New models of working together and
differently: the experience of GP Care
Dr Phil Yates
Darlington
11th June 2015
Agenda
1.
2.
3.
4.
5.
6.
Current pressures in Primary Care;
The agenda for primary care and the birth of GP Care;
Service Innovation;
Practice development & transformation;
The current context for Primary Care;
Summary.
1. Current Pressures in Primary Care
General Practice – unsustainable in its current form
Financial Pressure
More long term
conditions
Shift of work from hospital
Workforce –
fewer GPs
Aging population –
more complexity
Reduced Social Services funding
Extra responsibilities
e.g. CCGs
More regulation
e.g. revalidation / CQC
Contract changes risk
loss of permanence
Toughening targets
e.g. DESs, QIPP
General Practice
4
Financial Pressure!
Rising expenses
DDRB rejected
Public Pay
Squeeze
QIPP targets
New DESs to
‘earn back’
income
Higher
contributions
to NHSSS
Downsizing of
QOF – & less £
per point
Reduction
in MPIG
‘protection’
Cost of meeting
regulatory standards
Uncertainty
over premises
funding
Higher QOF
thresholds &
new targets
Revision of PMS
growth and
other baselines
Falling investment
in community &
primary care
Reductions in
funding for
teaching
Commissioner / Provider environment
Local
Authorities
CCGs
(& CSUs)
NHS England
& LATs
& PH England
Independent
Sector
Various FTs
GPs
Mental
Health
Optometrists
Dentists
Pharmacists
Independent Providers
Provider
CICs / SEs
NHS Commissioner
DH
Drive towards larger medically-based community
providers
Local
Authorities
CCGs
(& CSUs)
NHS England
& LATs
& PH England
Independent
Independent
Sector
Independent
Sector
Sector
Various FTs
GP
Care
Mental
Health
Optometrists
Dentists
Pharmacists
Independent Providers
Provider
CICs / SEs
NHS Commissioner
DH
2. The agenda for primary care and the
birth of GP Care
Local GPs’ early thoughts on
advantages of a provider entity
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;
• Risk minimisation for GPs & sustainability;
Remodelling Care
• Support of existing model of General Practice;
• Linking in-hours and OOH care and supporting patient access.
GP Care – Who are we?
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 on COI.
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.
We are about collaboration & integration not fragmentation
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
10 & Community delivered
Pre-primary
SSD / Pharmacist / Nurse
GP
Web-based
advice; self-help
tel, email & SMS;
expert patient;
community & 3rd
sector support
Diagnostic uncertainty
1st diagnosis
Complex problems
Follow ups
Sub-specialisation
Multiprofessional teams
Assessing risk
Minor illness & injury
Specialist nurses
LTCs & social care
Telemedicine
Telehealth
20 & 30
Consultants
Major surgery
High-tech
interventions
True ‘consultancy’
Teaching &
support
Services and our operational relationships
Commissioner
Chambers of
Consultants
Third & Charity
Sectors; SEs & CICs
Minor Surgery
Urology
Cardiology
Support functions:
•HR & trouble
shooting
•Finance & payroll
•Practice merger &
development
Support functions:
Consultant Link Service
– advice & guidance
GP Surgeries
& OOH bases
Anticoagulation
Ultrasonography & Dexa
Audiology
Nurses & HCAs
Acute and
Foundation Trusts
Urology
General Medicine
Radiology
Urodynamics
Audiology
Physio /MSK
Service Locations for Service Delivery
Deliberately
diffuse – use
bases where
people live
Network of 90+
premises – from
which we select
& operate
Counters
inequalities &
the ‘inverse care
law’ of health
provision
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
Key Principles for GP Care’s Services
Rapid Access
High quality
care this is
focused on the
patient
Care where the
patient needs it
to be
Consistent with NICE / best
practice guidelines
Supported by GPs &
Hospital colleagues
Impeccable clinical
governance
Robust administrative &
management arrangements
We are about collaboration & integration not fragmentation
Services and our operational relationships
Commissioner
Chambers of
Consultants
Minor Surgery
Urology
Cardiology
Physio
Third & Charity
Sectors; SEs & CICs
Urodynamics
Audiology
GP Surgeries
& OOH bases
Anticoagulation
Ultrasonography & Dexa
Audiology, Out of Hours
Nurses & HCAs
Acute and
Foundation Trusts
Urology
General Medicine
Radiology
3. Service Innovation
i. Ultrasound
• Platform service for other specialities (e.g. DVT,
urology, gynaecology, obstetrics, etc.);
• 25,000 patients / year;
• Multiple locations incl. Eastwood Park prison;
• Linked to centre and hospitals with N3, PACS &
Image Exchange Portal, SUS. No need for repeat
scan;
Mobile Ultrasound • Immediate advice available from Radiologist.
