Federating for Innovation - Primary Care Commissioning · Uroflowmetry - Dantec-Danflow Flexi-cystoscopy – Dantec & Endosheath system iii. Urology diagnostics • Remote electronic

Federating for Innovation: The experience

of ‘GP Care’

Dr Phil Yates July 2014

Biography

• GP in Bristol, 30 years;

• Senior Partner large general practice, 14 years;

• PEC Chair South Gloucestershire PCT, 6 years;

• National Clinical Advisor to Modernisation Agency, 2 years;

• APMS contract for 8-8 services, 5 years;

• Chairman of GP Care, 8 years;

• Council Member of South West Clinical Senate, 1 year;

• Council member of National Association of Primary Care, <1 year.

Agenda

1. Why Federate?

2. The provider environment & the birth of GP Care;

3. Innovative Services: a. Near patient testing

i. Ultrasound;

ii. DVT & Anticoagulation;

iii. Urology diagnostics;

b. Patient Record Network ‘PRN’ for Clinical Records;

c. Screening for referral value: i. Sleep Apnoea screening;

ii. Cardiac Arrhythmia screening;

d. Consultant Link Service – advice and guidance

4. Practice development & transformation

5. Accountable Care and re-modelling provision

6. Summary

1. Why Federate?

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;

Remodelling Care

• “Think like a patient: Act like a taxpayer”;

• Reform of General Practice and patient access;

• Linking in-hours and OOH care.

Supporting efficiency and financial NHS restructuring

• Prime Contractor → Accountable Care.

Why Federate?

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

Pre-primary 10 & Community delivered 20 & 30

SSD / Pharmacist / Nurse GP Consultants

Web-based

advice; self-help

tel, email & SMS;

expert patient;

community & 3rd

sector support

Assessing risk

Minor illness & injury

Specialist nurses

LTCs & social care

Telemedicine

Telehealth

Diagnostic uncertainty

1st diagnosis

Complex problems

Follow ups

Sub-specialisation

Multiprofessional teams

Major surgery

High-tech

interventions

True ‘consultancy’

Teaching &

support

2. The provider environment and the birth of GP Care

Commissioner / Provider environment

CCGs (& CSUs)

DH

Provider CICs / SEs Various FTs

Independent Sector

Mental Health

NHS England & LATs

Optometrists Dentists

Pharmacists

Policy

Co

mm

ission

er In

de

pe

nd

ent P

rovid

ers

GPs

Local Authorities

& PH England

Need for larger medically-based community providers

CCGs (& CSUs)

Provider CICs / SEs Various FTs

Independent Sector

Mental Health

NHS England & LATs

Optometrists Dentists

Pharmacists

Policy

Co

mm

ission

er In

de

pe

nd

ent P

rovid

ers

GP Care

Local Authorities

& PH England

DH

Independent Sector

Independent Sector

Independent Sector

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 controlling conflict of interests.

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.

GP Care – Who are we?

We are about collaboration & integration not fragmentation

GP Care’s Principles

• Focus on the patients’ experience;

• Reunite clinicians to improve care – each service is consultant and GP led;

• ‘Hide’ all patient-facing bureaucracy & governance: – Hassle free, dependable, speedy;

– Services where they’re needed;

• Exemplary clinical governance and quality;

• Prioritise relationship to the Commissioner;

• Ensure every ‘performer’ is incentivised.

Services and our operational relationships

Chambers of Consultants

GP Surgeries & OOH bases

Acute and Foundation Trusts

Hand surgery

Minor Surgery

Urology

Cardiology

Anticoagulation

Ultrasonography & Dexa

Audiology

Nurses, Physios & HCAs

Urology

General Medicine

Radiology

Respiratory / sleep

Third & Charity Sectors; SEs & CICs

Urodynamics

Audiology

Commissioner

Support functions: •HR & legal •Finance & payroll •Trouble shooting •Practice merger & development

Support functions: Consultant Link Service – advice & guidance Patient record network

Service Locations

Deliberately

diffuse – use

bases where

people live

Counters

inequalities &

the ‘inverse care

law’ of health

provision

Network of 90+

premises – from

which we select

& operate

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

Nature of GP Care and other GP Provider Companies

• Established as a Ltd Co but loose network with member practices;

• Working with Nuffield Trust on a national network of GP Provider Companies:

– Need to recognise these entities as ‘Providers in contract with the NHS’;

– Need as much support as any other provider organisation to develop integrated community services

e.g. N3; PACS; IEP; EMIS; SUS; PAS.

