dr-tim-burke-presentation by xiangpeng

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									The sharp end : making QIPP
   work for Primary Care
             Dr. Tim Burke,
             GP, Chulmleigh, Devon, Chair N
             Devon Locality Commissioning
             Board,
             Regional GP Advisor IAPT South
             West
The sharp end:making QIPP work for
Primary Care


   Why GP’s are key players
   But they’re not the only players
   QIPP – what does it mean to Primary Care?
   Pathways - “Follow the patient flows /Follow the money flows”
   Can we get better alignment in MH to allow earlier intervention?
    – access, IAPT, LTC’s, MUS & tarrif
   Critical appraisal of QIPP plans – clinicians, users, carers, GP
    commissioners
   White Paper – the new landscape
   Being brave – invest to really save
Primary Care - General Practitioners as
key players


So what is a GP?

 “A general practitioner or GP is a medical
  practitioner who treats acute and chronic
  illnesses and provides preventive care and
  health education for all ages and both sexes.
  They have particular skills in treating people with
  multiple health issues and comorbidities”
                                        Wikipedia
General Practitioners :


   Long-term presence in their community
   Long-term relationships with patients
   Operate open access
   Undifferentiated case load
   Shift to more pro-active care – QOF
   Commissioning role
    Trends in consultations in General
    Practice



         1995/1996                           2008/2009

   225 million p.yr.                 304million p.yr.
   21300 / ave. practice             34600 / ave. practice
   3.9 / yr./ave. patient            5.5 / yr./ ave. patient

QResearch & The Health & Social Care Information Centre 2009
Mental Health morbidity


   Almost 1 in 4 adults (23%) in England has at least 1 Psychiatric
    disorder

   7% have 2 or more disorders
     (Adult Psychiatric Morbidity Survey, 2007. NHS Information
       Centre)

   But only 3% access NHS Specialist Mental Health Services
     –   (Bournemouth & Poole, Neighbourhood Statistics 2008-9)
QIPP




   Planning for a sustainable future………
                        Impact of QIPP plans on delivery model
               Acute Hospital                                               Community Hospitals
                                      Operating as part of single point
Greater                               of access systems                                      Direct
               Admissions
focus on                              Greater focus on attending and
diagnosis,                            resolving not attending and           Admissions
               Day Events                                                                                   Focus on flexible
rapid                                 conveying
assessment                                                                                   Transfers      capacity and
               Beds                                                                                         integrated
                                                                            Outpatients
                                                                                                            workforce
               Staff
                                        Ambulance Services                  Beds                            operating as a
                                      Callouts                                                              combined entity
               Outpatients                                                                                  with community
                                      Deliveries                            Staff
                                                                                                            teams.
                                                                            Minor Injuries                  Preventing
                                                                                                            admission and
       Mental Health                                                                                        supporting timely
                                                                                                            discharge
                                           GP Practices
 Admissions                                                                     Community Health
                                                                                       Services
 Beds
                                GPs                                                                             Voluntary
                                                                            District nurses
                                                                                                                Sector
                                Minor Injuries                              Complex care teams
 Community and home-                                                                                            Home based
 based care                     Practice Nurses                                                                 support

 Staff
                                                                                                          Nursing Homes
                                   Focus on GP or Consultant                Home/Domiciliary
         Hospices                  elderly care expertise                           Care                 Beds            (      )
                                   supporting those with most             Social services
Beds                               complex needs.                         home response                  Cost of
                                                                                                         continuing HC
Cost                               Other primary care staff to            End of life care at
                                   take on more routine                   home                           Respite care
Home based specialist              primary care
support
Implementing QIPP

   Complex Health and Social Care landscape
   Not just Commissioners & Providers
   Primary Care view of the whole system
   Do clinicians support the changes?
   “Citizens’ view”- do they see the “boxes”?
   Does the local population support the
    changes?
   How do you know?
QIPP: who else needs to be involved?

   General population
   Local Authority structures
                Social care
                O & S Committees
                (Healthwatch?)
   Patients & Carers
   Clinicians – Primary Care & Secondary Care
QIPP: who else needs to be involved ?


   Specialists – pathway redesign eg. f/up rates,
    prescribing

   Primary Care clinicians including
                  Practice & Community Nurses
                  Pharmacists
                  Physiotherapists
                  Dentists
                  Psychological Therapists
QIPP:what does it mean at the sharp
end?


   Quietly Ignorant, PCT’s Problem

                OR



   Questioning, Involved, Pro-active, Promoting

        How do we find out ?
Engaging Primary Care with QIPP



      Involvement                Ownership




                    Confidence
“Follow the patients” : what’s the
pattern of need?


Kaiser Permanente Triangle
                                  Level 3
                                   Case
                                Management


                                   Level 2
                               Disease specific
                              care-management




                                  Level 1
                             Supported self-care
“Follow the money” : what’s the
pattern of spend?


                   Level 3
                    Case
                 Management


                    Level 2
                Disease specific
               care-management




                   Level 1
              Supported self-care
Provision and Funding of services


   Historical accident or planned?

