General Practice Transformation Champions: GP led integrated care in Dorset
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Workshops session 3 Presentation: GP led integrated care in Dorset by Dr Karen Kirkman
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General Practice Transformation Champions: GP led integrated care in Dorset
- 1. Integrated Care built around General Practice Dr Karen Kirkham ICS Clinical lead Dorset CCG
- 2. • 800,000 people • 86 GP practices • 13 community hospitals • 3 district general hospitals • 2 unitary local authorities • 1 county council • 6 district councils • 1 community and mental health provider • 1 ambulance trust • 1 clinical commissioning group - £1.2bn • Single STP, single leadership team The Dorset system
- 3. The case for change
- 4. Sustainability and Transformation Plan STP Tier 2 Integrated Community Services
- 5. Care models Current Care Models Future Care Models 1 Hospital centred disease specific, specialist led often by GP referral Community based teams and services in-reaching into specialist care centres. Teams bring together GP, specialists, nursing and therapy, physical and mental health 2 Lack of capacity, often hospital led Patient centred care planning with a named GP, health and social care co-ordination, rapid access to assessment, diagnosis, individual treatment and management plans, more responsive to intensive home based care needs, virtual ward models 3 Patient care managed by GP and Consultant by referral with care often not co-ordinated Promoting self-management and pro-active self-care. Empowering patients and supporting carers, mobilising local community resources around groups of general practices enabled by teams working across care settings. 4 Provided by independent general practices through a patient list Patient choice and ease of access to a local general practice service. Local access to diagnostic and treatment services. Same high quality service offer and access for patients no matter where you live. Focus on health and needs of local populations 5 Separate GP practices provide in-hours for urgent patient need, high variation in access both in and out of hours Urgent in-hours care delivered at scale with access based on clinical need. Effectively streaming out the management of urgent and emergency care. Delivering care in the right place at the right time by the right care professional. Collaborative aproach
- 7. Dorset Primary Care Strategy aligns to quadruple aim 1. New care model of Primary Care: Integrated locality teams delivering six priority areas based risk and care segmentation; Improved quality of care meeting the needs of the population. 2. Improved population health: Locality Profiling; Tackling unwarranted variation; Living Well programme for prevention. 3. Better use of health system resources: Shifting resources to deliver new care models; Commissioning at scale – Frailty; Access.- align resources 4. Workforce planning to increase resilience and create a better working life for clinicians, nursing and AHPs
- 9. GP Transformation at Scale, defined by localities Local population needs Services working together (GP at scale working ‘MOU’) Local plan for sustainability and transformation Transformation leadership team • GP at scale • New ways of working • New models of care • Integrated care teams • Workforce planning • Workflow optimisation • Infrastructure plans • Technology enabling care Engagement and co-design OUTCOMES
- 10. Dorset ICS Primary Care Home
- 11. Key Successes so far and areas of priority : • Frailty model, toolkit for frailty, integrated teams, support for practice MDT ; • Primary Care workforce centre; • Improving Access – Urgent and Routine Care; • Collaborative working developing across practices in each locality- diabetes care, paediatrics • Transformation – locality plans developed in Clinical networks, supported by transformation funds • Initiated the implementation of Primary Care Home
- 12. Westhaven Hub Frailty Hub covering 76000 patients •Health and social care teams , single site , integrated working, supported by extensivist GP and consultant •Multidisciplinary approach – physical and mental health •Most complex care needs, risk stratification •SPOA- highly popular with GPs Outcomes: Year 1 – 2000 patients- severely frail or frail •90% able to stay at home •10% reduction in acute bed days •7% reduction in ED attendances •50% step up beds for GPs ( and bed vacancies) •High patient , staff and carer satisfaction
- 13. Weymouth Urgent Care Centre •Brought together Walk- In centre, MIU and GP OOH •8am-10pm seven days per week •Collaboration of GP federation, Community provider ( DHC) and acute trust (DCH) •34,000 patients seen in first year •Detailed triage and clinical assessment •10% signposted to self care / pharmacy •Routine presentations redirected to GP •System value is high •High patient satisfaction •Urgent care stream same day from one General practice •Now site of improved access to GP services 7/7 •Federation increasingly involved in collaborative approach care • Site planned for increased diagnostics and therapy
- 14. Themes for successful transformation • Sufficient Scale for delivery partners-workforce, diagnostics • Standardising best practice , reducing variation, differentiation according to need • Integration and focus on prevention • Align financial incentives • Develop sustainable primary care • Digital and technical solutions – Dorset Care Record • Workforce redesign-new roles, new care models, passport for workforce • Multifunctional hubs to support community / primary interface • Data and analytical support to support decision making
- 15. New workforce models do mean change • Understand population need for service/team ‘what matters’ • Truly understand what each profession can/could do • What is it only certain professions can do? is this real? • How much flex do you have in who and what you have? • Foster trust, respect and understanding of roles • Move beyond developing one ‘trusted individual’ • Ensure recognisable/mobile qualifications • Train each other, train together at appropriate levels • Positively impact on learning environment • Ensure public safety and confidence • Focus on a better workload, work/life balance for happy teams
- 16. Kings Fund – West 2017: The four fundamental elements of a culture for innovative and high-quality care: • inspiring vision and strategy • positive inclusion and participation • enthusiastic team and cross-boundary working • support and autonomy for staff to innovate (Trust) Compassionate leadership plays a key role in nurturing each of these.
