GERAINT WYNNE - JONES

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GERAINT WYNNE - JONES

• INDEPENDENT
• NOT from LHB
• NOT from TRUST
• NOT from OOH PROVIDER

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DECLARATION OF INTEREST

• (PERSONAL NOT FINANCIAL)

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WHEN ALL IS SAID AND DONE- A LOT MORE IS SAID
THAN DONE

• W.E.C.A.C.
• D.E.C.S
• DESIGNED FOR LIFE
• MAKING THE CONNECTIONS
• WANLESS
• 1000 LIVES
• FULFILLED LIVES,SUPPORTING COMMUNITIES
• M.U.C.
• TIME TO MAKE A DIFFERENCE

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MODERNISING UNSCHEDULED CARE M. U. C.

• The
• Medusa of Unscheduled Care

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UNDERSTANDING OUR MEDUSA

• WHAT IS UNSCHEDULED CARE?
• HOW BIG IS THE PROBLEM?
• WHO ARE THE SNAKES?
• 6,000,000 ? HOW?????
• WHAT CAN PRIMARY CARE OFFER?

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WHAT IS U.C.?

• ANY UNPLANNED HEALTH OR SOCIAL CARE TO
  PATIENTS WHO NEED HELP TO CARE FOR THEMSELVES AT
  HOME
• 
  WALES AUDIT OFFICE
• 
  
  NOVEMBER 2008
• ANY EPISODE OF CARE PROVIDED FOR THE PATIENT
  WHICH IS UNPLANNED AND MAY REQUIRE PROMPT ACTION
  IN RESPONSE TO AN ACUTE, MINOR OR MAJOR INJURY OR
  ILLNESS WAG 2008
  

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HOW BIG?

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UNDERSTANDING HOW THE PUBLIC CHOOSES TO USE
UNSCHEDULED CARE SERVICES

• AWARD
• CHIRALJune 2008

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HOW BIG?

• WALES 2007- PATIENT CONTACTS
• AE 740,326
• NHSD 360,000
• GP 2,650,000 (ESTIMATED)

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UNSCHEDULED CARE
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UNSCHEDULED CARE TRUE PERSPECTIVE?

• FIRST CONTACTS
• GPs 63.5
• NHSD 6.0
• AE 5.5
• 999 3.3
• MIU 1.1

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MEDICAL STAFFING LEVELS 1997 TO 2007
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HEALTH BUDGET SCOTLAND 2006-07 (BILLION)
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FAMILY HEALTH CARE 2006-07 (BILLION)
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HOW BIG IN 2031 ?

• POPULATION WILL INCREASE BY 11
• PENSIONERS WILL INCREASE BY 31

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WHO ARE THE SNAKES?

• GPs
• W.A.G.
• TRUSTS
• LHBs
• WAST
• NHSD
• SOCIAL SERVICES
• MENTAL HEALTH
• PHARMACISTS
• I.T.
• PRESS
• PATIENTS
• SOLICITORS

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W.A.G.

• CONSTANTLY SEEM TO WANT TO BE SEEN DOING
  SOMETHING ABOUT THE POLITICAL HOT POTATO OF
  HEALTH
• THEY ENCOURAGE THE MEETINGS CULTURE
• THEY CREATE SOME OF THE U.C. PRESSURES
• THEY NEED TO GIVE CLEAR GUIDANCE TO PATIENTS
• THEY ARE OBSESSED WITH DATA AND EXERT NEEDLESS
  PRESSURE BY TARGETS

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• Politicians use statistics like a drunk uses a
  lampost
• for support not illumination
  ANDREW LONG

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Do AE clinical staff feel able to deliver
acceptable standards of service within the 4 hour
target?Paul Stevens M.A. Business Management
Thesis 2008

• 95 front line staff felt that the imposition of
  the 4 hour target had negatively impacted on the
  clinical care of patients.
• Pressure to meet time limit conflicted with
  professional care standards.
• Quantitative care was secondary to qualitative
  care.