- Phillips CX50
Winner of ‘Healthcare
Outcomes’ national
awards
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
iii. Urology diagnostics
Flexi-cystoscopy – Dantec
& Endosheath system
• 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
iv. Other innovation trials
Konica Minolta Pulsox 300i
• Other innovations
& initiatives to
manage patient
care solely in the
community
– Sleep apnoea
diagnostics
– Dysrhythmia
monitoring
Hypnogram
Broomwell
Healthwatch
Clinical split
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
Reunite clinical advice without moving the patient
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
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
GPs
Consultant Team(s)
Call routing
Results – Cardiology
Outcomes
2%
24%
Benefits
• Reduction in avoidable referrals:
• Better for patients
9%
• Reduced cost to the ‘system’
• Reduced referral/admission rates
• Improves flow of referrals where required 2%
• Restored clinical communications
• Improves overall ‘system’ efficiency
Referral avoided
Referral recommended
63%
Admission avoided
Admission recommended
Feedback
• Consistently positive feedback
- GPs “It’s good to be able to talk to consultants again”
- Consultants “It’s reduced outpatients where I can’t add value.”
Winner 2014 ‘Best use of Media & Technology
award. RCGP & GP Magazine
GP requested diagnostics
4. Practice Development & Transformation
GPs’ challenge – the case for a ‘scaled up’
organisation
Prohibitive
contracting
costs for small
organisations
Contracting unit
size has been
progressively
rising
Restricted
primary care
expertise e.g.
finance, legal,
HR, strategic.
Performance management
& quality variation
Patient
Choice
Personal
doctoring
Continuity
of care
Individualised
care
Practice
specificity
Competition &
Procurement Law
Duplication of
procedures &
protocols e.g.
CQC, registration,
summarisation,
audits, contract
monitoring.
Models of ‘primary care at scale’ emerging
Individual mergers
Foundation
Trusts
OR
Community
Trusts
Mega-practices: either
geographically compact
or spread
Integration with
Hospital or
Community Trust
sector
Loose Network
Loose Network with
internal mergers
Component Functions of ‘Federations’
GP ‘at
scale’
Rapid Access Diagnosis
and Treatment
Programme Management
of Long Term Conditions
General Practice ‘at scale’
Harmonisation of
scheduled & unscheduled
care
Links between GP Care & local GP OOH Provider
Prime Minister’s Challenge Fund
GP Care
Shared
functions
OOH provider
Elective / mainly
scheduled focus
Scheduling &
call-centre
Out of Hours / mainly
unscheduled focus
Need for housebound
transport access
Urgent care
functionality
Transport system used
at nights/weekends
Commissioners want higher critical mass for robustness & contract bids;
Links allow differentiation of Management team functions;
Move towards an Accountable Care Organisation;
What are our ‘at scale’ deliverables?
Patient record
available
wherever they
present
Practices
Own
GP
OOH
options
& links to
community
providers
Shared support
for template & IT
utilisation
EMIS-web
Practices
Practices
Practices
Shared in-hours
Shared Telephony – real or virtual centre
Integrated appointment booking capability
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
Practices
Care
plans
Booked
w/e review
for high risk
pts
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
Hub 1
• teams.
Practices A - G
Hub 2
Hub 3
Hub 4
Hub 5
Hub 6
Practices H - L
Practices M - O
Practices P - T
Practices U - Z
Practices i - v
Each Hub 1 – 6
Practices A
Standard General
Practice
OOH
Practices B
•
•
•
•
•
•
•
•
•
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 G
Standard General
Practice
Diabetes
Research
Practices F
Standard General
Practice / USS
Occupational
Health
Standard General
Practice
DVT
Urgent care
Practices C
Standard General
Practice
LTC / EoL
Practices D
Standard General
Practice
Urology
Intermediate care
Practices E
Standard General
Practice
Audiology
Training
Site managers
Clinical leaders
IT network
Locations for Practice Support delivery
structures
Virtual centre as
central resource
Initial findings suggest
resonance with GPs
& reminiscent of PCG
relationships
Hub 1
Share
‘back office’
resource
One OOH open
permanently per
hub area
Integrated
24 hour/day
7 day/week
provision
Hub 2
Hub 3
Could be foundation
for incorporation of
community health
staff
Hub 4
Hub 5
Hub 6
Working with
local OOH
provider to
integrate
5. Current context for Primary Care
Main thrusts of the 5YFV
More care in the
community
Technological
investment to
support self-care
& < NHS usage
Higher Focus on
Health
Maintenance &
Illness prevention
Patient
Rebalancing of investment between sectors
Hospitals
Community /
Primary care /
Social care
Reducing silos but (not accountability)
between organisations
Current Fractured Relationships
Family Doctors
Hospital
Physical health
Mental health
Health
Social Care
Multispecialty Community Providers
Urgent &
Emergency Care
- OOH, 111, Urgent
Care & A&E
Hospital
Specialists
Community
leads
Mental
Health
GPs &
Nurses
Community
Trusts
Social Care
Integrated
Community
Provider
Primary & Acute Care System
Urgent &
Emergency Care
- OOH, 111, Urgent
Care & A&E
Hospital
Hospital
leads
Mental
Health
GPs &
Nurses
Community
Trusts
Social Care
Matures into an Accountable Care Organisation
Accountable Care Organisation –
system maturity
Hospital
Urgent & Em. – Single point of access, OOH,
111, ED
Mental
Health
GPs &
Nurses
Community
Trusts
RADAT & Community Specialists
Social Care
Holds & spends whole capitated budget for its population
Vertically
Integrated
Provider
6. Summary
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 development of Federations can change and quality
assure services in the community;
• They are part of realising greater resilience in practices;
• We are heading towards more a strong out-of-hospital sector
and GPs’ place within that is likely to require alliances with
other providers.
Thank you
www.gpcare.org.uk