Notes de l'éditeur
- The importance of clinical engagement and clinical leadership in delivering change • How Dorset became an ‘outstanding’ STP and what this means for patients • Lessons learnt
- 2014 onwards 3 acutes 1 community 3 LA 1 ambulance Reducing number of GP practices Over 760,000 people 91 GP practices – keeps reducing 13 community hospitals 3 district general hospitals 2 unitary local authorities 1 county council 6 district councils 1 community and mental health provider 1 ambulance trust 1 clinical commissioning Group £1.2bn Devolved PC History of working together through CSR , case for change
- Dorset’s current population of ~750,000 is expected to grow to ~800,000 in 2023 with over 70s growing at > 4x faster than the overall population (~126k over 70’s today growing to ~165k by 2023) Small pockets of deprivation exist within Dorset resulting in health inequalities … and there are a number of areas which lack easily accessible public transport connections to an acute hospital There is significant variation in A&E attendances, emergency admissions & ACS admissions across GP practices Out-of-hours access and satisfaction rates have large variations across GP practices
- STP came along - Our plan sets out how we will achieve our vision over the next five years. Three programmes of work to enable us to realise our vision for health and care in Dorset: Prevention at Scale: will help people to stay healthy and avoid getting unwell. Integrated Community Services: will support individuals who are unwell, by providing high quality care at home and in community settings. One Acute Network: will help those who need the most specialist health and care support, through a single acute care system across the whole county. Prevention really pulled the LAs back in, we had become too clinically focussed, too acute focused Cannot underestimate the need for joint records as a key enabler, And if I was rewriting today I would add another emerging enabler as Data
- So we move from a disjoined , hospital centric model of care to a care model that works across the system , takes account of patient needs , focus on self management with an increasing view on technology
- Our approach is based on a Population approach , demographic , demand and projections Risk stratification approach to health needs , and care needed to support each of those Modelling tool to understand the workforce needed for redesign Acute reconfiguration dependent on a series of assumptions on transforming care to the community To deliver care differently – NEL, OP , closer to home , looked at acute , community and general practice locally STP- Acute , Integrated Community and Primary care, Prevention, Digital Leading and working differently This leads us organizationally to think about the new care models to support this , and as an NHS we need to think about how we train the workforce to deliver this new way of working , breaking through traditional organizational boundaries
- We now have 12 General practice groups representing all 93 practices across Dorset. Local Plans from these groups will inform joint working between providers as part of the STP plan–so it is important that these are fully developed and fully supported. This is why each local area has been given resources to do this. Each area has a Transformation team – 3 clinical leads; a Project Manager and a Relationship Manager who will help make links with the wider transformation support offer that the CCG has developed through a menu of support. Local plans focus on local needs and priorities. They achieve General Practice working at scale through a memorandum of understanding that makes a commitment to work together to achieve the change required for sustainability and transformation. They are led by a local transformation team and engage all Practice Clinical and Business leaders. Local plans aim to achieve General Practice working together on how core general practice can be delivered differently by adopting new models of care and new ways of working. Some of the key areas of change include improved access, developing integrated teams and putting systems in place to support this –workforce plans, workflow and care streaming, infrastructure plans including technology and estates.
- Community beds on site Reactive approach , within 4 hours
- Small practices increasingly vulnerable To deliver new MDT need scale to do this How to embed best practice and reduce variation Prevention high on agenda , need to identify people at an earlier stage and intervene Show dashboards New ways of working Look at needs Must have supporting data -