Primary Care Commission Study Visit. 26 March 2015

Transcription

1 Primary Care Commission Study Visit 26 March

2 Agenda 1. How we got to where we are? 2. Suffolk GP Federation 3. North East Essex diabetes service 4. Working at scale issues and challenges 2

3 1. How we got to where we are? 3

4 The cottage industry Suffolk 65 practices covering 630,000 patients 4 th oldest county in England Generally wealthy and healthy Deprivation and challenges in Ipswich 4

5 Strategic context Challenges for practices 7 day working Recruitment Profits falling Workload & patient expectations Shrinking market share Some LES being tendered New (unrealised) expectations from NHS England/CCGs Contract with less organisations Provide consistent performance Shifting work out of acutes Practices want Evolutionary change avoid mega-mergers Maintain independence & individual character Work more closely together as a hedge Our competitors 5

6 Strategic options 1. Do nothing/wait and see/retrench 2. Individual practices go it alone e.g. Hurley Group 3. Merger e.g. Vitality 4. Working more closely together e.g. by Federation 6

7 Why federate? The theory Worked in other industries Benefits a single practice would struggle to generate 1. Facilitate practices working together in an open, democratic and transparent way 2. Address issues which are optimally solved by collaboration (rather than by individual practices) 3. Provide a management infrastructure Lowest common denominator RCGP definition - an association of GP practices that come together to share responsibility for a range of functions, which may include providing services, training & education, back office functions, safety and clinical governance. 7

8 2. Suffolk GP Federation 8

9 Suffolk Federation One-off joining fee 30ppp 61 practice members of 65 in Suffolk 580,000 patients Practices remain independent partnerships Not for profit Community Interest Company limited liability so no obligations for practices Elected Board of GPs, PMs & CEO lucky GPs did not want to join CCG Board has delegated powers 9

10 Constitution Members Agreement Elected Board Most day to day decisions delegated to Board Obligations of membership Act in the spirit of working together Nominate a lead GP representative; Communicate with the Fed and share relevant data Allow access to practice manager Act with courtesy in all dealings with any other Members and the Board. Use reasonable endeavours to implement initiatives 10

11 Our business model Services to patients Ultrasound Lynmphoedema Cardiology Pain ENT Diabetes Financial contribution sustains the Federation Value added Create track record Services to practices Defence bulk discount Care home nursing Dementia searches COPD case finding Exploring automated reporting Sharing best practice Generate incremental income or reduce costs Working at Scale Over 75s admission avoidance PM Challenge Fund bid In development: Recruitment Career development Retiring GP support Services that can only be practically delivered at scale or which require skills practices do not have 11

12 Current organisation 12

13 Strengths & Weaknesses Strengths Can attract most practices - means working at a population level Third parties have someone to talk to & primary care organisation for MCP etc Retains the best part of the independent contractor model esp. continuity of care Facilitates change e.g. using peer pressure Avoids the disruption from mergers and destabilising super practices Positioned to support an expanded primary care scope e.g. Out of Hours, extended access, shifting outpatients into community Weaknesses Possibly too early primary care still commissioned on a practice by practice basis no scale commissioning Start-up costs high Expensive to run it needs the overhead associated with a provider group but without the scale Non-exec Board roles are demanding Independent partnership structure means significant cost saving is difficult What needs to change to make it a model for the future? Services commissioned at scale 13

14 3. North East Essex diabetes service 14

15 North East Essex CCG thinking Rising demand North Essex lower quartile outcomes Care processes % - below national mean HbA1c < out of 211 Hospital model seen as unsustainable Services fragmented want integration under umbrella of a single provider Tendered service to attract new thinking 15

16 The strategy Diabetes Service Board to manage the services Key performance indicators 8 care processes, HBA1c, cholesterol, referral for education and foot care 3 legged model to achieve them 1. Patient involvement - care planning & service delivery 2. Investment in primary care capacity & expertise 3. Diabetes Specialist Team 16

17 The Suffolk Fed contract Diabetes & podiatry, outpatients & education adult only Separate agreement for inpatients Fixed budget with 25% contingent on delivering key performance indicators 5 years with possibility of +2 year extension Any surplus reinvested in diabetes care locally 2.5m per annum 17

18 Investment in primary care Part 1 1. Governance Identify leads Annual audit Meet diabetes specialist team quarterly at GP practice lead GP & nurse Attend these quarterly leads meetings to share & compare 2. IT & data collection Agree data extraction Read code the various activities so monthly dashboard works 3. Case finding, education & single referral point Look for IGR in Q1 and check for conversion to overt DM Referrals via Diabetes Specialist Team (DST) Newly diagnosed people referred for structured education 18

19 Investment in primary care Part 2 4. Primary care Implement care planning model Nurses & HCAs attend training Manage wider range of patients stable T1, T2DM discharged from hospital Named diabetes specialist team nurse as day to day contact 5. Focus on Key Performance Indicators Move from 75 th centile to 25 th over 5 years 6.44 over 5 years 6. Involve partially engaged Visit housebound and care home patients for annual review Target partially engaged 5 of 8 care processes Practice responsibility 19

20 Diabetes Specialist Team Community diabetologist seconded from Colchester Hospital Clinical leadership, governance, specialist clinical advice, quarterly practice meetings, lead specialist clinics Specialist team Specialist Diabetes Nurses linked to practices and available for day to day advice Dieticians Specialist midwife Educators Role Support practices Transfer most care to community Triage referrals Transitional phase Revolving door 20

