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John Ribchester: Community integrated health care
1. Community Integrated Healthcare –
An Approach by Whitstable Medical
Practice
Transforming General Practice – Unlocking the Potential
Nuffield Trust, London
Wednesday 15 May 2013
Dr J M Ribchester
Executive & Senior Partner, Whitstable Medical Practice
12. OUR POPULATION’S HEALTH
NEEDS
Whitstable faces a growing health and social care challenge
associated with its ageing population.
The population of over 65s in East Kent will increase by
41% between 2005 and 2020.
Whitstable shows a greater proportion of over 65s in
comparison 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, to
60% for those aged 65 and over.
People with LTC’s use disproportionately more primary and
secondary care services, 52% of all GP appointments, 65%
of all outpatient appointments and 72% of all inpatient bed
days. This pattern will increase over time with an ageing
population.
WMP ranked 182 out of 287 GP practices in Kent & Medway
on the index of multiple deprivation
13. Long Term Conditions Registers
Disease Category Number % of Population
Hypertension 5052 15.14
Asthma 2105 6.31
Diabetes 1728 5.18
CHD 1323 3.96
COPD 579 1.74
Mental Health 208 0.62
Dementia 210 0.63
Heart Failure 313 0.94
Epilepsy 183 0.55
Obesity 2712 8.13
AF 680 2.04
Depression 3817 11.44
CKD 1172 3.51
Thyroid 1263 3.78
Stroke 669 2.00
16. ANSWER
Redesign the provision of healthcare in Whitstable
Better patient experience
Closer to home
Shorter waits
Less cost to the NHS
In short, the development of an economical model
of community integrated healthcare
17. Community Elective Services
Diagnostics:
Echocardiography 2006
Ultrasound 2009
Digital X-ray 2010
Dermatoscopy Service for
Diagnosis of Malignant Melanoma 2010
Mobile MRI Scanner 2012
Consultant-led outpatient clinics:
Cardiology (tertiary) 2006
Cardiology (secondary) 2010
Gynaecology x2 2010
Urology
Orthopaedics x3 2011
General Surgery
Colorectal Surgery
Pain Management
Dermatology 2011
Care of the Elderly and Joint GP Care
Planning
Hand, Wrist & Forearm 2012
GPSI/Specialist Clinics:
Insulin Initiation 2005
Rigid Sigmoidoscopy 2006
Prostate Clinic 2007
Warfarin Clinic 2008
Cardiology OPD 2008
Dermatology OPD 2008
Epilepsy OPD 2010
Cardiology 2010
Surgery in Primary Care (SIPC) 2010
Screening Services:
AAA National Screening
Programme Centre 2009
Guy’s Genetic Screening 2009
Paula Carr Retinal Photography
Service for Diabetes 2011
Day Surgery:
Carpal Tunnel Surgery and Injection Pathway
Dermatological Surgery
Local Steroid Injection Service
Upper Endoscopy Service (hosted by WMP and provided
by Prime Diagnostics Ltd)
Cataract Day Surgery Service (hosted by WMP and
provided by consultant ophthalmologists)
Therapists:
Hearing Aid Clinic 2005
Acupuncture 2006
Chiropractic 2006
Physiotherapy 2008
Long Term
Conditions
- Diabetes
- Cardiology
- COPD
- Dementia
Urgent Care
- Practice based
Level 3 Minor
Injury Unit
- Fracture clinic
- Co-located
ambulance
response
base
- co-located
community
pharmacy
Whitstable &
Tankerton
Hospital
Enhanced
Rehabilitation &
Intermediate Care
Detailed
WISH
Workstreams
18. WISH Stakeholders
Workstream A
Long Term
Conditions
Lead:
Dr J Ribchester
Dr H Pinnock – COPD
Dr D Kanagasooriam
– Mental Health
Dr R Pieters –
Cardiology
Dr R Brice – Diabetes
Supported by:
KCHT, KFS, EKHUFT,
PUG,
Workstream B
Urgent Care
Lead:
Dr J Ribchester
Dawn Gaiger ENP
Supported by:
KCHT, EKHUFT,
SECAmb,
Workstream C
Community
Elective
Services
Lead:
Dr J Ribchester
Supported by:
EKHUFT, PUG,
Workstream D
Whitstable & Tankerton
Hospital – Enhanced
Rehabilitation &
Intermediate Care
Lead:
Dr J Ribchester
Supported:
EKHUFT, Friends, PUG, KCHT,
KFS
University of
Kent
WISH Board
South East
Coast
Ambulance
(SECAmb)
East Kent
Hospitals
University
Foundation
Trust (EKHUFT)
Friends of
Whitstable
Hospital &
Healthcare and
Patient User
Group (PUG)
Whitstable
Medical
Practice
(WMP)
18 GPs, 140 staff
Kent
Community
Health NHS
Trust (EKHT)
Kent Family
Services
(KFS)
19. Long Term Conditions –
Interim Findings
Diabetes
Cost savings – 50% (delivery of Insulin
Initiation Clinics/non-insulin injectables)
Quality – patients below NICE recommended
HbA1c. Wait times for insulin initiation
down. Positive patient experience.
