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John Ribchester: Community integrated health care

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  • 1. Community Integrated Healthcare –An Approach by Whitstable MedicalPracticeTransforming General Practice – Unlocking the PotentialNuffield Trust, LondonWednesday 15 May 2013Dr J M RibchesterExecutive & Senior Partner, Whitstable Medical Practice
  • 2. Whitstable Health Centre &Chestfield Medical Centre
  • 3. Estuary View Medical Centre
  • 4. Estuary View Medical Centre
  • 5. Estuary View Medical Centre
  • 6. Whitstable© J M Ribchester
  • 7. Whitstable© J M Ribchester
  • 8. OUR POPULATION’S HEALTHNEEDS Whitstable faces a growing health and social care challengeassociated with its ageing population. The population of over 65s in East Kent will increase by41% between 2005 and 2020. Whitstable shows a greater proportion of over 65s incomparison with the rest of the locality. The probability of having a Long Term Condition (LTC)increases from 17%, for people under the age of 40, to60% for those aged 65 and over. People with LTC’s use disproportionately more primary andsecondary care services, 52% of all GP appointments, 65%of all outpatient appointments and 72% of all inpatient beddays. This pattern will increase over time with an ageingpopulation. WMP ranked 182 out of 287 GP practices in Kent & Medwayon the index of multiple deprivation
  • 9. Long Term Conditions RegistersDisease Category Number % of PopulationHypertension 5052 15.14Asthma 2105 6.31Diabetes 1728 5.18CHD 1323 3.96COPD 579 1.74Mental Health 208 0.62Dementia 210 0.63Heart Failure 313 0.94Epilepsy 183 0.55Obesity 2712 8.13AF 680 2.04Depression 3817 11.44CKD 1172 3.51Thyroid 1263 3.78Stroke 669 2.00
  • 10. WMP List Size GrowthSince 1998Whitstable Medical Practice List sizes 1.4.1998 - 1.4.201333,41433,81230,08031,99832,71432,41532,37030,96330,73631,19031,63429,69129,72929,51929,71033,13227,00028,00029,00030,00031,00032,00033,00034,00035,0001.4.98 1.4.99 1.4.00 1.4.01 1.4.02 1.4.03 1.4.04 1.4.05 1.4.06 1.4.07 1.4.08 1.4.09 1.4.10 1.4.11 1.4.12 1.4.13
  • 11. QUESTIONWhat has Whitstable Medical Practicebeen able to do differently?
  • 12. ANSWERRedesign the provision of healthcare in WhitstableBetter patient experienceCloser to homeShorter waitsLess cost to the NHSIn short, the development of an economical modelof community integrated healthcare
  • 13. Community Elective ServicesDiagnostics:Echocardiography 2006Ultrasound 2009Digital X-ray 2010Dermatoscopy Service forDiagnosis of Malignant Melanoma 2010Mobile MRI Scanner 2012Consultant-led outpatient clinics:Cardiology (tertiary) 2006Cardiology (secondary) 2010Gynaecology x2 2010UrologyOrthopaedics x3 2011General SurgeryColorectal SurgeryPain ManagementDermatology 2011Care of the Elderly and Joint GP CarePlanningHand, Wrist & Forearm 2012GPSI/Specialist Clinics:Insulin Initiation 2005Rigid Sigmoidoscopy 2006Prostate Clinic 2007Warfarin Clinic 2008Cardiology OPD 2008Dermatology OPD 2008Epilepsy OPD 2010Cardiology 2010Surgery in Primary Care (SIPC) 2010Screening Services:AAA National ScreeningProgramme Centre 2009Guy’s Genetic Screening 2009Paula Carr Retinal PhotographyService for Diabetes 2011Day Surgery:Carpal Tunnel Surgery and Injection PathwayDermatological SurgeryLocal Steroid Injection ServiceUpper Endoscopy Service (hosted by WMP and providedby Prime Diagnostics Ltd)Cataract Day Surgery Service (hosted by WMP andprovided by consultant ophthalmologists)Therapists:Hearing Aid Clinic 2005Acupuncture 2006Chiropractic 2006Physiotherapy 2008Long TermConditions- Diabetes- Cardiology- COPD- DementiaUrgent Care- Practice basedLevel 3 MinorInjury Unit- Fracture clinic- Co-locatedambulanceresponsebase- co-locatedcommunitypharmacyWhitstable &TankertonHospitalEnhancedRehabilitation &Intermediate CareDetailedWISHWorkstreams
  • 14. WISH StakeholdersWorkstream ALong TermConditionsLead:Dr J RibchesterDr H Pinnock – COPDDr D Kanagasooriam– Mental HealthDr R Pieters –CardiologyDr R Brice – DiabetesSupported by:KCHT, KFS, EKHUFT,PUG,Workstream BUrgent CareLead:Dr J RibchesterDawn Gaiger ENPSupported by:KCHT, EKHUFT,SECAmb,Workstream CCommunityElectiveServicesLead:Dr J RibchesterSupported by:EKHUFT, PUG,Workstream DWhitstable & TankertonHospital – EnhancedRehabilitation &Intermediate CareLead:Dr J RibchesterSupported:EKHUFT, Friends, PUG, KCHT,KFSUniversity ofKentWISH BoardSouth EastCoastAmbulance(SECAmb)East KentHospitalsUniversityFoundationTrust (EKHUFT)Friends ofWhitstableHospital &Healthcare andPatient UserGroup (PUG)WhitstableMedicalPractice(WMP)18 GPs, 140 staffKentCommunityHealth NHSTrust (EKHT)Kent FamilyServices(KFS)
