190326 Redesign for integrated care
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Presentation to Dudley CCG members' meeting, 26 Mar 2019. Looking at the lessons from some of the successes and disappointments of integrated care, and some of the top tips for redesigning general practice to release more of its potential.
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190326 Redesign for integrated care
- 1. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Dr Robert Varnam Director of General Practice Development england.nhs.uk/gp @robertvarnam
- 2. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 3. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 4. @robertvarnam #NHSLongTermPlan Pressure Opportunity Primary care is great – we could achieve so much more… It’s like they think I’m here for everything…
- 5. @robertvarnam #NHSLongTermPlan Based on: The Lancet doi: 10.1016/S0140-6736(12)60240-2 Why develop primary care?
- 7. @robertvarnam #NHSLongTermPlan 74% 7% 6% 4% 3% 3% 2% 2% Potentially avoidable GP appointments (audit by GPs) Other in practice Self care/Pharmacy Outpatients Sick notes / appeals Care navigation Continuity/preparation Other Data from 5,128 consultations GPs judged 26% of their consultations to be potentially avoidable
- 8. @robertvarnam #NHSLongTermPlan 74% 7% 6% 4% 3% 3% 2% 2% Other in practice Self care/Pharmacy Outpatients Sick notes / appeals Care navigation Continuity/preparation Other Data from 5,128 consultations GPs judged 26% of their consultations to be potentially avoidable … 18% are about how the practice manages its workload Potentially avoidable GP appointments (audit by GPs)
- 9. @robertvarnam #NHSLongTermPlan Continuity Accessible personal care built on a relationship from cradle to grave Community focussed Responsible for a registered population, improving wellbeing Holistic Dealing with the patient as a person not a disease or part of the body Comprehensive Handling wide range of problems, managing clinical uncertainty STRENGTHS OF PRIMARY CARE “Primary” … first, foremost, central, key Central Coordinating and connecting other teams, referring where appropriate
- 10. @robertvarnam #NHSLongTermPlan Continuity Community focussed Holistic Comprehensive STRENGTHS OF PRIMARY CARE Central Constraints on delivering the full potential: Demand >> workforce + funding Practices are set up to provide mostly medical care (reactive, individual > proactive, population focused) Hard to coordinate other inputs and ‘pull in’ specialist support Too small and isolated to have significant impact on population or system Primary care doesn’t need reinventing, but liberating to deliver its potential
- 11. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 12. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 13. @robertvarnam #NHSLongTermPlan Lessons so far… • Integrated care that doesn't include general practice usually achieves less than is hoped. And it isn't integrated care. • Refer-out has been the most common model • Why? • GP too separate / independent (perception + reality) • GPs don't have to work differently • GPs don't have time • ICTs often make high demand on GP time (attend whole mtg) • Disadvantages • GPs don't get to work differently • Breaks continuity of generalist care • Service spec often creates boundaries / constraints • Handovers involve create delays, inefficiencies and safety risks So … How do we want the clinical collaboration to work, in a wider multidisciplinary team? How do we ensure GPs have time to be a full part of joined-up multidisciplinary care
- 14. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 15. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 16. @robertvarnam #NHSLongTermPlan Redesigning care How would it be if… • GPs didn't have to be here for everything • It wasn't us and them but us - all with the same responsibility • We always asked “what happens next” • GPs weren't restricted to a conveyor belt of identical appointments Rethink access Right channel / person / time Broaden clinical options What next? Who next? How best? Where? Make self care a credible default Build knowledge, skills, confidence. Responsive support. New services for local needs Unmet need? Unnecessary break in continuity? Variance in outcome? Deliberately design teamwork First maximise each contribution. Then ask who’s in charge. Manage needs proactively Anticipate, plan, coordinate Key enablers… Invest in leadership Data >> hunches Build QI capabilities One patient, one record One population, one contract
- 17. @robertvarnam #NHSLongTermPlan GENERAL PRACTICE FORWARD VIEW 10 High Impact Actions Innovations from around England that release time for GPs to do more of what only they can do. bit.ly/gpcapacityforum
- 18. @robertvarnam #NHSLongTermPlan Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum GENERAL PRACTICE FORWARD VIEW 10 High Impact Actions
- 19. @robertvarnam #NHSLongTermPlan Innovations from practices throughout around England that release time and improve care. bit.ly/gpcapacityforum GENERAL PRACTICE FORWARD VIEW 10 High Impact Actions bit.ly/gpcapacityforum
- 20. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 21. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
- 22. @robertvarnam #NHSLongTermPlan Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form More than organisational form, success depends on: Shared purpose Culture for collaboration Capabilities for improvement and leadership
- 23. @robertvarnam #NHSLongTermPlan System: 1m+ “Integrated care system” Major partnerships & shifts in priority Workforce & infrastructure planning Large scale service reconfiguration Place: 100 – 500k “At Scale Primary Care Provider” / “Federation” Organisational infrastructure & governance Specialist staff & services Employment & career development Model design and population wellbeing Partnerships with all health & care providers Neighbourhood: 30-50k “Primary Care Network” Urgent care and resilience Locality-tailored services Shared MDT Partnerships with local providers General practice Coordinated, complex, multidisciplinary care ‘Place of belonging’ for patients needing continuity Doing the right thing at the right scale
- 24. @robertvarnam #NHSLongTermPlan Primary care networks: Opportunities for practices
- 25. @robertvarnam #NHSLongTermPlan@robertvarnam #NHSLongTermPlan Unleashing the potential of primary care Why change? Approaches to integrated care Redesigning care Critical success factors
Editor's Notes
- All change in general practice
- At the heart of the case for change is not the workload of practices – important though that is – it is the needs of patients, and they way they are changing. When the NHS was founded, its purpose was fairly simple. Every now and then, people got ill. When they did, they consulted their doctor. If it was a straightforward problem, they would give a prescription, the person would get better, return to work and, in a year or two, they might need the doctor again. If it was less straightforward, they would be referred to a clever doctor – who would give a prescription or cut out the offending part. The patient would then get better, return to work, and, in a year or two, they might become ill again. That accounted for the majority of the anticipated work of the NHS. And, for some patients, that’s still the kind of care that’s needed. However, a growing proportion of our work is fundamentally different. This now seminal chart illustrates the central fact underlying the quantitative and qualitative change in the work of primary care. It illustrates the rise in multimorbidity with age. As people get older, they have more simultaneous longterm conditions. So that, by the age of 75, for example, at least a third of people are living with four or more LTCs. And, as our demography changes, the proportion of older people increases. Dealing with longterm conditions already accounts for over half of work in primary care. It is set to increase. And, crucially, this represents a qualitative change in the nature of work. These are not people who visit the GP every year or two to get cured of their problem. These are people with problems that we cannot cure – they are living with multiple issues which will not go away, and they visit the GP six, seven, eight or more times a year. At least. Furthermore, the more simultaneous problems someone has, or the greater their frailty, the less helpful it is to pass their care to a doctor specialising in one part of the body. These people need treating as people, not diseases. So the population of people who need what only primary care can offer has grown, the amount of time they need has grown – and both are set to continue growing. This is the chief case for change in primary care, the pressure of patients’ needs. This is not a blip requiring a short-term correction to the priorities of the NHS. It is a fundamental shift which requires every developed nation on earth to turn away from what Muir Gray has termed the ‘century of the hospital’, and place the emphasis where the population’s need is.
- A growing collection – submit your own examples and questions.
- Resilience Economies of scale System partnerships Skillmix Innovation and improvement Staff development