The Roll-Out of Primary
Care Teams in 2011
Practice Managers February 19th 2011
Helen Deely HSE (Regional Specialist in
Primary Care Dublin Mid-Leinster)
Primary Care







Health Strategy 2001
Primary Care Strategy
Primary Care - 90 – 95% of
all health and social needs
Secondary Care – complex
and special needs
Central focus of the health
system
Team based approach to
health service provision.
Shift appropriate activity
from hospitals
Why develop a Primary Care Team?
Information and Service Flow in the past
- Non Integrated Local Service
PHN
Information and Service Flow now
- Integrated Primary Care Team
GP
Phy
Phy
PHN
GP
SW
OT
OT
Direct Referral
Referral Service Feedback
SW
Direct Referral and Feedback
Formation of PCT’s guided by the
following requirements:
To maximise coverage for 100% of population
 To ensure ease of access to services and
simplify communication and referral processes
 To support epidemiological population health
monitoring, especially health inequalities
 To facilitate community involvement in need
assessment
 To support evidence based decision making
 To support future management and
governance arrangements within HSE.
 To facilitate team working amongst health
professionals including GPs

Who’s involved in Primary Care?
Establishing the Team



GP
Practice
nurse
Practice
staff
Reconfigure existing staff:
PHN
RGN
Clerical Admin
Primary Care Team
Additional staff:
Physiotherapy
Occupational Therapy
Social Worker
Network Services & Linkages
Integrated
Services
PCT ‘A’
• Counselling
• Local
Multi
Agencies
• Child Protection
Hospitals
• Orthodontics
PCT ‘E’
PCT ‘B’
• Area
• Private
Providers
• Voluntary
• Psychiatry
PCT ‘D’
PCT ‘C’
• Dietetics
• Support
Groups
• Specialist
• Home
Help
• Other
• Alternative
Care
Each Primary Care
Team is planned to
be part of a wider
network known as the
Health & Social Care
Network.
Health & Social Care Network Services












Audiology Services
Psychology / Counselling Services
Podiatry Services
Community Health Medical Services (Area Medical Officers)
Community Welfare Services
Dental Services
Dietetic Services
Ophthalmology Services
Environmental Health Services
Civil Registration Services
Community Development Services
Carers Services
Where we came from?

Survey undertaken (August 2008) involving GPs and Public
Health Nurses who were not in Primary Care Teams
determined that:
 20% of GPs and PHN never had face-to-face contact
 29% of GPs indicated that they did not know the PHNs
by name
 97% of GPs and 81% of PHNs had no working email
address for each other
 56% of GPs and 77% of PHNs did not have each others
mobile phone number
 Although 45% of GPs and PHNs were in weekly phone
contact, as many 1 in 25 (4%) reported contact on less
than an annual basis. PCTs provide multidisciplinary
care, which was previously provided in a unidisciplinary
manner prior to the establishment of Teams.
Aim of the Primary Care Team
To provide Primary Care Services that are:
 Accessible
 Anyone who lives in the team geographic area
 Service users can self-refer
 High Quality:
 Care planning
 Service planning
 Continuous education
 Meet the needs of the local population
 Liaison with local community
 Needs assessment
 Once off needs & chronic complex needs
What do PCTs do?

First point of contact

Defined set of core community-based services

individual care plans for patients with chronic illness or other
complex needs.

Link with other community-based professionals such as mental
health.

Integrate with acute hospital services - reduce hospital admissions,
early discharge of patients and chronic disease management
programmes.
Clinical Team meetings







Central to Team functioning
Feedback from GPs highly positive
Business like fashion – agendas, list of
patients etc circulated in advance
Leadership within Team required – TDOs
facilitated work to date.
Acknowledged there is a myriad of contacts
outside of CTMs.
Supporting systems required – Admin and
governance
Variances apparent – need to identify reasons
and solutions
CTM Variances

Of the 246 Teams that held Clinical
Team meetings held in September:




71% of Teams held 1 CTM (175
PCTs)
21% of Teams held 2 CTMs (52
PCTs)
5% of Teams held 3 CTMs (13 PCTs)
2% of Teams held 4 CTMs (6 PCTs)

11% PCTs held no CTM in month

23% had CTMs without GPs
5% 2%
1
21%
2
3
4
72%
PCT Challenges





Change from traditional linear working
to multi-disciplinary
Different roles & personality
differences
Contractual differences
Leadership issues
For Teams to work well they must be
properly resourced – staff, skills,
training, information, equipments,
access to specialists etc
Challenges cont…







CHANGE!! Becoming a team
Recruitment & non replacement of staff
Capacity: cradle to grave; health & social services
Boundaries
Accommodation
Clinical audit : patient pathways
 Lack of systems to record how much we
do/how well we do it/ how much it costs us to
do it
IT: no single patient record, no secure email
GP Engagement
Locally through the TDO
 Estates for PPPs
 Primary Care Support Doctors – local &
national forums
 Exploration of CME Credits for education
element of CTMs (not agreed).
 Joint initiatives to engage GPs
 Business like approach to Mtgs – prove
the benefits.

