The Primary Care Home and 'Never Full Practice'

1. The Primary Care HomeThe Primary Care Home andand
‘‘Never Full PracticeNever Full Practice’’
A Primary Care led solution to the difficulties in urgent care provision in theA Primary Care led solution to the difficulties in urgent care provision in the
NHSNHS
Dr James KingslandDr James Kingsland
President NAPCPresident NAPC
St Hilary Group Practice, WallaseySt Hilary Group Practice, Wallasey

2. Primary Care definedPrimary Care defined
The NAPC identifies Primary Care as both a level in a health system (its form)
and a strategy or philosophy for organising approaches to care (its function).
The NAPC regards effective Primary Care as having four central features;
The first point of contact for all new health needs.
Person-centered (holistic), rather than disease-focused, continuous lifetime
care.
Comprehensive care provided for all needs that are common in a population.
Co-ordination and integration of care when a person’s need is sufficiently
uncommon so to require special services or provision from another sector
(secondary or tertiary care).

3. Primary Care definedPrimary Care defined
Primary care is therefore that first level which provides entry into a
health system for all new needs and problems.
It provides person-focused (not disease-oriented) care over time for all but
very uncommon conditions, and coordinates or integrates care provided in
other sectors.
It is where the majority of a population’s preventative and curative health
needs, health promotion and care monitoring are satisfied.
Primary Care provision is universally accessible, comprehensive and
community based and is supplied by a team of professionals accountable for
addressing a large majority of both personal and a population’s health needs.
These services are delivered in a sustained partnership with patients and
informal caregivers, in the context of family and community, and play a central
role in the overall coordination and continuity of people’s care.

4. The Primary Care HomeThe Primary Care Home
(a multi-specialty community provider)(a multi-specialty community provider)
 A model for transforming the organisation and delivery of ‘FirstA model for transforming the organisation and delivery of ‘First
Contact Care’Contact Care’
 Build on the best of traditional General Practice – the registered listBuild on the best of traditional General Practice – the registered list
 90% of care solely undertaken outside of hospital but more finished90% of care solely undertaken outside of hospital but more finished
episodes of care requiredepisodes of care required
 Both bio-clinical and social determinants of health can be theBoth bio-clinical and social determinants of health can be the
responsibility of one ‘provider’ organisation through multi-responsibility of one ‘provider’ organisation through multi-
professional teams. Improved workforce planningprofessional teams. Improved workforce planning
 Balance between personalised care and population health. SizeBalance between personalised care and population health. Size
mattersmatters
 Accountable for a total capitated budget to focus on ‘make or buy’Accountable for a total capitated budget to focus on ‘make or buy’
decisionsdecisions

5. Access and WaitingAccess and Waiting
the evidencethe evidence
 Accessible GP have fewer ED visits per registered patientAccessible GP have fewer ED visits per registered patient 11
 Patients self-refer to ED when unable to see GP within 2 weekdaysPatients self-refer to ED when unable to see GP within 2 weekdays 22
 A 1% increase in the proportion of patients able to access their GPA 1% increase in the proportion of patients able to access their GP
is associated with a £20K annual cost saving per average practiceis associated with a £20K annual cost saving per average practice 33
 £30 per head of registered population to deliver a ‘never full£30 per head of registered population to deliver a ‘never full
practice’ – approx 1.5% shift in current NHS funding in Englandpractice’ – approx 1.5% shift in current NHS funding in England 44
1. Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, et al. (2013) Access to Primary Care and Visits to Emergency
Departments in England: A Cross-Sectional, Population-Based Study. PLoS ONE 8(6):
2. Agarwal S, Banerjee J, Baker R, Conroy S, Hsu R, et al.. (2012) Potentially avoidable emergency department
attendance: interview study of patients' reasons for attendance. Emerg Med J.
3. Chauhan M, Bankart JM, Labeit A, Baker R. Characteristics of general practices associated with numbers of
elective admissions. Journal of Public Health 2012; 34(4): 584-90
4.4. Kingsland JP, Swinyard PW. Should general practices open for longer? BMJ 2013;347:f6832. doi:Kingsland JP, Swinyard PW. Should general practices open for longer? BMJ 2013;347:f6832. doi:
10.1136/bmj.f6832.10.1136/bmj.f6832.

