Community Integrated Healthcare – An Approach by Whitstable Medical Practice

Transforming General Practice – Unlocking the Potential

Nuffield Trust, LondonWednesday 15 May 2013

Dr J M RibchesterExecutive & Senior Partner, Whitstable Medical Practice

Whitstable Health Centre & Chestfield Medical Centre

Estuary View Medical Centre

Estuary View Medical Centre

Estuary View Medical Centre

Whitstable

© J M Ribchester

Whitstable

© J M Ribchester

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

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

WMP List Size Growth Since 1998

Whitstable Medical Practice List sizes 1.4.1998 - 1.4.2013

27,000

28,000

29,000

30,000

31,000

32,000

33,000

34,000

35,000

1.4.98 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

QUESTION

What has Whitstable Medical Practice

been able to do differently?

ANSWERRedesign the provision of healthcare in Whitstable

Better patient experienceCloser to homeShorter waitsLess cost to the NHS

In short, the development of an economical model of community integrated healthcare

Community Elective Services

Diagnostics:Echocardiography 2006Ultrasound

2009Digital X-ray

2010Dermatoscopy Service for Diagnosis of Malignant Melanoma 2010Mobile MRI Scanner 2012

Consultant-led outpatient clinics:Cardiology (tertiary) 2006Cardiology (secondary)

2010Gynaecology x2

2010Urology

Orthopaedics x3 2011General SurgeryColorectal SurgeryPain ManagementDermatology

2011Care of the Elderly and Joint GP CarePlanningHand, Wrist & Forearm

2012

GPSI/Specialist Clinics:Insulin Initiation 2005Rigid Sigmoidoscopy

2006Prostate Clinic 2007Warfarin Clinic 2008Cardiology OPD 2008Dermatology OPD 2008Epilepsy OPD

2010Cardiology

2010Surgery in Primary Care (SIPC)

2010

Screening Services:AAA National Screening Programme Centre 2009Guy’s Genetic Screening

2009Paula Carr Retinal Photography Service for Diabetes 2011

Day Surgery:Carpal Tunnel Surgery and Injection PathwayDermatological SurgeryLocal Steroid Injection ServiceUpper 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 2005Acupuncture

2006Chiropractic

2006Physiotherapy

2008

Long TermConditions

- 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 &TankertonHospital

EnhancedRehabilitation &Intermediate Care

Detailed

WISHWorkstreams

WISH Stakeholders

Workstream ALong TermConditions

Lead:Dr J RibchesterDr H Pinnock – COPDDr D Kanagasooriam

– Mental HealthDr R Pieters –

CardiologyDr R Brice – Diabetes

Supported by:KCHT, KFS, EKHUFT,

PUG,

Workstream BUrgent Care

Lead:Dr J RibchesterDawn Gaiger ENP

Supported by:KCHT, EKHUFT,

SECAmb,

Workstream CCommunity

ElectiveServices

Lead:Dr J Ribchester

Supported by:EKHUFT, PUG,

Workstream D

Whitstable & TankertonHospital – Enhanced

Rehabilitation &Intermediate Care

Lead:Dr J Ribchester

Supported:EKHUFT, Friends, PUG, KCHT,

KFS

University ofKent

WISH Board

South EastCoast

Ambulance(SECAmb)

East KentHospitalsUniversityFoundation

Trust (EKHUFT)

Friends ofWhitstableHospital &

Healthcare andPatient UserGroup (PUG)

WhitstableMedicalPractice(WMP)

18 GPs, 140 staff

KentCommunityHealth NHSTrust (EKHT)

Kent FamilyServices

(KFS)

Long Term Conditions – Interim FindingsDiabetesCost 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

Long Term Conditions – Interim FindingsCardiologyCost 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 timesDirect links to Cardiothoracic Services

Long Term Conditions – Interim FindingsDementiaIntegrated Care Pathway for dementia & adult

mental health at WHCReduction in anti-psychotic medications

prescribed in care homesCMHT & OPMHT delivered by KMPT in-houseDementia café by Alzheimer's Society at WHC

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

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

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%

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 Outpatient

Fracture ClinicFracture 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 SavingsOct 11 – Dec 12

£61,328.70

Percentage Cost Savings

63.0%

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 experience

Further work: - identify comparator cohort- identify cost savings of all

services

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

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.

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

Community Integrated Healthcare – An Approach by Whitstable Medical Practice

Transforming General Practice – Unlocking the Potential

Nuffield Trust, LondonWednesday 15 May 2013

Dr J M RibchesterExecutive & Senior Partner, Whitstable Medical Practice