3. Innovative services

a) Near patient testing

i. Ultrasound;

ii. DVT & Anticoagulation;

iii. Urology diagnostics;

Mobile Ultrasound

- Phillips CX50

i. Ultrasound

• DVT & urology support

• Non-obstetric, community-based delivery

• Pregnancy reassurance scans

• Linked to centre and hospitals with N3, PACS & Image Exchange Portal, SUS.

• Immediate advice available from Radiologist

• Uploadable to hospital so no repeat scans needed

Winner of ‘Community service redesign’ national

award for prison service

Winner of ‘Healthcare Outcomes’ national award

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

A

C

C S u r g e r y

POC D-dimer - Clexane Ultrasound, b/test & Rx

Clexane (daily) & POC INR (or other anticoagulants)

Average 4.7 visits to local base

Never darken the hospital’s doors

Convenient - to patient: integration with own GP

72% reduction in cost to the NHS

DVT

2nd win (2014) in 3 years for ‘Community

Innovation’

• Now being asked to widen our inclusion criteria

• Local haematologist is our 2ndy care lead

Uroflowmetry - Dantec-Danflow

Flexi-cystoscopy – Dantec

& Endosheath system

iii. Urology diagnostics

• 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


b. Patient Record Network (PRN) for clinical records

Patient Record Network

• EMIS-Web based clinical record system

• 500,000 records available (Read only) in: - – Hospital Emergency Departments

– GP Out of hours bases

– St Peter’s Hospice

• Secure Information Governance

• Probably superseded now by other national developments

c. Screening for referral value

i. Obstructive Sleep Apnoea

ii. Cardiac Arrhythmia


i. Obstructive Sleep Apnoea

• High referral levels with high costs to 20 care sleep laboratories

• Screening process to identify snorers v. obstructive sleep apnoea

• Home based kit with downloads to respiratory consultant for interpretation

• Only OSA need referral

Konica Minolta Pulsox 300i

Hypnogram

ii. Cardiac Arrhythmia Monitoring

• Worn constantly

• Pre-programmed to record events

• Identifies heart irregularities

• Analysed remotely

• To reduce avoidable referrals

• Patient reassurance

• To refer appropriate patients with data on the arrhythmia already available

Broomwell

Healthwatch

d. Consultant Link Service - Advice & Guidance



GP led

Consultant led



Limited ‘long-term conditions’ work



Long-term follow up of many conditions


GP led

Consultant led







Clinical split

Reunite clinical advice

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

Consultant Team(s) GPs

Call routing

Service Model

GP Practice Set-Up: - Unique tel # for each practice - GP Care sets up each practice with their preferred source of

advice for each specialty (can use up to 3 hospitals for each specialty)

Tel Call - Consultant Provides Advice - Consultants available 8am-6pm via mobile phone Hunt Group - GP and consultant conversation digitally recorded

Outcome Monitoring - Consultants stay on line and log the outcome of the call (during

trial period only

Digital sound file: • Sent to GP practice team and

attached to practice/team records

• Sent to hospital teams for records

and medico-legal purposes

Hospital Team Set-Up: - ‘Hunt Group’ of consultants set up for each specialty team at

each hospital - GP Care manages the Hunt Groups on a daily basis to ensure

that all and only available consultants are logged in

Set up:

Call routing:

Outcome Reporting - Reporting full performance metrics by practice, CCG, hospital

Call features: • GPs can call from practice or

mobile

• Paperless for consultants so no

extra clinical sessions

• Consultants can accept or reject

calls

GP makes the call - GP dials unique tel #

- Selects specialty - Keys in patient NHS number

- Call loops through consultant Hunt Group until one answers (15 seconds/different ring tones)

- If no answer then GP Care manages call overflow and arranges call-back

© GP Care UK Limited, registered number 0651 7384

Access 16 months to 30 January 2013 Average call answering time = 68 seconds Average call duration = 3 minutes

Outcomes (logged by consultants) • 63% referral avoided; • 2% admission avoided; • 9% GP requested diagnostics; • 24% referral recommended; • 2% admission recommended.

