Hugh ReeveWestmorland Primary Care CollaborativeNHS [email protected]
Developing clinician-led integrated services
The NHS in Cumbria circa 2006
A health community at war A series of unhappy mergers that failed to address
fundamental issues Clinicians (and in particular doctors) completely
disengaged Community services fragmented, with proposals to
close community hospitals Finance and activity out of control – £36.7m
historic debt – £100m deficit projected over 5 years
Another merger created NHS Cumbria
Growing clinical leaders
Growing clinical leaders
Primarily all about culture change
Getting the right people on board Nurturing them Learning together – on the job, on study
trips, and in tackling wicked issues together Building trust across the team and earning
autonomy
A medical degree isn’t a leadership qualification
GPs leading in partnership with senior managers
PCT Board
Clinical Senate(6 GP Locality Leads, 2 Medical Directors, DPH, 5 Executive Directors)
Six Localities
Allerdale Carlisle Copeland Eden Furness South Lakeland(Each locality has developed a slightly different structure and approach to
suit local circumstances)
Localities are responsible for 60% of commissioning (97% from April 2011) and provide leadership for general practice and all community services.
Clinical Senate
CarlisleEden
FurnessSouth
Lakeland
Allerdale
Copeland
Business Support Services
Integration across primary care
Welcome to South Lakeland
DGH
DGH
600 square miles population of 110,000
Westmorland Primary Care CollaborativeDoing the right thing for our patients
Commissioning Group of 21 practices and community teams – national ICO pilot
Integrated primary care information systemEMIS webAllows bi-directional sharing of clinical record across the local health community 20 of 21 practices using EMIS (21st by Jan 2011) All community nursing teams Specialist community teams (including Macmillan nursing) Community wards Read only access to GP summaries by GP out-of-hours, and in
PCAS and two local A&E departments
Integrating care for older people – the journey so far
Well elderly
Vulnerable/At risk
Crisis
End of Life
Generally healthy, many with at least one long term condition. All living either
totally or fairly independently at home.
Significant physical and/or mental health problems. Living
at home, or NH/RH
Sudden, significant deterioration in health status. At home, NH or hospital.
Palliative & terminal care. Home, hospice, hospital.
Multi-disciplinary end of life care
Short -term interventions –acute care and rehab.
Wherever possible at home.
Proactive interventions to reduce risk and promote independence.
GP care, specialist community teams, day hospital, respite care.
Multi-agency interventions to maintain health and
independence. Normal GP care and wider health-promoting
initiatives.
Our model of integrated care for older people
Integration of care for frail older people First challenge – get a grip on a system out of
control: develop alternatives to acute hospital caremake it easy for clinicians to do the right thing actively manage the interface with acute care.
The medium term – develop services and programmes aimed at keeping people well and independent for as long as possible.
Partnerships between primary care, specialist health care (physical and mental health), social care, third sector, district council and other public services.
Getting a grip …
In three years we’ve gone from
GP referral
999 Ambulance
DGH
DGH
DGH
Care homes
Urgent Care Pathway before April 2008
Four options
Walk in
DGH
999 Ambulance
Short-term intervention service
(nursing/therapy/SW)
GP/other clinicianreferral
Community IVantibiotic service
Community respiratory team
Short-term urgenthome care
Communityurgent care
hub
Step-up Step-down
beds
Single point of access
Care homes
DGH
DGH
Liaisonnurse
Liaisonnurse
Primary care assessment service
Urgent Care Pathway Autumn 2010
Walk in
All Cat C, others diverted after discussion with PCAS
DGH
999 Ambulance
Short-term intervention service
(nursing/therapy/SW)
GP/other clinicianreferral
Community IVantibiotic service
Community respiratory team
Short-term urgenthome care
Communityurgent care
hub
Step-up Step-down
beds
Single point of access
Care homes
DGH
DGH
Liaisonnurse
Liaisonnurse
Primary care assessment service
Urgent Care Pathway Autumn 2010
Walk in
All Cat C, others diverted after discussion with PCAS
One option
WPCC – the financials To deliver this we needed to release resources
£83m ‘hard’ budget for current year (60% of total PCT budget), with accountability devolved by chief executive to locality level
September 2010PBR expenditure in Sept 2010 £613k less than in
Sept 2009Prescribing: forecast year end under spend £538k
(-3.2%) on a prescribing budget of £17m (that was reduced by 1% on 09/10 budget)
Community services budget in balance
600
650
700
750
800
850
900
950
1000
1050
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2008/09 2009/10 2010/11
SOUTH LAKES TOTAL PBR NON-ELECTIVE INPATIENT SPELLS
Actual Trend
4.6% reduction over 2 years
SOUTH LAKES TOTAL PBR NON-ELECTIVE EXCESS BED DAYS
0
200
400
600
800
1000
1200
1400
1600
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2008/09 2009/10 2010/11
Actual Trend
26.5% reduction compared to last year
200
250
300
350
400
450
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2008/09 2009/10 2010/11
SOUTH LAKES TOTAL PBR ELECTIVE INPATIENT SPELLS
Actual Trend
No growth last 18 months
600
650
700
750
800
850
900
950
1000
1050
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2008/09 2009/10 2010/11
SOUTH LAKES TOTAL PBR DAY CASE SPELLS
Actual Trend
4% increase over 2 years
1500
1700
1900
2100
2300
2500
2700
2900
3100
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2008/09 2009/10 2010/11
SOUTH LAKES TOTAL PBR OUTPATIENT FIRST ATTENDANCES
Actual Trend
30% reduction over 2 years, 16% last year
(only 6.7% growth over last 12m in OP procedures)
3000
3500
4000
4500
5000
5500
6000
1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112
2008/09 2009/10 2010/11
SOUTH LAKES TOTAL PBR OUTPATIENT FOLLOW UP ATTENDANCES
Actual Trend
26.2% reduction over 2 years
Prescribing costs per prescribing unit 2008-2010
-26.1% -22.8%
Reflections Short-termism, over-analysis and procrastination
Last three years about getting a grip … the next five about delivering great healthcare consistently
Clinically-led integration: primary care and specialty clinicians in partnership clinical leaders (not clinical managers) who
understand the system, data and financial flows while staying in touch with patients
support and partnership of high-quality managers who believe in clinical leadership.
Integration v competition Complex care needs full integration across the
system, working within a single programme budget Competition risks duplication, inefficiency, added
expense, and leaving gaps in pathways of care
Getting the incentives right Patients are not ‘products’ that generate a profit PBR leads to hospitals and clinical teams being seen
as profit centres Incentives for all clinicians and teams – equalise the
incentives across the system
Keeping control by letting go