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TRUSTS

• HAVING A HARD TIME LATELY
• HAVE MADE SOME VERY POSITIVE CHANGES
• TENDENCY TO BE SELF CENTERED
• SOMETIMES ONLY PAY LIP-SERVICE TO THE CONCEPT OF
  CO-OPERATING WITH THE WIDER HEALTH COMMUNITY?

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LHBs

• LOCALLY DISTANT
• IDENTITY CRISIS REPRESENTING PRIMARY CARE - BUT
  ARE THEY?
• PROPOSED CHANGES 2009 MAY IMPROVE LINKS WITH
  GRASS ROOTS
• L.E.S. AND D.E.S. IMPACT ON PRIMARY CARE CAPACITY
  TO PROVIDE U.C.?

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WAST

• THE GLAMOUR BOYS (AND GIRLS) OF U.C. !
• HARD WORKING
• MADE BIG CHANGES TO WORKING PRACTICES
• BEST USERS OF THE MEDIA TO ACHIEVE THEIR AIMS
  (SLIGHT PRIMA DONA COMPLEX?)
• THE IMPACT OF EXTENDED ROLE PARAMEDICS ON U.C.?

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NHSD

• ON GOING IMPROVEMENT SINCE LINK WITH WAST
• WHY NOT MORE POPULAR WITH THE PUBLIC?
• WHAT SCOPE FOR INCREASING CALLS?

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• COMPUTER SAYS.
• CALL YOUR GP
• DIAL 999
• GO TO AE

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SOCIAL SERVICES

• A VAST ARMY OF SNAKELETS WORKING BEHIND THE
  SCENES
• OFTEN VILLIFIED BECAUSE NOT AVAILABLE 24/7 AND
  NOT SEEN
• A VITAL ROLE IN THE KEEPING IN, AND RETURNING OF
  PATIENTS TO, THEIR COMMUNITY
• BACK INTO THE VIVARIUM OF HEALTHCARE?

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MENTAL HEALTH TEAM

• A SMALLER GROUP OF PATIENTS BUT MORE
  TIME-CONSUMING OF STAFF
• APPEAR TO HAVE DIFFERENT
• TIME-SCALES TO THE REST

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PHARMACISTS

• MINOR AILMENT ADVICE MAY RELEASE CAPACITY IN
  PRIMARY CARE BUT NO DATA TO SUPPORT THIS SERVICE?
• WHAT ABOUT MINOR AILMENT NURSES IN PHARMACIES
  WITH OPEN ACCEESS TO LOCAL GP SURGERIES?

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I.T.

• NOT FOR DATA COLLECTION BUT TO SECURELY SHARE
  PATIENT INFORMATION BETWEEN CLINICIANS
• I.H.R.(INDIVIDUAL HEALTH RECORDS)

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THE MEDIA

• A LOT TO ANSWER FOR !!
• USEFUL COMMUNICATION TOOL
• VIPEROUS QUICK TO BITE,VENOMOUS AND NOT CHOOSEY
  ABOUT PREY !
• COZY WITH WAST AT PRESENT - BUT BEWARE KNOWN TO
  TURN ON THEIR YOUNG !

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PATIENTS

• CHANGING DEMOGRAPHICS HAS MADE THEM VULNERABLE
• NO LONGER SURE WHERE TO GO FOR HELP
• WHY DO SO FEW ACCESS NHSD?
• NEED GUIDANCE FROM W.A.G. AND PROFESSIONALS
  BEFORE THE EVENT
• SIGNPOSTING

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DR. FINDLAYS CASEBOOK
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GPs

• LOTS OF GOOD GPs - SOME BAD GPs
• ADEPT AT JUMPING THROUGH W.A.G. HOOPS
• ACCESS STILL A PROBLEM IN REALITY
• LACK OF CAPACITY AN ISSUE SMALL INCREASE IN GPs
  IN WALES
• LACK OF MINOR ILLNESS NURSE PRACTITIONERS
• TARGETS AND C.D.M. LIMIT U.C. CAPACITY

