Mutuality, A&E and Mutuality, A&E and Primary CarePrimary Care

Dr Adrian BakerDr Adrian Baker

Clinical Lead Nairn & ArdersierClinical Lead Nairn & Ardersier

Carers & Voluntary

AHP’s / Pharmacy

Nursing

GP’s

Community Hospitals

Secondary / Tertiary Care

99 ?

OR

999

Nairn and Ardersier c1997Nairn and Ardersier c1997

• The service has been in operation since March 1997.• PCEC 250-400 calls to the service each month. • A&E 100 – 300 attendances a month• There is minimal use of protocols, referring instead to

guidelines or a more experienced opinion when necessary. National guidelines are utilised when possible.

• Each nurse uses their own clinical judgement and defines their own level of competence (and doctors respect this).

• The PCEC service is fully integrated with A&E

Localities / Parish ?Localities / Parish ?

If we are honestly going to involve ourcommunities, our patients, the providers and thecurrent political systems then I think we have tolook back to our Scottish roots to give us a firmfoundation on which to build the new ScottishHealth Service. In the Scottish Nation 1700-2000T.M. Devine looked at the old parish model.

CommunityHospital

GP’s Mental Health

Children

Social ServicesCommunity

NursingSupport

HR, IT

Finance

CLINICAL LEADERSHIP

The Extended Primary Care Team in the Locality

Patient

Elected Representaion

Integrated responseIntegrated response

• GP• SAS / Home care alerts / telecare• A&E / PCEC integrated• Nurses for palliative care• Care plans, Alerts, Integrated IT (Vision)• Community Support Team / NHS Home

Care, OOH home care• Patients call single number

PRIMARY

999 Calls: 0.5m New: 2.8mNon Emergency: 1.8m Repeat: 8.5m

Calls: 0.7m

Treatments: 3.5mAdmissions: 0.5m Admissions: 0.2m Discharges: 0.4m

px items: 72.2m

New: 1.4mRepeat: 0.1m

ContactsNew: 7.2mRepeat: 13.1mActivity: 6.3m

Tests: 0.9m OOH: N/A Discharges: 0.7m

New: 24.1kDischarges: 0.6m Deaths: 28k

Hours: 27m

Attendances: 3m

KEYAdmissions: 59.5k Level of contacts

10 - 100 million1 - 10 million

discharges: 49.1k Deaths: 10.6k 100k - 1 million0 - 100kUnknown

COMMUNITY

ACUTE

Self to A&E: 0.9m

Outpatients/Nurse Clinics/AHPsAmbulance Service

NHS24

DentistsEmergency IP Elective IP Day Cases

Pharmacy

A&EAHPN/A

GP Practice

Discharges from HospitalOphthalmics

Discharge

Intermediate CareN/A

Day PatientsResidence Death

Death

Home Care

Day Care

Care Home

HealthIncidents

Self CareNon NHS care (e.g. private)other UK NHS

Transfers0.2m

Out of hours primarycare services ~1m

General PracticeGP and Practice Nurse

contacts: 23.7m

Day careAttendances: 3m

DentistTreatment courses:

3.5m

PharmacyItems: 82m

Community psychiatryteam

Visits: 863k

AHPAttendances: 2.3m

Healthincidents

Ambulance Service999 calls: 0.6mAir Ambulance: 3k

NHS 24Calls: 1.5m

OpthalmicsEye tests: 1.6m

Nurse & health visitorsVisits: 5.6m

Day patientsAttendances: 660k

Home careHours: 34mClients: 69k

Care home - long stayresident weeks: 1.9m

residents: 36k

Community learningdisabilities team

Visits: 85k

A&EAttendances: 1.6m

OutpatientsConsultant clinics 4.4mNurse-led clinics 0.7mAHP clinics 4.5m

Day cases430k

Long stay inpatientsPatient weeks: 361k

Inpatients (discharges)Acute specialities: Emergencies: 528k Elective: 408kOther short-term specialties: 157k

Community midwifeVisits: 412k

PRIMARY & COMMUNITY HOSPITALS

Ambulance (Patient Transport & Car Services)Patient journeys: 1.7 m

Note: the diagram excludes some other services provided in the community

Contacts20m +

10m - 20m5m - 10m1.5m - 5m

0.5m - 1.5munder 0.5m

Scottish Health and Care Activity 2007/08

Care home - respiteadmissions: 35k

Sources: ISD Scotland, SG

Home care£408m*

Out of hours primarycare services £68m*

General Practice£705m

Day care£232m*

Dentist£329m

Pharmacy£1.1bn

Community psychiatryteam

£143m

AHP£116m

Healthincidents

Ambulance Service999 calls: £136mAir Ambulance: £10m

NHS 24£55m

Opthalmics£78m

Nurse & health visitors£229m

Day patients£246m

Care home - long stay£724m*

Community learningdisabilities team

£29m

A&E£148m

OutpatientsConsultant clinics £552mNurse-led clinics £45mAHP clinics £269m

Day cases£317m

Long stay inpatients£696m

InpatientsAcute specialities: £2.1bnOther short-term specialties £470m

Community midwife£33m

PRIMARY & COMMUNITY HOSPITALS

Ambulance (Patient Transport & Car Services)£34m

Note: the diagram excludes some other services provided in the community* These figures refer to 2006/07

Scottish Health and Care Costs 2007/08

Care home - respite£50m*

Sources: ISD Scotland Costs Book; SG LocalFinancial Returns; NHS24; Scottish Government

Costs£1bn +

£500m - £1bn£250m - £500m£100m - £250m£50m - £100m

under £50m

Journey of DependenceJourney of Dependence

• Home Care - £6,000 per case per year(34M hours, 69,000 clients)

• NHS 24 - £36.67 per call• OOH PCEC £68.00• GP in hours contact £30.00• District nurse / Health Visitor £40.89• A&E £92.50• Admission (Ave 10 days) £2,784• 51x and other dispossessed patients• Long stay care £ 20,111 a year

EEA by practice for HighlandEEA by practice for HighlandPractice Elderly Emergency Admission Rates 2003-2005

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Pyramid to Oil TankerPyramid to Oil Tanker

EEA rates by Locality EEA rates by Locality (>65, >75, >85)(>65, >75, >85)

0.00

100.00

200.00

300.00

400.00

500.00

600.00

700.00

Badenoch &Strathspey

Caithness EastSutherland

Inverness Lochaber Nairn &Ardersier

NWSutherland

Ross &Cromarty

Skye &Lochalsh

Highland

Locality

EE

A / 1

000 P

op

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>65yrs

>75yrs

>85yrs

Local vs National systemLocal vs National system

• Local nurse talks to patient

• Same number – one point of contact 24/7

• Can See & treat• Local Knowledge -

ALERTS• Can discharge• Can call in extended local

Primary Care Team & Social Services

• Very Close, consistent working with GP’s

• Remote nurse• American Algorithm• 7% UK GDP vs 14% USA• Advice• Or GP• Or A&E• Or Ambulance• Ice cream• High cost (Effective?)• Remote working

Since Opt OutSince Opt Out

• NHS 24 1.5M calls a year

• A&E increase 6% a year

• Cost NHS 24 = £55M = £10 a patient

• Lochaber / Nairn & Ardersier = £150,000

• With a locally based Telephone triage system could this money be put to better use?

(NHS Highland £3.3M)

““If difficult…..If difficult…..

………….Don’t……..Don’t…….

………….Do”.Do”

VisionVision• Equity of funding and service• Local services to ensure local response• Clinically and socially appropriate

response. Mental Health• Ability to stabilise and transfer to

secondary care when necessary• Integration with Social Services