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Implementing care closer to home – Convenient quality care for patients
25 May 2007Botanical Gardens
Birmingham
Updated guidance on PwSI services including new robust governance arrangements for GPs and
Pharmacists with Special Interests.
Implementing care closer to home – Convenient quality care for patients
Introduction
Mark Cooke Chief ExecutiveDudley PCT
Implementing care closer to home – Convenient quality care for patients
Agenda13:00 Introduction
13:10 Implementing Our Health Our Care Our SayDr David Colin-Thomé, National Clinical Director for Primary Care, LTC ,18 weeks & co-lead for urgent care, Department of Health
13:25 The accreditation of GPs and Pharmacists with Special InterestsDr Matt Walsh, Executive Director of Commissioning and Medical Director, Leeds PCT
14:00 Market Place (and tea & coffee)
14:30 GPs with Special Interests – Dermatology & Skin Surgery Dr Julia Schofield, Consultant Dermatologist, West Hertfordshire Hospitals NHS Trust
14:40 Question and answer session
15:40 Chair’s summary
15:45 Close of workshop
Implementing care closer to home – Convenient quality care for patients
Implementing Our Health Our Care Our Say
Dr David Colin-ThoméNational Clinical Director for Primary Care, LTC ,18 weeks and co-lead for urgent careDepartment of Health
Implementing care closer to home – Convenient quality care for patients
Our health, our care, our say – a new direction for community services
Ambition Enabling health, independence and well
being Better access to GP Better access to community services Support for people with longer term needs Care close to home Ensuring reforms put people in control Making sure change happens
Implementing care closer to home – Convenient quality care for patients
More health care in the communityIncreasing % of healthcare provided locally reflecting:
international best practice advances in technology public preference ageing population Wanless review
Implementing care closer to home – Convenient quality care for patients
Keeping it Personal
Build on the best of traditional General Practice Primary Health Care more than general practice …but registered population and 80% of all NHS
clinical consultations 90% of care solely undertaken in primary care Support for self care Care Closer to Home The practice can link the wider public’s health
and bio-clinical care
Implementing care closer to home – Convenient quality care for patients
Infrastructure
Health and social system environment
Decision support tools and clinical information
system (NPfIT)
Community Resources
Delivery System
Disease Management
Case Management
Better outcomes
Prepared and proactive
health and social care
teams
Empowered and informed
patients
SupportedSelf care
Promoting Better Health
Supp
ortin
g
Cre
atin
g
The NHS & Social Care - Long Term Conditions Model
Implementing care closer to home – Convenient quality care for patients
36 pathways, covering common conditions, that have been developed and published in collaboration with the Royal Colleges
Help commissioners transform pathways by removing unnecessary stages in the patient journey and focussing on real quality improvements
Available on the 18 weeks website www.18weeks.nhs.uk Use of these and other pathways will greatly assist in
reducing waits
To improve clinical care - 18 weeks
Implementing care closer to home – Convenient quality care for patients
Other White Paper initiatives Care Closer to Home Demonstration Project
– 30 across England– Range of different models (nurse led, consultant
outreach, GPwSIs) – An evidence base for shifting care and lessons based
on experience
Community Hospitals– £750m capital funding available over 5 years – 14 schemes announced so far (c£100m)– With more to come and not just community hospitals –
community services eg primary care centres, mobile diagnostics, one stop health and social care centres
Implementing care closer to home – Convenient quality care for patients
DH worked with RCGP and developed broad strategic advice for PCTs and GPs, and also a series of detailed clinical guidelines for individual specialites
NatPaCT published practical advice
PCTs now report over 1750 GPwSIs
Frameworks developed for nurses, AHPs, Pharmacists and Community Dentists
-
Practitioners with Special Interests (PwSIs)
Implementing care closer to home – Convenient quality care for patients
Concerns over quality: some developed in isolation without appropriate training, CPD and governance arrangements …especially from secondary care
AOD found: 64% not within national guidelines 45% not been through any accreditation process 14% no experience of working in secondary care 75% did not attend clinical governance meetings
However…
Implementing care closer to home – Convenient quality care for patients
PWSI Principles First and foremost a generalist Must be able to act without direct supervision The level of skill or competence will always exceed
the core competencies of the individual’s normal professional role
A qualification alone will never demonstrate suitability for the role
Accredited PwSIs deliver clinical services directly to patients and it is the personal interaction and clinical relationship between a PwSI and a patient, which makes accreditation necessary
Implementing care closer to home – Convenient quality care for patients
Who can provide care closer to home?
