Practice Based Commissioning

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Practice Based Commissioning

• Dr Stephen Cox
• Joint Medical Director
• Royal College of General Practitioners
• Innovation Unit
• scox_at_rcgp.org.uk

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Master class Agenda

• Introduction
• Focus agenda for audience
• Background and overview of PBC

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Master class Agenda

• Key factors in service redesign and new service
  design in PBC
• Social Care integration
• Examples that went well.and those that didnt
  Obstacles and Solutions.
• Interactive Discussion
• Close

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Introduction

• RCGP Innovation Unit
• GP in St.Helens, Merseyside
• PCT/SHA/Deanery Links
• PBC Consortium Board
• Governance, Significant Event Analysis, Audit,
  Primary Care Poor Performance Management, Service
  redesign.

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Introduction

• The St Helens experience
• 190k PCT population/local authority
• 3 PBC groups
• My practice - Consortium of 100k patients
• Consortium Board
• Patient Forum PPI group

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Focused Agenda

• Your needs
• Your successes
• Your concerns

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Background to PBC

• The next step after PCTs
• Choice / CB
• Payment by results
• Opportunity to shape change

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Background to PBC

• Current Structure Options
• Individual Practice
• Consortia common models
• Locality based
• Shared Ideology
• Parent/Child..driver/passenger
• 3. PCT facilitated

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Background to PBC

• PRACTICE based commissioning
• Not
• PCT based commissioning

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Background to PBC

• Key partnership working primary, secondary and
  social care, WITH patients FOR PATIENTS
• England approx 35k GPs in 2005
• 28.5k FTEs
• Workforce changes
• Evolving PHCT commissioning of primary care
  services also an integral issue for PBC.

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Background to PBC

• Primary Care changes
• 40 Headcount GPs are female 27 in 1993
• 60 Registrars are female
• Also
• 28 GPs are 50-59
• 8 GPs are 60
• Urban areas up to 5 more retirement
• time-bomb.

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Background to PBC

• Av. List size 1700 PMS, 1600 GMS
• 61 Headcount GPs/100k pts in England 2004
• Range 53 NE London 69 SW Peninsula
• Wales 62, Scotland 84
• FTE/100k range 48.7 61
• Reduced job vacancy application rate.

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Key Factors

• Changing patient care and pathways across BOTH
  primary and secondary care
• New ways of working
• New pathways
• New venues
• New care providers eg HCAs NCs

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Key Factors

• Clinical Engagement
• Practices
• Individual GPs
• PHCT members DNs PNs etc
• Hospital Clinicians

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Key Factors

• Clinical Engagement
• Identify
• Wilful non-engagers refusniks
• Versus
• Un-witting non-engagers

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Key Factors

• Clinical Engagement
• Manage refusniks individuals/teams
• Establish close GP-Consultant Links

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Key Factors

• Professional Stakeholder Engagement
• Social Care Organisations
• PCTs and SHAs
• Secondary Care Balanced Clinical Partnership
• Other PBC Consortia
• Private Sector

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Key Factors

• Engage Patients
• PBC Patient Groups PPI
• PCT Patient Forum
• Voluntary Groups

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Key Factors

• Communication
• Within Consortium between practices
• Staff within Consortiums Practices
• Without PCT, Patients, Local Authority etc

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Key Factors

• Quality and Standards
• Integrated Governance
• Significant Event Analysis
• Evidence
• Patient and Stakeholder Feedback

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Key Factors

• Quality and Standards
• Quality Assuring Patient Pathways in PBC
• RCGP
• Patient Safety
• Probity

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Key Factors

• Informing Choice
• Knowledge Management
• Shared and Available to GPs
• Relevant data
• E.g. MRSA rates

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Key Factors

• Emergency Bed Days
• The key to success
• Re-admissions
• Admissions avoidance options
• Bed Utilisation
• Long term conditions agenda

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Key Factors

• EBDs
• GMS2/PMS work
• Readmissions data by patient NOT speciality

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Social Care Integration

• Partnership approach
• Public Health Choosing Health
• Local Authority agenda

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Social Care Integration

• Problem Solving approach
• Resource utilization
• Patient centred
• PBC Board links to Directors of Social Care