6. ResultsResults
 20 weeks reviewed in 5 batches20 weeks reviewed in 5 batches
 >1200 records reviewed by 6 GPs>1200 records reviewed by 6 GPs
 75-80% of all activity occurs in GP contracted hours75-80% of all activity occurs in GP contracted hours
 60% of A&E activity occurs between 0900 -180060% of A&E activity occurs between 0900 -1800
(2400 – 0600 = 10%)(2400 – 0600 = 10%)
 Of those attending on Saturdays 2/3 are between 0800 –Of those attending on Saturdays 2/3 are between 0800 –
13001300
 Every contact in the WIC could be seen in GPEvery contact in the WIC could be seen in GP
 40% of attendance at A&E could be safely dealt with in40% of attendance at A&E could be safely dealt with in
GPGP

7. Results 2Results 2
 1 call to GP OOHs (per 5000 pop) between 07001 call to GP OOHs (per 5000 pop) between 0700
– 0800 every 3 weeks– 0800 every 3 weeks
 1 call to GP OOHs every 2 days between 1830 –1 call to GP OOHs every 2 days between 1830 –
20002000
 40% of all WIC contacts s/b GP with same40% of all WIC contacts s/b GP with same
condition within 1/52.condition within 1/52.
 High correlation between MIU assessment andHigh correlation between MIU assessment and
needneed
 Extremely high patient satisfactionExtremely high patient satisfaction

8. Current costsCurrent costs
 A&E (HRG) range from £56 - £244 in 5A&E (HRG) range from £56 - £244 in 5
increments… but £8.5M block contractincrements… but £8.5M block contract
 National reference cost for WIC = £38National reference cost for WIC = £38
£3M total spend for CCG (~£10 capitation£3M total spend for CCG (~£10 capitation
fee)fee)
 ADHC (Darzi) vfm unknown. V low activityADHC (Darzi) vfm unknown. V low activity
 GP OOHs vital but could be downsizedGP OOHs vital but could be downsized
 NHS 111 ?NHS 111 ?

9. 5000 more GPs needed?5000 more GPs needed?
 340M consultations in GP per year340M consultations in GP per year
 Consultation rates ~ 7 (GP=6)Consultation rates ~ 7 (GP=6)
 Variable reports about appropriate care – between 25%Variable reports about appropriate care – between 25%
and 80%and 80%
 Say 50% could be safely managed by PHCTSay 50% could be safely managed by PHCT
 Safe care for average GP = 15 consultations per sessionSafe care for average GP = 15 consultations per session
 FTE GP = 8 clinical sessions/ weekFTE GP = 8 clinical sessions/ week
 FTE delivers 8 x 15 x 45 = 5400 consultations per yearFTE delivers 8 x 15 x 45 = 5400 consultations per year
 36K FTE GPs could deliver 195M consultations36K FTE GPs could deliver 195M consultations

10. Case for ChangeCase for Change
 Right skill mix with right resource = rightRight skill mix with right resource = right
care and can significantly improve NHScare and can significantly improve NHS
budget utilisationbudget utilisation
 Rethink and reform rather than restructureRethink and reform rather than restructure
 Change to duty of careChange to duty of care
 NHS contracts change (iconic) and tariffNHS contracts change (iconic) and tariff
developmentdevelopment
 Workforce redeployed and estates closedWorkforce redeployed and estates closed

11. Vision for Primary CareVision for Primary Care

Responsive and fast convenient accessResponsive and fast convenient access
TOTO
 Multidisciplinary teams operating across organisationalMultidisciplinary teams operating across organisational
boundariesboundaries
PROVIDINGPROVIDING
 An extended range of quality services and care in theAn extended range of quality services and care in the
least invasive ways delivered locallyleast invasive ways delivered locally
ININ
 Modernised premises with integrated ITModernised premises with integrated IT
ANDAND
 Based on needs of informed patients registered with thatBased on needs of informed patients registered with that
teamteam