  • 15. Long Term Conditions –Interim FindingsDiabetesCost savings – 50% (delivery of InsulinInitiation Clinics/non-insulin injectables)Quality – patients below NICE recommendedHbA1c. Wait times for insulin initiationdown. Positive patient experience.Next Steps – Identify number of acute,emergency & unplanned (re)admissions qv4 comparator practices
  • 16. Long Term Conditions –Interim FindingsCardiologyCost savings – 38% (delivery of GPSI clinic incardiology has reduced OPD referrals)Direct patient journey’s to the right station –- GPSI Triage- In-house consultant clinics (Kings &EKHUFT consultants)- Heart Failure, Arrhythmia & RehabCommunity NursesReduced waiting timesDirect links to Cardiothoracic Services
  • 17. Long Term Conditions –Interim FindingsDementiaIntegrated Care Pathway for dementia & adultmental health at WHCReduction in anti-psychotic medicationsprescribed in care homesCMHT & OPMHT delivered by KMPT in-houseDementia café by Alzheimers Society at WHC
  • 18. Urgent Care- Practice Based Minor Injuries Unit Level 3- Digital X-Ray Imaging- Consultant-led Fracture Clinic &TeleMedicine advice- Co-located Ambulance Response Base- Co-located Community Pharmacy
  • 19. Tariffs MIU Level 3 Tariffs (11/12): £40 = Minor £50.15 = Minor + £73.95 = Standard £99.45 = Major A&E National Tariffs £52.54 = Minor Injury £78.82 = Minor + £111.15 = Standard £134.39 = Major
  • 20. MIU Level 3 at Estuary View Apr 2011 – Dec2012Receipts £Total Activity (no. of pts)Minor 9869 £394,760Minor + 12,596 £631,689Standard 880 £ 65,076Major 6,027 £599,385Total No. of Patients 29,372Total Receipts MIU Level 3 Apr 2011 –Dec 12£1,690,910Comparative Cost A&E alternativeMinor Injury 9869 £524,703Minor + 12,596 £1,006,108Standard 880 £98,084Major 6,027 £811,537Total Cost Comparative for A&E £2,440,432Potential Cost Savings Apr 11 – Dec 12 £749,522Potential Percentage Cost Savings 31%
  • 21. The cost savings arecalculated using thefollowing assumptions:MIU tariffs:£50.15 = Fracture Clinic£99.45 = Fracture Clinic(with X-Ray)National Tariffs forTrauma and Orthopaedics£148 = First OutpatientFracture ClinicFracture Clinic atEstuary View MIUOct 2011 –Dec 2012Receipts £Total no. of clinicsTotal no. of patients78658Fracture Clinic w/oX-Ray596 £29,889.40Fracture Clinic withX-Ray62 £ 6,165.90Total ReceiptsFracture Clinic£36,055.30Comparative CostTrauma &Orthopaedics658 FA £97,384.00Actual CostSavingsOct 11 – Dec 12£61,328.70Percentage CostSavings63.0%
  • 22. Community Elective Services& Diagnostics- Cost savings. Examples:1. Urology GPSI OPD – 35% savings2. Carpal Tunnel Decompression:- Surgery – 77% saving- Injection – 83% saving- Reduction in referrals- Less OPD follow-ups- More one-stop clinics- Positive patient experienceFurther work: - identify comparator cohort- identify cost savings of all services
  • 23. Whitstable & Tankerton Hospital- Integrated Committee formed in 2010 toexplore funding options for an IntegratedHealth and Social Care Centre inWhitstable- OBC prepared by WISH Manager with inputfrom all stakeholders- Work due to commence at C4G to considerfuture of all 3 Community Hospitals
  • 24. IF THIS IS AN ACCEPTABLE NEW MODELFOR URBAN GENERAL PRACTICES WHATARE THE OBSTACLES? Practices combining to serve largerpopulations – perhaps 30,000-35,000 GP buildings that are fit for purpose New GP Management structures Buy-in from CCGs, NHS CB, RCGP, BMAetc New financial challenges Potential for upsetting local acute trustand others.
  • 25. AND THE PRIZES ARE ….. Benefits to patient care – more personal care,closer to home, shorter waits Benefits to the health economy – servicesdelivered at less cost Benefits to the general practice – fulfilment,education, upskilling, integrated healthcarecommunity, more of a buzz! Better patient and public engagementBUT IT TAKES TIME AND EFFORT
  • 26. Community Integrated Healthcare –An Approach by Whitstable MedicalPracticeTransforming General Practice – Unlocking the PotentialNuffield Trust, LondonWednesday 15 May 2013Dr J M RibchesterExecutive & Senior Partner, Whitstable Medical Practice

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