   Is it what we want?

   If not what are the drivers for change?
Quality as the key driver for Primary
Care


   Accessibility – timeliness & location
   Fully implement the service!
   Clear streamlined pathways agreed by Primary and Secondary
    care – what about MoM approach?
   Referrals to the right place first time – no “bouncing”
   No gaps between services
   “Seamless” from user perspective (across both health & social
    care)
   Take account of local realities - eg. rurality, deprivation
   Involve Primary Care in monitoring – quality & performance
Avoid the “tenacity test”


   “Not appropriate for our service”
   “Not in our area”
   “Not on the right Performa”
    Narrow “opt-in” options & time-frame
   “No one answers the phone”
   “Answer machine, no one rang back
Innovation


   Achieving the above would seem like innovation!
   Seek feedback – users, carers
   Share best-practice – not many truly new ideas
   Pilots – be prepared to stop or roll-out – avoid
    “limbo”
   Enhanced Primary Care role – opportunities in lower
    level interventions – tariff a factor?
Productivity & Prevention:where are
the opportunities?

   Timely access to existing, evidence-based services
    – avoid escalation
   Linking with all of Primary Care – widening the
    catchments – more entry points
   Primary Care enhanced role – LES ? , Tariff
   Long-term conditions (LTC)– improving outcomes,
    avoiding acute events
   Medically unexplained symptoms (MUS) – improving
    outcomes, avoiding unnecessary interventions
Timely access

   Public education – awareness , reduced stigma
   Promotion of self help & self referral eg. IAPT
   More appropriate GP consulting
   Reduced GP consultation rate – CSR estimates 3-5
    visits over 2 yrs post recovery
   Reduced referrals/admissions/outpatient procedures
   Reduced prescribing - NICE Guidance
   Better outcomes –wellbeing, return to productivity,
    prevention of relapse
Linking Mental Health Services better
with wider Primary Care


   A&E
           view as part of Primary Care
           empower staff – robust psychosocial assessments, liaison
            services
           fewer attendances?
           fewer admissions?


   Signposting opportunities
           Pharmacists,
           Physiotherapists
Long-Term Conditions

   Depression is 2-3 times more common in people
    with diabetes
   Approx. 450,000 people with diabetes and
    depression in England
   Associated with increased use of healthcare
    resources
   Associated with increased self-perceived symptom
    load
Long-Term Conditions


   Cost of treating co-morbid diabetes and depression
    is 250%
   Cost of all treatment is 400%
   Diabetes associated with 10% of Acute sector spend
Long-Term Conditions


   NICE Guidance - CG91 – stepped care including
    “Collaborative Care”
   Opportunities for Primary Care staff to deliver low
    intensity interventions
   Who is best placed to co-ordinate Collaborative
    Care? - GP / PN / C Matron?
   Training / supporting role for IAPT / Mental Health
    service providers?
Other Long-Term Conditions


   COPD – repeated acute admissions –
        disruptive, costly- ? All necessary
   Ischaemic Heart Disease – reduced
        admissions and interventions
   Other conditions: Chronic Pain, Neurology,
        Gynaecology, Gastroenterology, ENT
Medically Unexplained Symptoms


   Up to 300,000 people may be affected in England
   Significant workload and consumption of resources
   Both in Primary & Secondary Care
   Risks of interventions
   Unrelieved “patient” distress
Medically Unexplained Symptoms


   Needs to be included in QIPP plans across a range
    of specialities
   Will need investment – re-directed resources
   Will need clear Clinical Pathways – Primary and
    Secondary Care agreed
   Will need education of Public & Clinicians
Summary:QIPP as a tool for
sustainability


   Clinical engagement is key at all levels
   Primary Care particularly
   Early intervention helps everyone
   Primary Care can deliver some aspects itself
   Mental Health service investment can realise
    savings elsewhere
   What’s future commissioning landscape & what
    happens beyond QIPP?
 What shape commissioning in the
future?

   GP Consortia
   April 2013 onward - real budgets & accountabilty
   Shadow form from April 2011
   Appropriate size not determined
   Levels of commissioning not known
   Mental Health likely of keen interest to GP Consortia
   Tariff – outcomes based, will need services to be
    responsive to avoid disinvestment, enables Primary
    Care extended role?
Commissioning Development Schematic

                      North Devon GP Practices                 NHS Devon
                         Nominations Vote & Appointment




Oct 2010
                  NDLCB             Core Team     NHS Devon Locality       White Paper



                                                                           Consultation


Apr 2011    Shadow Consortium
                                                                             Primary &
                                                                            Secondary
                                                                            Legislation
                                   TRANSFER
                                          OF
                                   FUNCTION                                   Contract




                                                                         Level of GP
Apr 2013   Control & Accountability                                    Commissioning
 QIPP : make it a positive and see the
    opportunities because ……..


“Nothing travels faster than the speed of light,
  with the possible exception of bad news
  which obeys its own special laws.”
                  Douglas Adams,HHGTTG.
Thank you




    Tim.Burke@nhs.net

								
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