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PBC Projects

• 1. Re-admissions Project
• Mortality link to re-admission rate
• Morbidity profile
• Case Review project / SEA
• Approx 33 each GP, Social, Hospital

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PBC Projects

• Re-admissions Project
• 2nd re-admission
• Practice Review
• Case Management by Community Matron
• Hospital Case Management flagging, PHCT
  communication, all pending tests done when
  inpatient, longer admission, planned discharge.
• Social Care link

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PBC Projects

• 2. Nursing and Care Home Scheme
• Central call collation and filtration
• Top slicing of visits
• Team do Fire-fighting on visit
• PLUS Chronic Disease Management and Medication
  Review

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PBC Projects

• 2. Nursing and Care Home Project
• NH visiting team GPsWI, Practice Pharmacist,
  Community Matron, Social Worker.
• Education.
• Admissions reduction.

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PBC Projects

• 3. Palliative Care Scheme
• Care at home, inappropriate hospital admissions
  avoidance
• Gold Standards - PHCT Education scheme and
  support
• Finite number of Hospice beds

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PBC Projects

• 3. Palliative Care Scheme
• GPwSI lead / PHCT / Social Care partnership
• Nursing Home dedicated beds
• Nursing Home staff education
• Home Care and Carer support DN liaison.

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PBC Projects

• 4. Other
• GPwSI ENT, Dermatology and M.Skeletal services.
• Ophthalmolgy GPwSI post-op and glaucoma follow-up
  service.

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PBC Projects

• 4. Other
• Learning Disabilities.
• CAMHS Child/Adolescent MH Services
• Anticoagulant monitoring in PHCT
• OOH central call handling for GP, DN, Midwifery
  and Home Care services
• Routine Appointments OOH
• SEA across primary and secondary care

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Obstacles and SolutionsReal examples

• Which Service to redesign?
• PPI group PHCT/stakeholder forum Complaints
  data PCT Performance monitoring data Provider
  consultation.
• Engagement within Consortia for projects etc.
• Key worker per team or refusnik protected time
  communication quick wins for evidence admin
  support.
• GP-Consultant liaison issues.
• Direct phone numbers available SEA meetings
  email discussion groups Visiting Consultant on
  PBC Board.

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Obstacles and Solutions

• GPs PBC vision/enthusiasm and PCT apathy.
• Communication Joint meetings PCT Board
  awareness Local Authority support SHA support
  quick win projects for evidence, use PCT Patient
  Forum to sell ideas to PCT.
• Differing Agendas?
• Achieve understanding of stakeholder views by
  linking PHCT, PPI group, Social and Secondary
  Care in a facilitated away day. Some small
  changes may dramatically improve working lives
  and care eg fax medication list for 999
  admissions.

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Obstacles and Solutions

• High Admission Rate?
• Check demography high morbidity? Any out-lying
  practice rates? Share data in GP Forum. Check A/E
  admission rate for patients assessed once in A/E.
  Check A/E attendees source of attendance
  self/GP/WiC/999/out of area. Check
  re-admission rates. Public / GP / OOH service /
  AED education?
• High Nursing Home Admissions?
• Specific Home? Specific Day, time, staff member
  or medical condition? Check re-admission rate
  and admission duration with care episode
  completion.

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Obstacles and Solutions

• High medical readmissions?
• Incomplete care episodes pending tests,
  pressure of beds leading to deferred out patient
  investigations. Flag re-admissions cases,
  complete investigations before discharge,
  hospital must always talk to PHCT before
  discharge, share clinical info admission
  notification. Matron, pharmacist and social
  worker team in hospital.
• EMI patients and carer issues in the community?
• Unable to establish team. Try similar visiting
  team led by GP, with link to Psychiatrist. Link
  respite services to specific EPH/NH and support
  them with that team. Improve comms and liaison
  home care to DNs.

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Interactive Discussion

• Can we solve any issues together?
• Do you wish to share any successes?
• Or pit-falls?
• Or any solutions to failures which became
  successes?

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PBC Master class

• Thank you for participating!
• Dr Stephen Cox
• RCGP Innovation Unit
• scox_at_rcgp.org.uk
• Please see the RCGP stand in the conference hall.