Shifting to the left: building capacity and capability in primary careDr Simon Freeman, Managing DirectorProfessor Azhar Farooqi OBE ChairDr Umesh Roy, Locality Chair

Agenda

• About the CCG and our patients• Left-shift• Examples in practice• Questions

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The CCG• 329,839 resident population• Diverse yet disadvantaged• Co-terminus with local authority• Health inequalities• Complex health needs• Low life expectancy and gap

between communities• Major contributors to the life

expectancy gap:− Circulatory disease− Respiratory disease

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On average city residents live 4 years less than those in the county

• In some areas of the city the life expectancy gap rises to 10 years• While life expectancy is improving, the gap with the rest of England is

widening

Priorities

• Cardiovascular disease• Chronic obstructive pulmonary disease• Mental health• Older people

• Left-shift an integral part of the strategy

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Reasons for left-shift

• Cost reduction in secondary care• High mortality and morbidity• Focus on prevention not cure

• Barrier: lack of investment in primary care v secondary care

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Left-shift

• Treating more patients in primary care or in the community• Reducing referrals and treatment in secondary care• Examples:

− Diabetes− Musculoskeletal conditions− CVD

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Left shift – the barriers

• Capacity in the community • Capability• Systems and integration (agreed care pathways, joint working

with social care etc.)

GP and consultant increases: 2002-2012Investment geared to increasing secondary care capacity

25000

27000

29000

31000

33000

35000

37000

39000

41000

43000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

GPs

Consultants

1. Transformingdiabetes services

• Diabetes can result in 10-15 years loss of life and 12% of NHS costs

25,000 people in Leicester have diabetes, one of the highest rates in the UK.

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• Programme budgeting data indicates that Leicester City PCT has a higher than average expenditure per patient with diabetes, and poor outcomes.

Expenditure and outcomes for diabetes care

Diabetes Transformation Project

• £1 million transformation funding, 2012/13• Leicester, Leicestershire and Rutland (LLR)• Investigate how LLR can deliver the best diabetes service in

the UK• Representation from all stakeholders• Recommendations agreed• Convert to commissioning contracts in 13/14 with new service

fully commissioned in 14/15

Key issues

• Prevention• Inequality of care• Improved standards to reduce complications• More community based care • Reducing unplanned care (hospital admissions) • Better inpatient care

Proposed model of diabetes care

1.Primary care (core)

2.Primary care(enhanced

Primary care setting Secondary and tertiary care setting

‘The Super Six’1. Inpatient care2. Insulin pumps

3. Renal4. Foot

5.Children/adolescents6. Pregnancy

6+complex and rare

3.Specialist support for

Primary care (CDSST)

‘The Necessary Nine’

1. Screening2. Prevention

3. Regular review/surveillance

4. Prescribing5. Insulin

6. Patient education7. Cardiovascular

8. Housebound/care homes

9. Outcomes/audit

4.Complex care

13 recommendations for commissioners

• 1-4 Primary care including – defining core service– enhanced service– training and professional development for primary care– high risk patients

• 5 Community specialist support service• 6-11 Specific specialist contracts ( super seven)• 12-13 Patient education and empowerment

GP practices’ capability: training and development

• Mini-modules ( 3 hrs)• Certificate in diabetes ( 10 days)• Msc Diabetes ( 30 days)

• HCA training• Nurse support• Mentorship

• Case reviews & management• Regular updates• Behaviour change training• Patient education support

• Ensure high level delivery of core services and to enable practices to deliver enhanced services: £300,000 year investment with education provider (local university)

• Each practice has a PDP for diabetes

• Training is free and up to £2000 backfill cover

Diabetes service provision by general practice (64 practices)

Core service: 34 practices

• Screening and diagnosis• Management of type 2 diabetes

(QOF)• Annual review• Management of emergencies• Appropriate prescribing• Referral