Generalist care provided in community settings
Specialist care provided in community settings
Specialist care provided
in acute settings
Accredited PwSIs:
GPwSI
PhwSI
DwSI
Accredited PwSIs:
GPwSI
PhwSI
DwSI
NHS staff providing
specialist care:
Nurses, AHPs, medical/consultant staff, pharmacists,
healthcare scientists
NHS staff providing
specialist care:
Nurses, AHPs, medical/consultant staff, pharmacists,
healthcare scientists
Implementing care closer to home – Convenient quality care for patients
Clinical engagement and leadership First contact primary care - ‘Keeping it Personal’ Practice based commissioning Generalist and specialists need to work together Consultants have pivotal role in accreditation Secondary care clinicians key role in shaping
redesigned services High levels of oppositional behaviour imply that
confrontation and criticism are valued more than creativity and risk taking
Implementing care closer to home – Convenient quality care for patients
The accreditation of GPs and Pharmacists with Special Interests
Dr Matt WalshExecutive Director of Commissioning and Medical DirectorLeeds PCT
Implementing care closer to home – Convenient quality care for patients
Introduction• Credentials
GP trainer Director of Commissioning, Clinical Governance
lead and Medical Director Developed Bradford GPwSI accreditation process Chair of Bradford & Airedale accreditation panel.
Implementing care closer to home – Convenient quality care for patients
The CommissioningCycle
Implementing care closer to home – Convenient quality care for patients
Assess needs
Review current service
provisionDecide
priorities
Design service
Shape structure of
supply
Manage demand and
ensure appropriate access to
care
Clinical decision making
Managing performance
(quality, performance,
outcomes)
Patient and public
feedback
Strategic planningService redesignManaging demand
Managing performance
Implementing care closer to home – Convenient quality care for patients
Background & ReflectionsPolicy Context
Emerging focus upon shifting care (GP fund-holding, HSC 1996/35, NHS Plan targets, OHOCOS)
Emerging focus upon clinical quality & risk Choice & plurality, PBC & PBR
Impact Variable geographical uptake and distribution of
PwSI initiatives Focus upon reducing outpatient attendances
• Opinion–based specialties Technical interventions
• Endoscopies, cystoscopies• ECG, 24hr BP, anticoagulation
Implementing care closer to home – Convenient quality care for patients
Emerging Concerns
Specific Definition Clinical risks Accreditation Qualification Standards & Quality Service vs Individual
General Local service and pathway coherence in a
competitive environment• PBR and competition on quality• VFM and effectiveness
Supporting patients• Local services• Assumptions about quality• Choice as it relates to PwSIs
Implementing care closer to home – Convenient quality care for patients
What’s this all about?
CPLNHS and proper commissioning– Improving access – Improving quality– Addressing health inequalities– Provider development
Clarifying definitions and rationale Supporting innovation Managing risk & protecting patients
Implementing care closer to home – Convenient quality care for patients
Vision What does good clinical governance look like for
PwSI services? Minimum necessary bureaucracy Not duplicating other regulatory processes Clear responsibilities for:
– PwSI– Commissioners– Providers– Accreditation bodies
Implementing care closer to home – Convenient quality care for patients
Emerging themes
Gate-keeping function of primary care Blurring boundaries between clinicians Focus upon assessment of competencies
required vs those demonstrated Coherent service planning and development Guarding the notion of specialism. Refreshed specialty specific guidance
Implementing care closer to home – Convenient quality care for patients
Key points Core generalist role Receive and manage referrals
– Referral as the trigger point Higher levels of skill
– Specialty specific guidance Independent – ie no direct supervision
Implementing care closer to home – Convenient quality care for patients
New PwSI definition“A GP or a Pharmacist with a Special Interest supplements their core generalist role by delivering an additional high quality service to meet the needs of patients. Working principally in the community, they deliver a clinical service beyond the scope of their core professional role or may undertake advanced interventions not normally undertaken by their peers. They will have demonstrated appropriate skills and competencies to deliver those services without direct supervision. “
Implementing care closer to home – Convenient quality care for patients
The Accreditors Subset of PCT and include, as a minimum:
Senior commissioner Senior professional rep (LMC, PEC, LPC, Lead Pharmacist, GP from RCGP) Lay person Senior clinician
Adhere to set of competencies (Page 9)
Implementing care closer to home – Convenient quality care for patients