Benefits • Reduction in avoidable referrals

• Better for patients • Reduced cost to the ‘system’

• Reduced referral/admission rates support reduction in bed capacity • Improves flow of referrals when they are appropriate • Improves communication and integration between primary and secondary care • Provides case based learning for primary care • Improves overall NHS ‘system’ efficiency (using existing Consultant Resource)

Feedback • Consistently positive feedback - GPs “It’s good to be able to talk to consultants again”

Outcomes – Cardiology

Referral avoided Admission avoided GP requested diagnostics

Referral recommended Admission recommended

63%

2%

24%

9%

2%

4. Practice Development & Transformation

GPs’ challenge – the case for a ‘scaled up’ organisation

Individualised care

Person

al d

octo

ring C

on

tin

uit

y o

f ca

re

Practice specificity

Patient Choice

Contracting unit size has been progressively

rising

Performance management & quality variation

Duplication of procedures & protocols e.g.

CQC, registration, summarisation, audits, contract

monitoring.

Prohibitive contracting

costs for small organisations

Restricted primary care expertise e.g. finance, legal, HR, strategic.

Competition & Procurement Law

Links between GP Care & local GP OOH Provider

GP Care

Elective / mainly

scheduled focus

Need for housebound

transport access

OOH provider

Out of Hours / mainly

unscheduled focus

Transport system used

at nights/weekends

Head Office,

Board. IT &

Commercial

functions

Scheduling &

call-centre

Urgent care

functionality

Commissioners want higher critical mass for robustness & contract bids;

Links allow differentiation of Management team functions;

Move towards an Accountable Care Organisation;

PMCF

Practices Practices Practices Practices Practices

EMIS-web Shared support

for template & IT

utilisation

Shared Telephony – real or virtual centre Integrated appointment booking capability

Own

GP

OOH

options

& links to

community

providers

Booked

w/e review

for high risk

pts

Patient record

available

wherever they

present

Care

plans

What are the PMCF deliverables?

Shared in-

hours

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

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

• teams.

Practices A - G

Hub 1 Hub 2 Hub 6 Hub 4 Hub 5

Practices H - L Practices P - T Practices U - Z Practices i - v

Hub 3

Practices M - O

Each Hub 1 – 6

• 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 A

Practices B

Practices C Practices D

Practices E

Practices F

Practices G

Standard General Practice

OOH


LTC / EoL

Standard General Practice Urology

Intermediate care


DVT Urgent care

Standard General Practice / USS Occupational

Health


Audiology Training

Standard General Practice Diabetes Research

Site managers Clinical leaders

IT network

Practice Support structures

Share

‘back office’

resource

Working with

local OOH

provider to

integrate

One OOH open

permanently per

hub area

Integrated

24 hour/day

7 day/week

provision

Could be foundation

for incorporation of

community health

staff

Initial findings suggest

resonance with GPs

& reminiscent of PCG

relationships

Virtual centre as central resource

Hub 1

Hub 3

Hub 4

Hub 2

Hub 5 Hub 6

5. Accountable Care & Remodelled provision

5. Accountable Care & Re-modelled provision

• Partnering with other provider organisations to provide the Business Intelligence functions to risk manage speciality budgets in their entirety;

• Link and operate all parts of the patient pathway from primary to tertiary care;

• Share savings across the provider network and with commissioners.


GP led

Consultant led







10 20 and 30 Care

Model clinical speciality / care delivery around patient need

Manage whole pathway commissioned in its entirety from pre-primary to tertiary

Provider partnerships with risk-sharing / savings arrangements with commissioners

Clinical split

Commission whole pathways of care: accountable provider with a capitated budget

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 innovation of GP Provider Companies / Federations are key to realising the above.

Thank you

www.gpcare.org.uk

Documents

Federating for Innovation - Primary Care Commissioning · Uroflowmetry - Dantec-Danflow Flexi-cystoscopy – Dantec & Endosheath system iii. Urology diagnostics • Remote electronic