff
Kent Family
Services
(KFS)
Friends of
Whitstable
Hospital &
Healthcare and
Patient User
Group (PUG)
WISH Board
East Kent
Hospitals
University
Foundation
Trust (EKHUFT)
South East
Coast
Ambulance
(SECAmb)
University of
Kent
Workstream A
Long Term
Conditions
Lead:
Dr J Ribchester
Dr H Pinnock – COPD
Dr D Kanagasooriam
– Mental Health
Dr R Pieters –
Cardiology
Dr R Brice – Diabetes
Supported by:
KCHT, KFS, EKHUFT,
PUG,
Workstream B
Urgent Care
Lead:
Dr J Ribchester
Dawn Gaiger ENP
Supported by:
KCHT, EKHUFT,
SECAmb,
Workstream C
Community
Elective
Services
Lead:
Dr J Ribchester
Supported by:
EKHUFT, PUG,
Workstream D
Whitstable & Tankerton
Hospital – Enhanced
Rehabilitation &
Intermediate Care
Lead:
Dr J Ribchester
Supported:
EKHUFT, Friends, PUG, KCHT,
KFS
Long Term Conditions –
Interim Findings
Diabetes
Cost savings – 50% (delivery of Insulin
Initiation Clinics/non-insulin injectables)
Quality – patients below NICE recommended
HbA1c. Wait times for insulin initiation
down. Positive patient experience.
Next Steps – Identify number of acute,
emergency & unplanned (re)admissions qv
4 comparator practices
Long Term Conditions –
Interim Findings
Cardiology
Cost savings – 38% (delivery of GPSI clinic in
cardiology has reduced OPD referrals)
Direct patient journey’s to the right station –
- GPSI Triage
- In-house consultant clinics (Kings &
EKHUFT consultants)
- Heart Failure, Arrhythmia & Rehab
Community Nurses
Reduced waiting times
Direct links to Cardiothoracic Services
Long Term Conditions –
Interim Findings
Dementia
Integrated Care Pathway for dementia & adult
mental health at WHC
Reduction in anti-psychotic medications
prescribed in care homes
CMHT & OPMHT delivered by KMPT in-house
Dementia café by Alzheimer's Society at WHC
Urgent Care
- Practice Based Minor Injuries Unit Level 3
- Digital X-Ray Imaging
- Consultant-led Fracture Clinic &
TeleMedicine advice
- Co-located Ambulance Response Base
- Co-located Community Pharmacy
Tariffs
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MIU Level 3 Tariffs (11/12):
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£40 = Minor
£50.15 = Minor +
£73.95 = Standard
£99.45 = Major
A&E National Tariffs
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£52.54 = Minor Injury
£78.82 = Minor +
£111.15 = Standard
£134.39 = Major
MIU Level 3 at Estuary View
Apr 2011 – Dec
2012
Receipts £
Total Activity (no. of pts)
Minor
Minor +
Standard
Major
Total No. of Patients
9869
£394,760
12,596
£631,689
880
£ 65,076
6,027
£599,385
29,372
Total Receipts MIU Level 3 Apr 2011 –
Dec 12
£1,690,910
Comparative Cost A&E alternative
Minor Injury
Minor +
Standard
Major
Total Cost Comparative for A&E
Potential Cost Savings Apr 11 – Dec 12
Potential Percentage Cost Savings
9869
£524,703
12,596
£1,006,108
880
£98,084
6,027
£811,537
£2,440,432
£749,522
31%
Fracture Clinic
Fracture Clinic at
Estuary View MIU
Oct 2011 –
Dec 2012
Total no. of clinics
Total no. of patients
78
658
Fracture Clinic w/o
X-Ray
596
£29,889.40
Fracture Clinic with
X-Ray
62
£ 6,165.90
Total Receipts
Fracture Clinic
Comparative Cost
Trauma &
Orthopaedics
Actual Cost
Savings
Oct 11 – Dec 12
Percentage Cost
Savings
Receipts £
£36,055.30
658 FA
£97,384.00
£61,328.70
63.0%
The cost savings are
calculated using the
following assumptions:
MIU tariffs:
£50.15 = Fracture Clinic
£99.45 = Fracture Clinic
(with X-Ray)
National Tariffs for
Trauma and Orthopaedics
£148 = First Outpatient
Community Elective Services
& Diagnostics
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Cost savings. Examples:
1. Urology GPSI OPD – 35% savings
2. Carpal Tunnel Decompression:
- Surgery – 77% saving
- Injection – 83% saving
Reduction in referrals
Less OPD follow-ups
More one-stop clinics
Positive patient experience
Further work:
- identify comparator cohort
- identify cost savings of all services
Whitstable & Tankerton Hospital
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Integrated Committee formed in 2010 to
explore funding options for an Integrated
Health and Social Care Centre in
Whitstable
OBC prepared by WISH Manager with input
from all stakeholders
Work due to commence at C4G to consider
future of all 3 Community Hospitals
IF THIS IS AN ACCEPTABLE NEW MODEL
FOR URBAN GENERAL PRACTICES WHAT
ARE THE OBSTACLES?
Practices combining to serve larger
populations – perhaps 30,000-35,000
 GP buildings that are fit for purpose
 New GP Management structures
 Buy-in from CCGs, NHS CB, RCGP, BMA
etc
 New financial challenges
 Potential for upsetting local acute trust
and others.
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AND THE PRIZES ARE …..
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Benefits to patient care – more personal care,
closer to home, shorter waits
Benefits to the health economy – services
delivered at less cost
Benefits to the general practice – fulfilment,
education, upskilling, integrated healthcare
community, more of a buzz!
Better patient and public engagement
BUT IT TAKES TIME AND EFFORT
Community Integrated Healthcare –
An Approach by Whitstable Medical
Practice
Transforming General Practice – Unlocking the Potential
Nuffield Trust, London
Wednesday 15 May 2013
Dr J M Ribchester
Executive & Senior Partner, Whitstable Medical Practice