Next Steps – Identify number of acute,
emergency & unplanned (re)admissions qv
4 comparator practices
20. Long Term Conditions –
Interim Findings
Cardiology
Cost savings – 38% (delivery of GPSI clinic in
cardiology has reduced OPD referrals)
Direct patient journey’s to the right station –
- GPSI Triage
- In-house consultant clinics (Kings &
EKHUFT consultants)
- Heart Failure, Arrhythmia & Rehab
Community Nurses
Reduced waiting times
Direct links to Cardiothoracic Services
21. Long Term Conditions –
Interim Findings
Dementia
Integrated Care Pathway for dementia & adult
mental health at WHC
Reduction in anti-psychotic medications
prescribed in care homes
CMHT & OPMHT delivered by KMPT in-house
Dementia café by Alzheimer's Society at WHC
22. 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
23. 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
24. MIU Level 3 at Estuary View Apr 2011 – Dec
2012
Receipts £
Total Activity (no. of pts)
Minor 9869 £394,760
Minor + 12,596 £631,689
Standard 880 £ 65,076
Major 6,027 £599,385
Total No. of Patients 29,372
Total Receipts MIU Level 3 Apr 2011 –
Dec 12
£1,690,910
Comparative Cost A&E alternative
Minor Injury 9869 £524,703
Minor + 12,596 £1,006,108
Standard 880 £98,084
Major 6,027 £811,537
Total Cost Comparative for A&E £2,440,432
Potential Cost Savings Apr 11 – Dec 12 £749,522
Potential Percentage Cost Savings 31%
25. The cost savings are
calculated using the
following assumptions:
MIU tariffs:
£50.15 = Fracture Clinic
£99.45 = Fracture Clinic
(with X-Ray)
National Tariffs for
Trauma and Orthopaedics
£148 = First Outpatient
Fracture Clinic
Fracture Clinic at
Estuary View MIU
Oct 2011 –
Dec 2012
Receipts £
Total no. of clinics
Total no. of patients
78
658
Fracture Clinic w/o
X-Ray
596 £29,889.40
Fracture Clinic with
X-Ray
62 £ 6,165.90
Total Receipts
Fracture Clinic
£36,055.30
Comparative Cost
Trauma &
Orthopaedics
658 FA £97,384.00
Actual Cost
Savings
Oct 11 – Dec 12
£61,328.70
Percentage Cost
Savings
63.0%
26. Community Elective Services
& Diagnostics
- Cost savings. Examples:
1. Urology GPSI OPD – 35% savings
2. Carpal Tunnel Decompression:
- Surgery – 77% saving
- Injection – 83% saving
- Reduction in referrals
- Less OPD follow-ups
- More one-stop clinics
- Positive patient experience
Further work: - identify comparator cohort
- identify cost savings of all services
27. Whitstable & Tankerton Hospital
- Integrated Committee formed in 2010 to
explore funding options for an Integrated
Health and Social Care Centre in
Whitstable
- OBC prepared by WISH Manager with input
from all stakeholders
- Work due to commence at C4G to consider
future of all 3 Community Hospitals
28.
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32. IF THIS IS AN ACCEPTABLE NEW MODEL
FOR URBAN GENERAL PRACTICES WHAT
ARE THE OBSTACLES?
Practices combining to serve larger
populations – perhaps 30,000-35,000
GP buildings that are fit for purpose
New GP Management structures
Buy-in from CCGs, NHS CB, RCGP, BMA
etc
New financial challenges
Potential for upsetting local acute trust
and others.
33. AND THE PRIZES ARE …..
Benefits to patient care – more personal care,
closer to home, shorter waits
Benefits to the health economy – services
delivered at less cost
Benefits to the general practice – fulfilment,
education, upskilling, integrated healthcare
community, more of a buzz!
Better patient and public engagement
BUT IT TAKES TIME AND EFFORT
34. Community Integrated Healthcare –
An Approach by Whitstable Medical
Practice
Transforming General Practice – Unlocking the Potential
Nuffield Trust, London
Wednesday 15 May 2013
Dr J M Ribchester
Executive & Senior Partner, Whitstable Medical Practice