Overview
Page 8
Implementing care closer to home – Convenient quality care for patients
Commissioners preliminary role
Page 10
Develop service specification by defining: Patient inclusion criteria Referral arrangements to and from all other services How they communicate and integrate with relevant clinical networks Physical, human, audit and financial resources required to deliver the service Robust and integrated clinical governance arrangements Support required from other health and social care professional and services Evidence of the ways in which local people have been involved in developing
and planning the service A clear definition of the role that the individual GPwSI or PhwSI will play within
the service Arrangements to ensure that the GPwSI or PhwSI understands clearly the
nature of all the services which support the patient pathway, clinical network, and referral system
Arrangements for the GPwSI’s or PhwSI’s ongoing continuing professional development
That appropriate indemnity cover is in place Requirement that there is a properly authorised statement of compliance with
Standards for Better Health
Implementing care closer to home – Convenient quality care for patients
Page 11
Step 1Invite applications from individuals who wish
to be accredited
Implementing care closer to home – Convenient quality care for patients
Page 12
Step 2Verify the skills and competencies of the
individual GPwSI or PhwSI and reach a decision about individual accreditation
Implementing care closer to home – Convenient quality care for patients
Page 13
Step 3Optional service visit to validate the quality of
the provision and the role of the individual GPwSI or PhwSI
Implementing care closer to home – Convenient quality care for patients
Page 14
Step 4Re-accreditation of the individual GPwSI or PhwSI and the service in which they work (at
least every three years)
Implementing care closer to home – Convenient quality care for patients
Local (PCT held) list
g• GPwSI/PhwSI
• Length/dates of accreditation
• Specialty
• Available for public inspection
Implementing care closer to home – Convenient quality care for patients
PCT Directions
NATIONAL HEALTH SERVICE
THE ACCREDITATION OF GENERAL PRACTITIONERS AND PHARMACISTS WITH
SPECIAL INTERESTS DIRECTIONS 2007
The Secretary of State for Health, in exercise of the powers conferred by section 8 of the National Health Service Act 2006(1), gives the following Directions:
Citation, commencement and application
1.—(1) These Directions, which may be cited as the Accreditation of General Practitioners and Pharmacists with Special Interests Directions 2007, shall come into force on 1 June 2007.
(2) These Directions are given to Primary Care Trusts in England and apply in relation to England.
Compliance with guidance document: the accreditation of General Practitioners and Pharmacists with Special Interests
2. A Primary Care Trust shall have regard to the provisions of the guidance document entitled “Implementing care closer to home – Convenient quality care for patients Part 3: The accreditation of GPs and Pharmacists with Special Interests” issued by the Department of Health in April 2007 when—
(a) commissioning any services to be provided by a General Practitioner with Special Interests or by a Pharmacist with Special Interests, or
(b) assessing or accrediting a General Practitioner with Special Interests or a Pharmacist with Special Interests as suitable to provide any services the Primary Care Trust wishes to commission.
Signed by authority of the Secretary of State for Health Jeff Peers A member of the Senior Civil Service Department of Health 17 May 2007
(1) 2006 c.41.
PCTs shall have regard to the provisions set out in Part 3 when commissioning, assessing or accrediting a GP/PhwSI service
Implementing care closer to home – Convenient quality care for patients
Implementation timescales All existing GPwSIs be re-accredited by March 2009
All new GPwSIs and PhwSIs be accredited in accordance with these guidelines.
If the GPwSI or PhwSI’s work is discontinued, or if for any other reason after the commencement of the service the individual is unable to use their enhanced skills for a period longer than twelve months, they should be re-accredited before they work again as a GPwSI or PhwSI.
Implementing care closer to home – Convenient quality care for patients
Market Place(and tea & coffee)
14:00 – 14:30
Implementing care closer to home – Convenient quality care for patients
GPs with Special Interests
Dermatology & Skin Surgery
Dr Julia SchofieldConsultant DermatologistWest Hertfordshire Hospitals NHS Trust
Member PwSI Steering Group and Dermatology GPwSI guidance development group
Implementing care closer to home – Convenient quality care for patients
Dermatology GPwSIs: Background
NHS Plan 2000:
‘..up to 1000 specialist GPs to take referrals from their colleagues for a range of conditions..’
