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National Primary Care ConferenceSustainable Primary Care & New Models: Healthy Prestatyn IachDr Chris Stockport
Background• Currently ~22,000 patients in Prestatyn area
• Went live in April 2016 following contract resignations
• Decision to run as a Health Board directly managed practice
• Departure from traditional model to an MDT based model, with an emphasis on a ‘social model of care’
• Another ~50,000 patients in BCU run practices, and at varying points of implementing locally-tuned versions
General principles
• Prudent HealthcareUnderstand what this means – it’s not just for secondary care. It is fundamental for sustainable primary care.
Areas targeted so far have only scraped the surface.
Lots of what we’re doing is overly complex, overly medicalised and adds little discernible value to individuals.
General principles
• Social Focus‘Medicalise only when necessary.’
Social and lifestyle-related problems are often best managed with social and lifestyle-related solutions.
General principles
• Risk & InnovationBeware of analysis paralysis
Be risk aware and not risk averse
Be honest about the ‘do nothing’ risks
General principles
• Contractual basisLets not get distracted by all of this!
‘Directly Managed’ was the only option for Prestatyn.
ALL have advantages and disadvantages. Choose the best contract vehicle for local need.
Collaboration & sharing practice across contractual vehicles is key.
GMS
APMS
Health Board run
General observations for the future
• GP availabilityWe’ll always need GPs
…. but doing proper ‘GP’ stuff.
There are plenty of other people working in Primary Care who are much better at dealing with some of the things I used to have to deal with.
Prestatyn
• Common initial misperception was that the driver was GP shortage.
• In fact it created an opportunity with a large enough footing to be able to explore the practicalities of MDT working and model redesign
• Prestatyn was a ‘crisis’ we needed
The HPI model
There are many influences, but three stand out:
• South Central Foundation, Alaska – NUKA
• Community Health Workers, Brazil
• Bromley by Bow, London
The HPI model
Population split across 5 (MDT)‘KeyTeams’4 general teams + 1 housebound & care home teams
The HPI model
Population split across 5 (MDT)‘KeyTeams’4 general teams + 1 housebound & care home teams
The HPI model: KeyTeams
1.5 GP(s)
Complex medical stuff
Nurse Prac’s
O.T.
The‘demedicaliser’
Pharmacist
Coordinator
KeyTeams = multidisciplinary teams replacing the traditional GP role
per 6,000 pts
The HPI model: KeyTeams
Supporting all of the teams:
Practice & Treatment Room Nursing
In-house Physio
Audiologist
Mental Health Practitioners
Research Team
KeyTeam principles
• All team members have an equal contribution to make
• Stable team – professionals get to know how each other works, strengths, interests
• Co-located in one office for all of their admin rather than in ‘own’ consulting room
• Team members are around for advice or to discuss patients they are concerned about
Learning, so far
MDT glue
Learning, one year in:Non-clinical KeyTeam coordinators
Case holding
Incoming correspondence
Sign-posting
Form filling
Result filingProblem solving
Learning, one year in:Non-clinical KeyTeam coordinators
• A definite winner!
• Already ….Estimated to have avoided 10,000 face to face appointments through signposting, or direct resolution of issue in the first year
Direct actioning and filing of 75%+ of incoming correspondence. Work ongoing looking at results
Case-holding complex patients
• Training programme created, with support from Bevan Commission
Learning, one year in:Primary Care Occupational Therapists
Builds upon the NUKA ‘Behaviouralist’ role
Proving to be very successfulextremely well received by public
growing evidence of successful demedicalising
big growth in local partnerships and use of social prescribing
Further to go, including evolving the skill-mix
Learning, one year in:MDT approach
Space, space, space.
GPs who were previously GMS partners take time to adjust (but can do) - but it takes time and support.
An evolved role for the GP – medical complexity, typically multi-morbidity. The easy stuff has been stripped away. This is not the same role as the traditional ‘salaried GP’ role.
Learning, one year in:Training costs
This isn’t just about GPs – we’re not training enough of ANY advanced practice professional to work in primary care.
Bringing experienced professionals out from secondary care can work, but they still need considerable on-the-job training to adapt and acclimatize.
Don’t underestimate the initial cost of this.