Dr. Anita Sharma. GPwSI Gynaecology Clinical Lead Oldham GP Federation Educational Lead North West FDA NICE QSAC GP Member

Transcription

1 Dr. Anita Sharma GPwSI Gynaecology Clinical Lead Oldham GP Federation Educational Lead North West FDA NICE QSAC GP Member

2 BUSY A&E

3 OVERWORKED PRIMARY CARE

4 Practice Closures Plymouth: Fifth of the practices have closed Brighton: closure of 9 GP surgeries in last 4 years North Wales: Larger than average elderly population Folkstone Bridlington FOI: 2016(136),2017(134)

5 Why NHS is creaking? Increasing needs and expectations of aging population The cost of cradle to grave comprehensive medical care, free at the point of delivery for a population of more than 65 million More and more investigations including expensive CT and MRI scan Obesity crisis, Mental health and lack of provision of social care

6 HOW CLINICIANS AND CLINICAL MODELLING CAN CONTRIBUTE 6

7 NEW FINANCIAL MODEL

8 Five Year Forward View 2016/17

9 Commissioning for Value and Right Care

10 Driving through changes Why patients are attending A&E? Community clinic Reducing unnecessary referrals to secondary care Acute care collaboration 10

11 How to Change Cross Sector collaboration Enhance health in care homes Improve health promotion Workforce productivity In house Pharmacists Physician Associates 11

12 What do I Want? PATIENTS OVERSEEING QOC

13 Health in Oldham Registered population 242,970 (1/1/16) 21% of households in fuel poverty 20% BME population Marked regional variation in health/mortality High smoking prevalence High levels of obesity Low levels of physical exercise 13

14 Main causes of death in Oldham

15 Future Challenges Ageing population: 65 yrs (19%), 75 yrs (26%), 85 yrs (27%) in next 10 yrs Increasing obesity, smoking, alcohol and drug abuse Multiple pathology - Increasing complexity Marked regional variations, wider health inequalities Financial constraints 15

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17 OLDHAM ANTIMICROBIAL CHALLENGES

18 Oldham s Antimicrobial Prescribing Challenges Oldham prescribed large numbers of antibiotics QIPP indicator showed Oldham in the bottom national quartile 22 practices within the bottom national quartile 16 practices within the top national quartile 18

19 This toolkit is here to help clinicians and commissioners to use antibiotics responsibility and meet CQC requirements 19

20 NICE pathway (POC) CRP Test NICE guideline CG191 recommends that GPs should consider carrying out a point of care (POC) C-reactive protein (CRP) test for people presenting in primary care with symptoms of lower respiratory tract infection. Pneumonia not diagnosed or not clear if antibiotic should be prescribed < 20mg/L CRP rapid test mg/l >100 mg/l Do not routinely offer antibiotic therapy Consider a delayed antibiotic prescription Offer antibiotic therapy 20

21 NICE GUIDELINES NICE CG 191 published Dec 2014: reduction in 40 % or 10 million prescriptions 21

22 Why measure C-reactive protein? CRP is a major acute phase protein produced in response to infection or tissue injury. CRP is normally present at trace levels in serum, but increases rapidly in response to a variety of infectious or inflammatory stimuli. Its levels typically are highest in patients with a bacterial infection and are lower in those with viral infection. 22

23 Current Prescribing in Primary care 78.5% of antibiotic prescribing is in Primary Care. Antibiotic prescribing by GPs increased by 4% between 2010 and Over half of antibiotics prescribed in Primary Care are for respiratory tract infections (RTI). However, systematic reviews have shown that most of these infections are viral and patients derive little benefit from antibiotic treatment. 23

24 Reducing Antimicrobial Prescribing OLDHAM CRP PROJECT 24

25 PROJECT PLAN 25

26 PROJECT PLAN 26

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28 GP staff interviews The GP staff interview findings are published in the BMJ Open, Oct C-reactive protein point-of-care testing in Oldham CCG

29 WHAT NEXT FOR OLDHAM PoC CRP testing well received by GP practice staff as an additional diagnostic tool to support clinical decision NICE guidelines CG191 recommends PoC CRP testing Used in Norway, Sweden, Netherlands, Germany, Estonia, Czech Republic 29

30 QUALITY PREMIUMS In April 2015, NHS England included antibiotic prescribing in the 2015/16 Quality Premium guidance for Clinical Commissioning Groups (CCG). Of the total 5 per patient available to CCGs, 10% is attributed to improving antibiotic prescribing, an average of 127,000.* 30

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32 Peripheral Arterial Disease Community Clinic in Oldham

33 Peripheral arterial disease Is most commonly due to atherosclerosis Affects around 13% of western population who are more than 50 years old CLI the most severe manifestation of the disease 33

34 Risk Factors Age Sex: Male to female ratio is 2:1 Ethnicity Smoking: Most important modifiable 34

35 Risk Factors Diabetes Hypertension Raised Cholesterol Other factors 35

36 ABPI Interpretation 36

37 Critical Limb Ischaemia Ulceration Gangrene Rest pain consistently > 2 weeks True rest pains usually affects the toes or foot of the affected limb 37

38 Acute Limb Ischaemia 6Ps: Pain at rest Pallor Pulselessness Paraesthesia Paralysis Perishing cold 38

39 Peripheral Arterial Disease One way of reducing CLI is to have a dedicated community PAD clinic PAD is important for commissioners as a disease but also a marker for Heart Disease and Stroke. Primary care has an important role in ensuring that NICE QS52 are met

40 Vascular Vision DH CVD Outcome Strategy May 2013 Key principle of the strategy Doing things differently

41 Innovation Fund Legal requirement for all CCGs to support Innovation O/M CCG was keen to build this concept

42 OLDHAM DRAGON S DEN Launched Shortlisted Winners

43 Service Description Pathway The PCFT Tissue Viability Service Cardiovascular risk assessment/treatment Promote self care agenda Work collaboratively NICE CG 147 August

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45 Referral to secondary care Urgently refer any patient presenting with CLI or acute limb ischaemia Diabetic foot ulcer Claudication affecting QOL, not improving after 3/12 SET 45

46 Results May 2014 May Referrals 17 7 DNA 7 Inappropriate 17 Appropriate

47 Vascular Referrals and treatment

48 Primary Care Clinic Cost Efficiency for 12 Months 76,

49 WORK FORCE CRISES

50 A Pharmacist In Practice Will Freeup Valuable GP Time But How?

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52 Overall statistics from wave 1 Total GP time saved per month across Oldham Federation pilot sites: 420 hours Total combined annual saving for Oldham Federation pilot sites: 267,120 * Data based on 2.8 WTE Clinical Pharmacists working within 8 surgeries across the borough. Extrapolated via NHS England reporting structure.

53 PHYSICIAN ASSOCIATE 53

54 Who are they? A new HCP who, while not a doctor works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and Rx with in the general practice and /or GP team under defined level of supervision Department of Health 54

55 Support Primary Care Support GP in the diagnosis and management of patients Work under direct supervision of GP Taking medical history, minor ailments, Path labs, telephone consultations, ECG, Spiro 55

56 Surely time has come to address which services NHS should and should not provide

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