21 Monthly data extract from each practice INDICATORS Baseline Frequency Year 1 Target patients receiving all 8 care processes (Weight, BP, Smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, foot examination) % of newly diagnosed Type 1 patients OFFERED education within 24 months of diagnosis Method of Measuremen t 40.1% Monthly 2% increase Diabetes Dashboard 0.0% Monthly >=98% Diabetes Dashboard Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb % 40.4% 40.6% 40.8% 41.0% 41.1% 41.3% 41.5% 41.6% 41.8% 42.0% 39.1% 38.2% 37.4% 36.7% 45.3% 46.3% 47.0% 48.2% 50.1% 53.8% 55.2% 8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 5.5% 9.3% 15.1% 17.1% % of newly diagnosed Type 2 patients OFFERED education within 12 months of diagnosis 0.0% Monthly >=98% Diabetes Dashboard 8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 13.2% 16.4% 27.8% 35.7% Patient empowerment change from baseline to 6 weeks following XPERT education 32.3% Quarterly >=32.3% XPERT Database >32.3% >32.3% >32.3% Not due Not due 16.7% Not due Not due 47.2% Not due Not due 37.1% Not due Not due percentage of patients with diabetes in whom the last IFCC-HbA1c is 64mmol/mol or less[<8% in DCCT values] in the preceeding 15 months Increase in the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l or less. Increase in the percentage of patients with diabetes in whom the last blood pressure is 140/80 or less. 71.3% Monthly Monthly Increase the number of type 1 Diabetics who have had a foot check. 63.0% Monthly 1.17% increase or 69th centile 79.0% Monthly 0.88% increase or 48th centile 78.4% maintain upper quartile 10% increase Diabetes Dashboard Diabetes Dashboard Diabetes Dashboard Diabetes Dashboard 71.4% 71.5% 71.6% 71.7% 71.8% 71.9% 72.0% 72.1% 72.2% 72.3% 72.4% 68.9% 69.0% 69.0% 69.4% 69.7% 70.1% 70.4% 69.9% 69.1% 67.9% 69.1% 79.1% 79.1% 79.2% 79.3% 79.4% 79.4% 79.5% 79.6% 79.6% 79.7% 79.8% 76.5% 76.7% 77.0% 77.2% 77.1% 76.9% 76.7% 76.7% 76.8% 76.6% 78.9% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 77.1% 76.3% 76.3% 76.5% 76.0% 75.5% 74.1% 72.5% 72.1% 72.3% 73.1% 63.5% 64.1% 64.6% 65.1% 65.7% 66.2% 66.7% 67.2% 67.8% 68.3% 68.8% 63.0% 63.0% 61.0% 61.0% 67.0% 65.8% 65.0% 66.1% 67.9% 70.4% 70.8% Appropriate referral - increase number of patients with foot ulcers referred to podiatry. 8.7% Monthly 10% increase Diabetes Dashboard 8.8% 8.8% 8.9% 9.0% 9.1% 9.1% 9.2% 9.3% 9.3% 9.4% 9.5% 8.7% 9.3% 8.5% 8.0% 7.0% 7.2% 8.1% 11.2% 13.5% 14.2% 17.1% Increasing the number of people assessed as having high foot risk in primary care who are referred to podiatry. 26.2% Monthly 10% increase Diabetes Dashboard 26.4% 26.6% 26.9% 27.1% 27.3% 27.5% 27.7% 28.0% 28.2% 28.4% 28.6% 25.6% 26.0% 26.5% 27.1% 26.7% 26.5% 26.1% 29.0% 29.2% 39.6% 40.3% Reduction in readmission rates within 12 months for people admitted with diabetic ketoacidosis, or Hypoglycaemia or Hyperglycaemia. 49/88 DKA 56% 0/4 Hyper 0% 98/188 All 52% 49/96 Hypo 51% Quarterly 10% reduction CCG 50.7% 49.4% 48.1% Not due Not due 26.0% Not due Not due 38.0% Not due Not due 40.0% Not due Not due Increase the number of diabetic patients with care plans. 16.0% Monthly 10% increase Diabetes Dashboard 16.1% 16.3% 16.4% 16.5% 16.7% 16.8% 16.9% 17.0% 17.2% 17.3% 17.4% 15.8% 16.1% 16.0% 16.2% 16.4% 16.7% 16.9% 17.2% 17.8% 19.8% 21.1% 21

22 Using data to generate peer pressure for change Patients receiving all 8 care processes % change 1/4/14 to 12/14 Practices 22

23 Year 1 progress All non-inpatient care successfully transferred to community 68% of former hospital patients discharged (44% T1s & 83% T2s) Outcomes % receiving all care processes +15.1% to 55.2% HbA1c (-2.2% - 64 or less), BP (-5.3% 140/80) & Cholesterol (- 0.1% <5) 100% newly diagnosed offered structured education % T1s having foot check +7.8% - high risk feet referred +14.1% 10% reduction in readmissions for diabetic ketoacidosis, or Hypoglycaemia or Hyperglycaemia 23

24 Issues Improving clinical outcomes takes time Very complex contract to manage with significant risks not for the faint hearted! Not all practices able to fully engage Hard to reach patients need a separate strategy Changing role of consultant Pace of change 24

25 4. Working at Scale Issues & Challenges 25

26 Issues & challenges Starting up is difficult and expensive Federation roles are emerging and not yet clear Commissioning primary care at scale will be the key driver Suffolk GP Fed is positioned for the future 26