Enhanced service: 30 practices

• Insulin initiation and titration for type 2• Management stable type1 patients • GLP-1 initiation• Monitor referrals and active

repatriation of suitable patients• Accreditation and a PDP plan• Action plans those at high risk of

admission• Support and monitoring by 4 CCG

diabetes mentors

Community diabetes specialist support team

• A locality based, community diabetes specialist support team service (CDSST) for complex patients

• Support care of care for complex patients (including those at high risk of unplanned hospital admissions)

• Insulin initiation• GLP1 initiation where this is not provided by practices.• Support for audit, patient and professional education and

research• Typical team – DSN, consultant sessions, dietetics, educators

How we fund the transformation

• Training and education for GP staff: non recurrent investment

• Enhanced service for GPs and the community diabetes specialist support service:

– active repatriation of patients from secondary care (reduce specialist outpatients by 50%)

– reduced new referrals, and reduce admissions by more active management of high risk patients

• Full year effect cost of enhanced service (provided by ½ of our practices): £325,000

– OPD savings £620,000 – net saving £300,000 to be reinvested in service

Primary care: capability and capacity in diabetes• PDP for each practice and enhanced skills- specialist

mentorship• £22 per diabetes patient in enhanced service on top of QOF

(average extra 10k per practice)• Community specialist support team ( including mentorship, help

line , website etc.) • Increased support from community services for housebound

patients • Average 10k per practice for screening and CVD health checks

Summary -The ‘Left-shift Effect’ for diabetes1. Training and development in practices to provide more and better

care2. Fund primary care to provide enhanced care 3. Active repatriation of patients to the community/practices4. A locality based, community diabetes specialist support team

service (CDSST) for complex patients and for non enhanced practices

5. Patient education for self care OUTCOME - 50% saving in traditional specialist OPD costs.to be reinvested – ongoing primary care training

- increased care for housebound and patients at risk of admission

-better quality specialist and inpatient care

2: Musculoskeletal conditions

The problem

• 14,000 MSK referrals to secondary care annually

• 4,000 are discharged after the first outpatient appointment without an Intervention.

• Better managed in primary care – not complicated

• 30% of GP consultation time is spent with patients with MSK problems

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GP Mentor

Hospital physiotherapist

GP practice

Patient

Referring GP

The model• 7 GP mentors• Team of 10 extended scope

physiotherapists• 3 hour clinic in the referring GP

practice• 30 minute session booked by

practice (6 patients)

Objectives

• Provide an in-house MSK clinic and physiotherapy service

• Up-skilling GPs to diagnose and manage MSK conditions

• Reduce non-surgical MSK referrals to secondary care

• Sustainable for longer term

• Patient satisfaction and empowered to self manage

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EXPERIENTIAL LEARNING CYCLE• Building capacity, capability

and sustainability in primary care using:

- Teaching- Training- Treatment

Benefits for GPs/clinical staff

• GPs are up-skilled with improved confidence in treating and managing MSK conditions

• GP receives hands on training, which can be translated into everyday practice

• Improved ability to plan and monitor MSK interventions across a patient’s care pathway: empowers patients and staff

• Training is cost neutral to GPs

• £67.83 per patient compared to national tariff for secondary care £90-£149 per patient. £130 average

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3: CVD

CVD left-shift examples

• Preventing hospital admissions and referrals− DVT− Anticoagulation− Cardiology− Atrial fibrillation− Prevention of Stroke

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Challenges

• High mortality• Early revascularisation rates• Increased emergency admissions• High deprivation

• Wide variability in GP skills• Wide variability in Nurse / HCA skills• Lack of structured education and training programme• Personal accountability to patients

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QIPP

• Quality

• Innovation

• Prevention

• Quality + Innovation + Prevention = Productivity

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3 T CARDIOLOGYComprehensive training session with “exam”

• Heart failure diagnosis and management• Clinical interpretation of an echo report• Atrial fibrillation and stroke prevention• DVT training• Anticoagulation training

Objectives

• detection• appropriate investigation and interpretation• pharmacological optimisation• appropriate referral to secondary care• long term monitoring35

