New models of working together and differently: the experience of GP Care Dr Phil Yates Darlington 11 th June 2015

Agenda 1.Current pressures in Primary Care; 2.The agenda for primary care and the birth of GP Care; 3.Service Innovation; 4.Practice development & transformation; 5.The current context for Primary Care; 6.Summary.

1. Current Pressures in Primary Care

General Practice More regulation e.g. revalidation / CQC More regulation e.g. revalidation / CQC Toughening targets e.g. DESs, QIPP Toughening targets e.g. DESs, QIPP Workforce fewer GPs Workforce fewer GPs Extra responsibilities e.g. CCGs Extra responsibilities e.g. CCGs Contract changes risk loss of permanence Shift of work from hospital Reduced Social Services funding Financial Pressure More long term conditions Aging population more complexity General Practice unsustainable in its current form 4

Financial Pressure! QIPP targets New DESs to earn back income Revision of PMS growth and other baselines Higher QOF thresholds & new targets Downsizing of QOF & less per point Falling investment in community & primary care Public Pay Squeeze Reductions in funding for teaching Higher contributions to NHSSS Uncertainty over premises funding Reduction in MPIG protection Rising expenses DDRB rejected Cost of meeting regulatory standards

Commissioner / Provider environment CCGs (& CSUs) DH Provider CICs / SEs Various FTs Independent Sector Mental Health NHS England & LATs Optometrists Dentists Pharmacists NHS Commissioner Independent Providers GPs Local Authorities & PH England

Drive towards larger medically-based community providers CCGs (& CSUs) Provider CICs / SEs Various FTs Independent Sector Mental Health NHS England & LATs Optometrists Dentists Pharmacists Independent Providers GP Care Local Authorities & PH England DH Independent Sector Independent Sector NHS Commissioner

2. The agenda for primary care and the birth of GP Care

Support New income streams for primary care; Preventing cherry picking by the commercial sector; Ensuring integration with general practices; Back office support; Bidding & Risk Sharing Bidding at scale for contracts; Quality Assurance of service delivery; Risk minimisation for GPs & sustainability; Remodelling Care Support of existing model of General Practice; Linking in-hours and OOH care and supporting patient access. Local GPs early thoughts on advantages of a provider entity

About us Ltd Co: 100 GP practices; 700 GPs; 850,000 population coverage; Provider of community-based care to the NHS; Articles of Association similar to a CIC or SE; strict regulations on COI. Our objective To facilitate the shift of NHS healthcare services into primary care/community; To deliver innovation that benefits patients and the public purse; To support existing NHS Clinicians. Our operational model A bidding and contract holding entity; Subcontract clinical care to existing local teams (both 1 0 & 2 0 care); Redesign admin pathways and manage patients. GP Care Who are we? We are about collaboration & integration not fragmentation

Re-modelling Out-of-hospital Care 1 0 Care2 0 & 3 0 Care GP ledConsultant led All undifferentiated illness Little cross referral Limited long-term conditions (LTCs) Most access to diagnostics Acute management major conditions Long-term follow up of many LTCs Pre-primary1 0 & Community delivered 2 0 & 3 0 SSD / Pharmacist / NurseGPConsultants Web-based advice; self-help tel, email & SMS; expert patient; community & 3 rd sector support Assessing risk Minor illness & injury Specialist nurses LTCs & social care Telemedicine Telehealth Diagnostic uncertainty 1 st diagnosis Complex problems Follow ups Sub-specialisation Multiprofessional teams Major surgery High-tech interventions True consultancy Teaching & support Future Present

Services and our operational relationships Chambers of Consultants GP Surgeries & OOH bases Acute and Foundation Trusts Minor Surgery Urology Cardiology Anticoagulation Ultrasonography & Dexa Audiology Nurses & HCAs Urology General Medicine Radiology Third & Charity Sectors; SEs & CICs Urodynamics Audiology Physio /MSK Commissioner Support functions: HR & trouble shooting Finance & payroll Practice merger & development Support functions: Consultant Link Service advice & guidance

Service Locations for Service Delivery Deliberately diffuse use bases where people live Counters inequalities & the inverse care law of health provision Network of 90+ premises from which we select & operate GP Care provides 1. the critical mass for commissioning of different services in the community 2. Quality Assurance Places specialists where patients need specialist care Mobile kit means anachronistic institutional care outmoded