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GPs

• OUR ROLE HAS BEEN CHANGED BY W.A.G.
• WE ARE NO LONGER DOCTORS OF
• ILLNESS -
• WE HAVE BECOME MANAGERS OF WELLNESS

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OTHERS

• SOLICITORS-
• THE AMERICANISATION OF MEDICAL LITIGATION IS
  IMPACTING ON U.C. MANAGEMENT.
• GPs ADEPT AT MANAGING RISK BUT BECOMING MORE
  DEFENSIVE MEDICO-LEGALLY-
• ? REASON FOR GP ADMISSIONS INCREASING- JUST LIKE
  CONSULTANTS IN AE/AMU ADMITTING TO DECIDE NOT
  DECIDE TO ADMIT- SO PUTTING FURTHER PRESSURE ON
  THE SYSTEM

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6,000,000 QUESTIONHOW?
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INDUSTRIAL MODEL OF CARE

• INPUT
• THROUGHPUT
• OUTPUT

• PRE HOSPITAL
• INPATIENT
• DISCHARGE

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PRIMARY CARE TEAM

• EXPERIENCE
• GENERALIST SKILLS
• STABILITY
• ADAPTABILITY
• COMMUNICATORS
• VALUED

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GPs IN AE / U.C. - FUTURE

• TRAINING -? GPWSI
• SINGLE FRONT DOOR
• I.H.R.
• LINKED I.T.
• ACCESS TO IN-HOURS APPOINTMENTS
• ACCESS TO BOOK IN-HOURS SERVICES

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PRIMARY CARE ROLE IN-HOURS

• INCREASE NUMBERS OF MINOR ILLNESS TRAINED NURSES
  TO RELEASE GPs TO DEAL WITH MORE U.C. CASES
  IN-HOURS
• TRAIN RECEPTIONISTS TO FIELD CALLS MORE
  APPROPRIATELY PROTOCOLS
• FACILITATE CONTACT WITH OTHER TEAMS LESS US
  AND THEM
• EXPAND COMMUNITY GP BEDS
• EXTENDED OPENING
• GPs IN AE / UNSCHEDULED CARE CENTRES

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The Edinburgh model

• Alastair Crosswaite
• Alastair.Crosswaite_at_luht.scot.nhs.uk

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• CHANGE OF PHILOSOPHY
• TEAMWORK
• CO-LOCATION
• GP BEDS _at_ DGH
• PRIMARY CARE PHYSICIANS
• Daily clinical sessions 5/7
• Experienced generalist with primary care
  sensibilities in acute secondary care setting
• Working at the primary/secondary care interface
  to manage patients in both directions

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LOCATION, LOCATION LOCATION .
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The Acute GP Service(AGPS)Challenging
Traditional Non-Elective Care
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Main Objectives

• To Transform traditional ways of working
• Challenging existing pathways of care, and ways
  of thinking about care
• Creating effective clinician to clinician
  dialogue
• Highlighting the need for inter-dependence of all
  services that support patients

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Operational Overview

• Monday- Friday 9am 7pm
• Covering and working from AMU
• Take all community telephone referrals for
• adult medical admissions, as well as providing
  advice to community based colleagues
• Onsite advice/opinion to secondary care
• colleagues

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Outcomes April 2007 March 2008

• Total Days of Service
  222
• Total Calls taken
  3170
• 
  
• Total Patients under AGPS Care 989
• Admissions avoided 899 (28)
• AGPS OPDs 845 (27)
• 
  

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PRIMARY CARE CAPACITY?

• ZERO !!!!!

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SAFE JOURNEY HOME
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DREAM SCENARIO?

• A LOCAL SERVICE WHERE
• I.T. CONNECTIVITY FACILITATES A VIRTUAL ROOM
  LINKING PRIMARY CARE, AE, WAST,DISTRICT NURSES,
  CPNs, SOCIAL SERVICES AND DENTAL SERVICES WHERE A
  SAFE, RISK-MANAGED (NOT RISK-AVERSE)
• DIVERSION COULD BE MADE EITHER TO PRIMARY CARE
  IN-HOURS OR OOH TO A
• CO-LOCATED FACILITY TO PROVIDE THE MOST
  APPROPRIATE SERVICE FOR THE UNSCHEDULED PROBLEM.