CobasH232

• Single device offering testing of multiple parameters• Therefore can use as part of different care pathways• D-dimer• NT-proBNP• TroponinT

• Quantitative results achieved, removing operator dependent interpretation• User has increased confidence

• Practical, fast and portable for use in primary care

• Simple to use

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Emergency HF Admissions2009/10 2010/11 2011/12 2012/13

ActivityFinal Payment

With MFF ActivityFinal Payment

With MFF ActivityFinal Payment

With MFF ActivityFinal Payment

With MFFLeicester City CCG 553 £1,760,338 521 £1,649,652 548 £1,758,172 523 £1,705,372

locality1 196 £597,435 193 £600,145 232 £733,053 202 £661,794Practice 6 £14,868 6 £19,782 3 £9,156 5 £15,965Practice 29 £91,555 30 £82,688 30 £86,741 34 £111,018Practice 17 £60,688 17 £46,594 26 £92,213 22 £66,304Practice 32 £97,142 19 £51,323 23 £76,869 21 £77,138Practice 3 £9,928 1 £2,498 8 £26,801 1 £10,703Practice 4 £10,942 7 £18,454 4 £19,277 10 £25,906

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Heart Failure – A Case StudyPatient symptoms• 65 yr old with Phx of HT, IHD, diabetes presents with SOBE, cough, ankle oedema. heart failure

suspected

Examination• temp normal , sats- 93%, pulse 86/min , bilateral ronchi and crackles, BP– 106/66mm. ECG– bigimini,

widened QRS

Diagnostic testing• POCT – BNP ------ Positive , routine bloods sent to lab. HF confirmed• Referred for direct access echo – 2 week appointment . Hospital OPD appointment C&B 60 days

Treatment• Treated for HF increasing dose of diuretics and uptitrating ACE and bisoprolol . • GP review in 48 hrs again review at week one – symptoms improving

Follow up• GP review again in 2 weeks – mild sob, oedema resolved. Echo confirms severe HF

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Savings£4000

DVT Nice Guidelines

• DVT suspected• Scan not available in 4

hours• Scan confirms DVT• Provoked• Unprovoked

• Scan with in 4 hours• Administer LMWH

arrange scan 24hrs• Initiate warfarin• 3 months • 12 months / longer

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Two-level DVT Wells score• User friendly

approach to clinical practice

• Step by step approach

• Encourages full clinical assessment in line with the NICE.

A template patient record Two-level DVT Wells score, which you can print, complete and then add to patient records can be downloaded from the NICE

website http://guidance.nice.org.uk/CG144/TemplateWellsScore/doc/English

DVT DATA

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Year DVT Referral Activity (University Hospitals Leicester)

Cost

2010 2242 £359,0002011 2517 £350,0002012 2200 £350,0002013 1550 £276,000

GRASP AF TOOL

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• Mandatory training and exam

• Base Line audit data using GRASP AF tool− % pts with CHADS2

score > 0 on warfarin

• Targeted screening and ECGs to find new AF patients

AF Data

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No of practices

Actual No Of AF Patients (QoF)

Patientsanticoagulated

High Risk Requiring anticoagulation

Estimated prevelance

No of patients undiagnosed

34 2,221 1,008 763 3,243 1,044

AGE and CHADS2Score of 2 or more and NOT prescribed Warfarin

OutcomesExisting AF reviewed 117

Patients warfarin initiated 46

Opportunistic AF diagnosed 13

NOAC drug referral 13ECGs in house 34OP referrals saved 15

Existing HF optimised 7

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• Practical examples of improving productivity and efficiency

• 3-4 month pilot results

Summary

• Left shift requires increased capability and capacity in primary care

• We have described how up skilling and investment in primary care can enhance the ability to promote left shift

• The commissioning process can promote left shift but takes time, effort and planning

• Effective primary care champions are essential in making any progress: agreeing pathways, engaging primary care, alternative credible clinical voice to specialists

• The political status of secondary care and differential investment remains a major barrier to left shift

Questions?