Key Principles for GP Cares Services High quality care this is focused on the patient Impeccable clinical governance Robust administrative & management arrangements Supported by GPs & Hospital colleagues Consistent with NICE / best practice guidelines Rapid Access Care where the patient needs it to be We are about collaboration & integration not fragmentation

Services and our operational relationships Chambers of Consultants GP Surgeries & OOH bases Acute and Foundation Trusts Minor Surgery Urology Cardiology Physio Anticoagulation Ultrasonography & Dexa Audiology, Out of Hours Nurses & HCAs Urology General Medicine Radiology Third & Charity Sectors; SEs & CICs Urodynamics Audiology Commissioner

3. Service Innovation

Mobile Ultrasound - Phillips CX50 i. Ultrasound Platform service for other specialities (e.g. DVT, urology, gynaecology, obstetrics, etc.); 25,000 patients / year; Multiple locations incl. Eastwood Park prison; Linked to centre and hospitals with N3, PACS & Image Exchange Portal, SUS. No need for repeat scan; Immediate advice available from Radiologist. Winner of Healthcare Outcomes national awards

ii. DVT & Anticoagulation Point of care d-dimer tests Immediate results Reduced administration Reduced clinical risk Immediate treatment Point of care INR monitoring Less administration Face to face discussion with patients for clarity Reduced costs to NHS

Flexi-cystoscopy Dantec & Endosheath system iii. Urology diagnostics Remote electronic consultant triage reduces demand by 15% One stop shop Delivered in surgeries by our ultrasound team and the acute Trusts consultants Innovative sheath technologies 60% patients managed entirely within primary care Seamless onward referral for 2WW and cancer care

iv. Other innovation trials Other innovations & initiatives to manage patient care solely in the community Sleep apnoea diagnostics Dysrhythmia monitoring Konica Minolta Pulsox 300i Hypnogram Broomwell Healthwatch

1 0 Care2 0 & 3 0 Care GP ledConsultant led All undifferentiated illness Little cross referral Limited long-term conditions work Most access to diagnostics Acute management major conditions Long-term follow up of many conditions 1 0 Care2 0 & 3 0 Care GP ledConsultant led All undifferentiated illness Little cross referral Limited long-term conditions work Most access to diagnostics Acute management major conditions Long-term follow up of many conditions Clinical split Reunite clinical advice without moving the patient

Objective:Supporting GPs managing more patients in primary care Concept:Immediate, telephone access to consultant Advice & Guidance Key points:Use of consultant mobile phones Voice recording calls making the service paperless Consultant Team(s)GPs Call routing

Benefits Reduction in avoidable referrals: Better for patients Reduced cost to the system Reduced referral/admission rates Improves flow of referrals where required Restored clinical communications Improves overall system efficiency Feedback Consistently positive feedback - GPs Its good to be able to talk to consultants again - Consultants Its reduced outpatients where I cant add value. Results Cardiology Outcomes Winner 2014 Best use of Media & Technology award. RCGP & GP Magazine

4. Practice Development & Transformation

GPs challenge the case for a scaled up organisation Individualised care Personal doctoring Continuity of care Practice specificity Patient Choice Contracting unit size has been progressively rising Performance management & quality variation Duplication of procedures & protocols e.g. CQC, registration, summarisation, audits, contract monitoring. Prohibitive contracting costs for small organisations Restricted primary care expertise e.g. finance, legal, HR, strategic. Competition & Procurement Law

Models of primary care at scale emerging Loose Network Mega-practices: either geographically compact or spread Foundation Trusts OR Community Trusts Integration with Hospital or Community Trust sector Loose Network with internal mergers Individual mergers

Component Functions of Federations GP at scale Rapid Access Diagnosis and Treatment Programme Management of Long Term Conditions General Practice at scale Harmonisation of scheduled & unscheduled care

Links between GP Care & local GP OOH Provider GP Care Elective / mainly scheduled focus Need for housebound transport access OOH provider Out of Hours / mainly unscheduled focus Transport system used at nights/weekends Shared functions Scheduling & call-centre Urgent care functionality Commissioners want higher critical mass for robustness & contract bids; Links allow differentiation of Management team functions; Move towards an Accountable Care Organisation; Prime Ministers Challenge Fund