Dermatology one of the specialities identified as suited to the role of GPwSIs
Implementing care closer to home – Convenient quality care for patients
Dermatology GPwSIs: 2003 framework
Implementing care closer to home – Convenient quality care for patients
Dermatology GPwSIs: 2003 framework
THE GOOD NEWS
Action on Dermatology pilots: Reduced waiting times for those
attending clinics
Several sessions needed across a health community to reduce overall access times
Quality of care and patient experience good
Good links with secondary care optimise seamless patient care
Implementing care closer to home – Convenient quality care for patients
Integrated model, works well, robust training and accreditation programme
Big increase in capacity (10 clinics per week) Trivial referrals received initially Reduction in referrals to secondary care Secondary care referrals more appropriate
Threat to secondary care funding?
‘previously unmet demand is now being met and met appropriately..’
Eastern Wakefield PCT: Lessons
Implementing care closer to home – Convenient quality care for patients
Dermatology GPwSIs: ConcernsFollowing audit* against DH framework BAD/PCDS/AoD meeting requested (Feb 2005):
More robust accreditation framework for dermatology
Some standardisation of terms and conditions
Audit, quality and outcome measures
*Schofield JK, Irvine A, Jackson S, Adlard TP, Gunn S, Evans N. General Practitioners with a Special Interest (GPwSI) in Dermatology: results of an audit against Department of Health (DH) guidance. Br J Dermatol 2005; 153 (suppl. 1):0-1
Implementing care closer to home – Convenient quality care for patients
Developed by multidisciplinary working group including reps from BAD, PCDS, SCC, RCGP
Aims to ensure the commissioning of high quality dermatology services
Implementing care closer to home – Convenient quality care for patients
ContentsContents
Service models for dermatology and skin surgery
The support and facilities required The curriculum and core competencies
required Key points to consider Assessment tools Assessment requirements
Implementing care closer to home – Convenient quality care for patients
Possible models of
service delivery
Diagnostic and disease
management service only with no surgery
Community skin cancer service
GPwSI dermatology skin surgery service
(excluding skin cancer)
Diagnostic and disease
management service with more advanced
surgery
Diagnostic and disease
management with a limited skin surgery
service
Implementing care closer to home – Convenient quality care for patients
Implementing care closer to home – Convenient quality care for patients
Assessment tools
Implementing care closer to home – Convenient quality care for patients
Skin surgery: GPwSIs and PwSIs
Dermatology guidance specifically for GPwSIs
BUT includes standards for all performing skin surgery (PwSIs)
Commissioners advised to use the document when developing skin surgery services
Competencies may be further developed for other PwSIs (PhwSIs)
Implementing care closer to home – Convenient quality care for patients
Specialty Specific Guidance
RCGP co-ordinating refresh through relevant professional bodies
Evidence to support commissioners and accreditors during accreditation process
Competency based
In most cases applicable to all PwSIs
Published throughout 2007
Implementing care closer to home – Convenient quality care for patients
Developing Dermatology GPwSI services Assess need, Part 2 guidance, patient centred
process involving all key players
Define model of care and identify local skills and resources
Accredit the individual once the model of care has been agreed
Be mindful of National Guidance (NICE skin cancer)
Implementing care closer to home – Convenient quality care for patients
Developing Dermatology GPwSI services
Whatever the barriers try and be joined up
Integrated services work best for patients
Think quality, access, patient experience first
Value for money last!!
Implementing care closer to home – Convenient quality care for patients
How do we get there?
DONALD RUMSFELD: There are known knowns. There are things we
know that we know. There are known unknowns. That is to say, there are things that we now know
we don't know. But there are also unknown unknowns. There are things we do not know we
don't know.
Implementing care closer to home – Convenient quality care for patients
Question & Answer session
14:40 – 15:40
Panel Members
Dr David Colin-ThoméDr Matt WalshDr Julia Schofield
Implementing care closer to home – Convenient quality care for patients
Close
Contacts for further information
Have a safe journey home..
Beth [email protected]
Phil [email protected]
www.dh.gov.ukwww.primarycarecontracting.nhs.uk