Example of PCT initiatives
Dietitian Clinic & shared Care diabetes
 Smoking Cessation
 Falls Prevention Groups
 Incredible years
 Antenatal clinics
 Reduction in outpatient appointments
physio/dietetics clinics, etc.
 Joint discharge planning between acute &
Primary Care
 Pharmacy engagement

Infrastructure






PPP progress has been slower than anticipated in
2010 due to the funding difficulties by developers
HSE Board approved 210 locations under the PPP
initiative.
HSE has signed 12 lease agreements, 23
Agreements to Lease and 82 letters of
intent.
12 locations have been completed within the
past 12 months accommodating 17 PCTs
A further 42 have been identified to be completed
in 2011
By 2013 - 115 PCCs operational supported by
160 PCTs
Integrated Working with
Acute
Essential that Acute and Primary Care Services are a seamless service –

PCT first point of contact
 with patient
 Acute Hospital Service
 Post Admission

Chronic Disease Management
 Shift from episodic acute hospital care
 integrated care focused on primary care.

Hospital Integration
 Discharge planning
 Shared care – diabetes, asthma
 Current hospital care to be provided in the community e.g. cancer
initiative, minor surgery
 Access to Diagnostics
 OPD direct access to hospital
Primary Care Team Development

Target to have 527 Teams in place by end of
2011

Plan to create 134 Health and
Social Care Networks
Steps to Primary Care Development…
Step 1 – Develop PCTs Foundations
(complete by end 2011)
 Step 2 – Strengthen functionality of Teams






Identify and address staffing deficits
Strengthen team working though training or
otherwise
Implement standard business processes
Complete health needs assessment &
strengthen community participation
Hold regular CTMs with log of care plans
Steps to PC Development…(cont’d)

Step 3 – Development of Network Services




Implementation of governance and management
structures.
Alignment of specialist and care group services.
Implementation of general principles of referral and
shared care arrangements with secondary care, care
group and specialist services.
Step 4 - Develop health promotion and proactive
services within the team



Roll out of Chronic Disease Management
Falls prevention programmes
Locally targeted programmes
Supporting Developments









Management and Clinical Governance
ICT
Chronic Disease Management
Community Needs Assessments – guidance doc
nearing completion
Reconfiguration of Admin staff Plan
Resource Pack for PCTs
DVD
Community Engagement Guidelines
Pharmaceutical Engagement Guidelines (draft)
Primary Care Performance Activity

350 Teams in operation at end of December 2010
(89% of 2010 target)

Additional 31 Teams holding multi-disciplinary
clinical meetings between HSE staff without GPs

2,615 Staff assigned to functioning Teams

Over 1,309 GPs participating on Teams
Primary Care Performance Activity &
Performance Indicators cont…

ICT Supports – Hardware requirements, work with GPIT
group to progress secure e-mail

Enhancement of Primary Care Services –
 Community Intervention Teams
 IV Therapy
 Falls Prevention
 CMHTs
 Smoking cessation
 Breast feeding training for PHNs

Prescribing (QCCD) – cost effective prescribing choices
Primary Care Performance Activity &
Performance Indicators cont…

Cancer Services
 training for practice nurses in cancer prevention care,
 community nurse education programme further developed,
 information/training sessions for GPs and
 electronic referral cancer systems developed within the GP
software packages

Chronic Disease Management (QCCD) – Commencement of
Clinical Leadership for primary care & Guidelines for disease
management for 7 priority programmes pertinent to Primary Care
–
 Stroke
 Heart Failure
 Asthma
 Diabetes
 COPD
 Dermatology/Rheumatology
 Care of the Elderly
Chronic Disease Management in
Primary Care

Most of the care of patients with chronic conditions takes
places within the primary healthcare sector. This includes:




Diagnosis, treatment and rehabilitation of patients with chronic
conditions;
Early detection, assessment and follow-up comprehensive
medical treatment
Preventive activities including smoking cessation, dietary
advise and support of patients’ self care.
Estimated 15-16 million consultations in general practice
while approximately 1.9 million consultations take place in
out-patient departments each year.
Why focus on Chronic Disease





80% of GP consultations
60% of hospital bed days
2/3rds of emergency medical admissions to hospitals.
8 of the top 11 causes of hospital admissions are due to
chronic diseases
5% of inpatients with a long-term condition account for
42% of all acute bed days.