Practices EMIS-web Shared support for template & IT utilisation Shared Telephony real or virtual centre Integrated appointment booking capability Own GP OOH options & links to community providers Booked w/e review for high risk pts Patient record available wherever they present Care plans What are our at scale deliverables? Shared in-hours On-line repeat prescription service Email consultations or support for electronic self-help (e.g. Hurley group) Clinical support to consortium members & Professional A&G line

Modelling Practice Support Provision to each hub of: Practices business development service development; private services, interface with commissioners and other health & social care organisations, bidding agency for other community based healthcare activities; Operations contract delivery, clinical governance / quality assurance, scheduling & access, infection control, staff deployment, results & document management; Human Resources recruitment, skill mix, locum pool, in-house training, policies & procedures; Relationship & liaison patient participation groups, public involvement, complaints; Clinical professional behaviour, clinical training, mentorship and development, appraisal; Centralised Home Visiting All practice home, nursing & residential care visits and transportation (from home to surgery and for home visiting / housebound care); IT hardware & software, template setup & management, training and clinician support; Data maximising effectiveness of IT, data quality & record summarisation, IT governance, audit & reporting; Finance - payroll, accounts, contracting & bidding, efficiency, remuneration, budgetary control; Facilities - Practice premises, CQC & DDA compliance, rental & repairs, space & occupancy planning; * Future integration with community matrons / extended care practitioners / specialist nurse teams. Practices A - G Hub 1 Hub 2 Hub 6 Hub 4 Hub 5 Practices H - L Practices P - TPractices U - Z Practices i - v Hub 3 Practices M - O

Each Hub 1 6 Networked OOH & 7/7 working with base; Diagnostics: USS & other near patient tests; Links to End of Life care; IT support [eg to clinicians on returns on clinical services]; Intermediate care / risk assessment & care planning; Private medical work; Clinician training & mentorship / research; Range of extended services; * Future base for District Nurse & CNOP teams. Practices A Practices B Practices C Practices D Practices E Practices F Practices G Standard General Practice OOH Standard General Practice LTC / EoL Standard General Practice Urology Intermediate care Standard General Practice DVT Urgent care Standard General Practice / USS Occupational Health Standard General Practice Audiology Training Standard General Practice Diabetes Research Site managers Clinical leaders IT network

Locations for Practice Support delivery structures Share back office resource Working with local OOH provider to integrate One OOH open permanently per hub area Integrated 24 hour/day 7 day/week provision Could be foundation for incorporation of community health staff Initial findings suggest resonance with GPs & reminiscent of PCG relationships Virtual centre as central resource Hub 1 Hub 3 Hub 4 Hub 2 Hub 5 Hub 6

5. Current context for Primary Care

Main thrusts of the 5YFV Patient More care in the community Hospitals Community / Primary care / Social care Technological investment to support self-care & < NHS usage Higher Focus on Health Maintenance & Illness prevention Rebalancing of investment between sectors Reducing silos but (not accountability) between organisations

Current Fractured Relationships Hospital Mental health Social Care Physical health Health Family Doctors

Multispecialty Community Providers GPs & Nurses Community Trusts Social Care Mental Health Specialists Integrated Community Provider Community leads Urgent & Emergency Care - OOH, 111, Urgent Care & A&E Hospital

Primary & Acute Care System GPs & Nurses Community Trusts Social Care Mental Health Hospital Matures into an Accountable Care Organisation Urgent & Emergency Care - OOH, 111, Urgent Care & A&E Hospital leads

Accountable Care Organisation system maturity GPs & Nurses Community Trusts Social Care Mental Health Hospital Holds & spends whole capitated budget for its population Vertically Integrated Provider Urgent & Em. Single point of access, OOH, 111, ED RADAT & Community Specialists

6. Summary

Summary The NHS financial & service challenge will only be met by radically changing how care is provided: New localism; Using current & future technologies; Streamlining care & removing inefficiencies; Integration of care across organisational boundaries. The development of Federations can change and quality assure services in the community; They are part of realising greater resilience in practices; We are heading towards more a strong out-of-hospital sector and GPs place within that is likely to require alliances with other providers.

Thank you www.gpcare.org.uk

Documents

New models of working together and differently: the experience of GP Care Dr Phil Yates Darlington 11 th June 2015