Community Integrated Healthcare –

An Approach by Whitstable Medical

Practice

Transforming General Practice – Unlocking the Potential Nuffield Trust, London Wednesday 15 May 2013 Dr J M Ribchester Executive & Senior Partner, Whitstable Medical Practice

Whitstable Health Centre &

Chestfield Medical Centre

Estuary View Medical Centre

Estuary View Medical Centre

Estuary View Medical Centre

Whitstable

© J M Ribchester

Whitstable

© J M Ribchester

OUR POPULATION’S HEALTH

NEEDS

Whitstable faces a growing health and social care challenge associated with its ageing population.

The population of over 65s in East Kent will increase by 41% between 2005 and 2020.

Whitstable shows a greater proportion of over 65s in comparison with the rest of the locality.

The probability of having a Long Term Condition (LTC) increases from 17%, for people under the age of 40, to 60% for those aged 65 and over.

People with LTC’s use disproportionately more primary and secondary care services, 52% of all GP appointments, 65% of all outpatient appointments and 72% of all inpatient bed days. This pattern will increase over time with an ageing population.

WMP ranked 182 out of 287 GP practices in Kent & Medway on the index of multiple deprivation

Long Term Conditions Registers Disease Category Number % of Population

Hypertension 5052 15.14

Asthma 2105 6.31

Diabetes 1728 5.18

CHD 1323 3.96

COPD 579 1.74

Mental Health 208 0.62

Dementia 210 0.63

Heart Failure 313 0.94

Epilepsy 183 0.55

Obesity 2712 8.13

AF 680 2.04

Depression 3817 11.44

CKD 1172 3.51

Thyroid 1263 3.78

Stroke 669 2.00

WMP List Size Growth

Since 1998

Whitstable Medical Practice List sizes 1.4.1998 - 1.4.2013

33,4

14

33,8

12

30,0

80

31,9

98 3

2,7

14

32,4

15

32,3

70

30,9

63

30,7

36

31,1

90

31,6

34

29,6

91

29,7

29

29,5

19

29,7

10

33,1

32

27,000

28,000

29,000

30,000

31,000

32,000

33,000

34,000

35,000

1.4.98 1.4.99 1.4.00 1.4.01 1.4.02 1.4.03 1.4.04 1.4.05 1.4.06 1.4.07 1.4.08 1.4.09 1.4.10 1.4.11 1.4.12 1.4.13

QUESTION

What has Whitstable Medical Practice

been able to do differently?

ANSWER

Redesign the provision of healthcare in Whitstable

Better patient experience

Closer to home

Shorter waits

Less cost to the NHS

In short, the development of an economical model of community integrated healthcare

Community Elective Services

Diagnostics: Echocardiography 2006

Ultrasound 2009

Digital X-ray 2010

Dermatoscopy Service for

Diagnosis of Malignant Melanoma 2010

Mobile MRI Scanner 2012

Consultant-led outpatient clinics: Cardiology (tertiary) 2006

Cardiology (secondary) 2010

Gynaecology x2 2010

Urology

Orthopaedics x3 2011

General Surgery

Colorectal Surgery

Pain Management

Dermatology 2011

Care of the Elderly and Joint GP Care

Planning

Hand, Wrist & Forearm 2012

GPSI/Specialist Clinics: Insulin Initiation 2005 Rigid Sigmoidoscopy 2006 Prostate Clinic 2007 Warfarin Clinic 2008 Cardiology OPD 2008 Dermatology OPD 2008 Epilepsy OPD 2010 Cardiology 2010 Surgery in Primary Care (SIPC) 2010

Screening Services: AAA National Screening

Programme Centre 2009

Guy’s Genetic Screening 2009

Paula Carr Retinal Photography

Service for Diabetes 2011

Day Surgery: Carpal Tunnel Surgery and Injection Pathway

Dermatological Surgery

Local Steroid Injection Service

Upper Endoscopy Service (hosted by WMP and provided by Prime Diagnostics Ltd)

Cataract Day Surgery Service (hosted by WMP and provided by consultant ophthalmologists)

Therapists: Hearing Aid Clinic 2005

Acupuncture 2006

Chiropractic 2006

Physiotherapy 2008

Long Term

Conditions

- Diabetes

- Cardiology

- COPD

- Dementia

Urgent Care

- Practice based Level 3 Minor Injury Unit

- Fracture clinic

- Co-located ambulance response base

- co-located community pharmacy

Whitstable & Tankerton

Hospital Enhanced Rehabilitation & Intermediate Care

Detailed

WISH

Workstreams

WISH Stakeholders

Workstream A Long Term Conditions

Lead: Dr J Ribchester Dr H Pinnock – COPD Dr D Kanagasooriam

– Mental Health Dr R Pieters –

Cardiology Dr R Brice – Diabetes Supported by: KCHT, KFS, EKHUFT,

PUG,

Workstream B Urgent Care

Lead: Dr J Ribchester Dawn Gaiger ENP Supported by: KCHT, EKHUFT,

SECAmb,

Workstream C Community

Elective Services

Lead: Dr J Ribchester Supported by: EKHUFT, PUG,

Workstream D

Whitstable & Tankerton Hospital – Enhanced

Rehabilitation & Intermediate Care

Lead: Dr J Ribchester Supported: EKHUFT, Friends, PUG, KCHT,

KFS

University of Kent

WISH Board

South East Coast

Ambulance (SECAmb)

East Kent Hospitals University Foundation

Trust (EKHUFT)

Friends of Whitstable Hospital &

Healthcare and Patient User Group (PUG)

Whitstable Medical Practice (WMP)

18 GPs, 140 staff

Kent Community Health NHS Trust (EKHT)

Kent Family Services (KFS)

Long Term Conditions –

Interim Findings

Diabetes

Cost savings – 50% (delivery of Insulin Initiation Clinics/non-insulin injectables)

Quality – patients below NICE recommended HbA1c. Wait times for insulin initiation down. Positive patient experience.