CDMP - 50% reduction in unplanned hospital admissions as
well as a 50% reduction in bed day rates
Falls Prevention





34,000 treated per year due
to falls = 703,000 bed days
Hip fractures – €35m per year
2 out of 3 over 65 who
fracture hip never return
home
Falls Prevention
 PCT delivered
 >25 PCT’s delivering Fall
Programmes
 Programmes reduce falls
by 15 – 30 %
Potential savings: €17.5 m
Diabetes

10% total healthcare
budget -700m per year

Complications of DM cost
€696m per year

4.1% reduction in Stroke/
MI in a 3 year structured
DM programme
Heart Failure
A structured shared care model
between Primary Care/
Hospital would prevent:

> 4,000 hospitalisations per
year

free up 50,000 bed days.

Equivalent to building a small
to medium size hospital at a
cost of €27m.
Asthma

5,000 admissions
per annum
Structured Primary
Care Model
(Finland)
 54% reduction in
hospital bed days
 90% reduction in
deaths
COPD





Estimated by 2020 COPD will be third leading cause of
death worldwide.
2003 - COPD caused 4.9% of all deaths in the UK
At least 10% of emergency admissions to hospital are
COPD related
Average hospital stay of nine days per exacerbation, three
to four times a year
Integrated care intevertion including education, coordination among levels of care and improved accessibility,
reduced hospital readmissions in COPD after 1 year.
Stroke

Rates in Irish Population



Stroke/TIA Hospital Bed Use


Stroke: 1.93/1,000 pop. (NDPSS)/ TIA: 0.62/1,000 pop. (NDPSS)
10,817 new stroke/TIA nationally per year- 1 every hour
9,570 hospital admissions/yr (2000-06, HIPE)
Stroke/TIA Combined:

5% of all hospital bed days (HIPE, 2000-06)

Estimated 2009 Total Direct Costs - €405m

Atrial fibrillation







Atrial fibrillation (irregular heartbeat) in 10-20% of over-70s
Extensive brain injury  disability, NH care common
30% of all stroke (NDPSS, INASC)
Easy and inexpensive to detect (pulse, ECG)
70% preventable (blood-thinning anticoagulation)
Only 25% of known AF treated (NDPSS)
600 missed opportunities - potentially-preventable severe strokes in 2006
Benefits of Primary Care Team
Improved service to the client
 Safer more co-ordinated care
 Clearly identifiable for patients
 Named Nurses, physiotherapists, occupational therapists, social
worker on the team, relationship building
 Shorter waiting times for Occupational Therapy, Physiotherapy,
Social Work
 Range of services provided increased
 Increased clinical contacts with clinical rooms
 Single referral form/self referral
 More focus on:

health promotion
disease prevention
Improved communication and information sharing
 Communication with other agencies e.g. hospitals, voluntary
groups and community groups
Benefits to staff: high staff retention levels

Benefits of PCTs cont…












Local personal relationships with clients/patients
Community-based services near patients’ home
Better use of the clinical skills of the various professionals;
Identify and tackle critical local health issues e.g. suicide prevention;
Less duplication and fragmentation in the health system due to better
communication structures;
Decrease hospital attendance through the delivery of chronic
disease management programmes
Transfer services from acute hospitals to the community e.g.
diagnostics, minor surgery, wound management, IV therapy in the
community;
Facilitate early discharge through the delivery of CITs, pre-hospital
and discharge planning, timely access to appropriate multi-disciplinary
services in the PCTs;
Support patients in the community e.g. falls prevention programme;
Offer multidisciplinary health promotion initiatives
De-stigmatise the provision of Mental Health services in the
community
In complex cases a Key Worker navigates health system on behalf of
the patient
Feedback on Development to date…..
Lack of Resources: Those teams without
premises feel very strongly about this
position and feel they will not work as a
“team” until this is rectified.
 The moratorium is leaving teams without
resources and this has been identified as a
key risk in a number of teams.
 Lack of basic IT equipment coupled with
no administrative support is impinging
on team effectiveness.

Next Steps…









Continue roll out of PCTs
 Staff reconfiguration
 Engagement with GPs
Strengthen exiting Primary Care Teams
 Implementation of governance arrangements
 Strengthen team working though training or otherwise
 Implement standard business processes
 Complete health needs assessment
Primary Care Centre Developments
Development of Performance Metrics
PCT Needs Assessments
Progress Engagement with Acute
Develop Health and Social Care Networks
Roll out of Chronic Disease Management Programmes
Updated and clear information needs to be communicated to the
public, PCT members, and HSE literature and websites.
We know
Patients feel they get a better service from a
multi-disciplinary team
 Staff are happier working in well functioning
teams
 Happier staff deliver better services
 Countries with advanced health systems are
moving to this way of working

Discussion….