Next Steps – Identify number of acute, emergency & unplanned (re)admissions qv 4 comparator practices

Long Term Conditions –

Interim Findings

Cardiology

Cost savings – 38% (delivery of GPSI clinic in cardiology has reduced OPD referrals)

Direct patient journey’s to the right station – - GPSI Triage

- In-house consultant clinics (Kings & EKHUFT consultants)

- Heart Failure, Arrhythmia & Rehab Community Nurses

Reduced waiting times

Direct links to Cardiothoracic Services

Long Term Conditions –

Interim Findings

Dementia

Integrated Care Pathway for dementia & adult mental health at WHC

Reduction in anti-psychotic medications prescribed in care homes

CMHT & OPMHT delivered by KMPT in-house

Dementia café by Alzheimer's Society at WHC

Urgent Care

- Practice Based Minor Injuries Unit Level 3

- Digital X-Ray Imaging

- Consultant-led Fracture Clinic & TeleMedicine advice

- Co-located Ambulance Response Base

- Co-located Community Pharmacy

Tariffs

MIU Level 3 Tariffs (11/12):

£40 = Minor

£50.15 = Minor +

£73.95 = Standard

£99.45 = Major

A&E National Tariffs

£52.54 = Minor Injury

£78.82 = Minor +

£111.15 = Standard

£134.39 = Major

MIU Level 3 at Estuary View Apr 2011 – Dec

2012

Receipts £

Total Activity (no. of pts)

Minor 9869 £394,760

Minor + 12,596 £631,689

Standard 880 £ 65,076

Major 6,027 £599,385

Total No. of Patients 29,372

Total Receipts MIU Level 3 Apr 2011 –

Dec 12

£1,690,910

Comparative Cost A&E alternative

Minor Injury 9869 £524,703

Minor + 12,596 £1,006,108

Standard 880 £98,084

Major 6,027 £811,537

Total Cost Comparative for A&E £2,440,432

Potential Cost Savings Apr 11 – Dec 12 £749,522

Potential Percentage Cost Savings 31%

The cost savings are

calculated using the

following assumptions:

MIU tariffs:

£50.15 = Fracture Clinic

£99.45 = Fracture Clinic

(with X-Ray)

National Tariffs for

Trauma and Orthopaedics

£148 = First Outpatient

Fracture Clinic

Fracture Clinic at

Estuary View MIU

Oct 2011 –

Dec 2012

Receipts £

Total no. of clinics

Total no. of patients

78

658

Fracture Clinic w/o

X-Ray

596 £29,889.40

Fracture Clinic with

X-Ray

62 £ 6,165.90

Total Receipts

Fracture Clinic

£36,055.30

Comparative Cost

Trauma &

Orthopaedics

658 FA £97,384.00

Actual Cost

Savings

Oct 11 – Dec 12

£61,328.70

Percentage Cost

Savings

63.0%

Community Elective Services

& Diagnostics

- Cost savings. Examples:

1. Urology GPSI OPD – 35% savings

2. Carpal Tunnel Decompression:

- Surgery – 77% saving

- Injection – 83% saving

- Reduction in referrals

- Less OPD follow-ups

- More one-stop clinics

- Positive patient experience

Further work: - identify comparator cohort

- identify cost savings of all services

Whitstable & Tankerton Hospital

- Integrated Committee formed in 2010 to explore funding options for an Integrated Health and Social Care Centre in Whitstable

- OBC prepared by WISH Manager with input from all stakeholders

- Work due to commence at C4G to consider future of all 3 Community Hospitals

IF THIS IS AN ACCEPTABLE NEW MODEL

FOR URBAN GENERAL PRACTICES WHAT

ARE THE OBSTACLES?

Practices combining to serve larger populations – perhaps 30,000-35,000

GP buildings that are fit for purpose

New GP Management structures

Buy-in from CCGs, NHS CB, RCGP, BMA etc

New financial challenges

Potential for upsetting local acute trust and others.

AND THE PRIZES ARE …..

Benefits to patient care – more personal care, closer to home, shorter waits

Benefits to the health economy – services delivered at less cost

Benefits to the general practice – fulfilment, education, upskilling, integrated healthcare community, more of a buzz!

Better patient and public engagement

BUT IT TAKES TIME AND EFFORT

Community Integrated Healthcare –

An Approach by Whitstable Medical

Practice

Transforming General Practice – Unlocking the Potential Nuffield Trust, London Wednesday 15 May 2013 Dr J M Ribchester Executive & Senior Partner, Whitstable Medical Practice