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National Primary Care Conference

15 November 2018

#PrimaryCare18

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Transforming Access – reflections on progress across Wales

15 November 2018

#PrimaryCare18

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Community Pharmacy

15 November 2018

Dylan Jones

#PrimaryCare18

Community Pharmacy Independent Prescriber

72 94 107 163 128 129 140 117 105 139 112 150 159 229 112 153 118 155 1500

2

4

6

8

10

12

14

16

18

20

0

50

100

150

200

250

Da

ys

Pro

vid

ed

Co

nsu

lta

tio

ns

Service availability and consultation numbersDec 2016 to Jun 2018

Cardiac1%

CNS1%

Injury2%GI

3%Nasal

3%

Eye4% UTI

5%

Other5%

Musculo7%

Ear11%

Mouth13%

Skin20%

Respiratory25%

Condition type (Dec 2017 to Jun 2018)

GP Pharm Total GP Pharm Total GP Pharm Total

Consultation

Impact

(Yr 1 v Yr 2)

GP Impact

(Yr 1 v Yr 2)

Consultation

Impact

(Yr 1 v Yr 3)

GP Impact

(Yr 1 v Yr 3)

Chest/Cough 857 0 857 766 123 889 663 221 884 4% -11% 3% -23%

Rash/Skin 644 0 644 499 94 593 509 126 635 -8% -23% -1% -21%

Sore Throat 219 0 219 167 78 245 144 80 224 12% -24% 2% -34%

UTI 169 0 169 129 21 150 112 37 149 -11% -24% -12% -34%

Ears 282 0 282 220 71 291 199 72 271 3% -22% -4% -29%

Conjunctivitis 57 0 57 36 31 67 21 15 36 18% -37% -37% -63%

Total 2228 0 2228 1817 418 2235 1648 551 2199 0% -18% -1% -26%

Search strategy amended from previous searches to more accurately capture variety of data recording methods used by all prescribers.

All data periods from 1st Dec to 30th May

Dec 15 to May 16 (Yr 1) Dec 16 to May 17 (Yr 2)

Condition

Dec 17 to May 18 (Yr 3)

GP Practice on average seeing 26% less patients for these conditions Over 33% for some conditions now being seen at the pharmacy

0

500

1000

1500

2000

2500

GP Cons Yr 1 Pharm Cons Yr 1 GP Cons Yr 2 Pharm Cons Yr 2 GP Cons Yr 3 Pharm Cons Yr 3

Impact of Pharmacy IP service on GP consultation ratesChest/Cough Rash/Skin Sore Throat UTI Ears Conjunctivitis

26% Reduction in

GP

Consultation Outcomes

182

128117

67

206

128

0

50

100

150

200

250

Monday Tuesday Wednesday Thursday Friday Saturday

Saturdays key day for service provision Mondays, Fridays most consultations

(Dec 2017 to Jun 2018)

Examples of consultations

“Very useful service in the event of the doctors’ surgery being busy. The pharmacist was very knowledgeable, friendly and put me at ease.”

It’s not a pharmacy service…

…it’s coordinated primary health care that patients access at a pharmacy.

dylan@dudleytaylor.co.uk

jason.carroll@wales.nhs.uk

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Community Optometry

15 November 2018

Andy Britton

#PrimaryCare18

From PEARS to WECS

Dropping a vowel but picking up more work in a

community setting

Andy Britton, Optometrist, Haverfordwest

Committed to excellence in eye care

Something old – the service before

• PEARS – Primary Eye Acute Referral Service - Optometry Led

• WEHE’s – Wales Eye Health Examination – Optometry Led

• The Wales Low Vision Service – Optometry Led

• Diabetic Retinopathy Screening – non Optometry Led

• Glaucoma Monitoring – non Optometry Led

Sheen NJ, Fone D, Phillips CJ, Sparrow JM, Pointer JS & Wild JM. Novel optometrist-led all Wales primary

eye-care services: evaluation of a prospective case series. Br J Ophthalmol.2009, 93 (4) 435-438.

A WECS / EHEW is

born!

Providing the people of Wales with:

• Eye health examinations

• Further investigations

• Follow-up services

Enhanced

Scheme

Evaluation

Project (ESEP)

How does the new service work?

• Accreditation by Wales Optometry Post Grad Education Centre

• List of accredited practices

• Three types of appointment

eye health examination

further investigations following a sight test

follow-ups to an eye health examination

• Banded fee structure commensurate with time taken

and level of skill

• In built clinical audit – Data at last!

Welsh Government Together for

Health – an Eye Care Plan for

Wales 2013-2018

Moving services where appropriate to a

community setting

Using primary care professionals to deliver eye

care services

Expanding the role of primary care based

optometrists

But What Does It Mean?

Smoking Cessation

Post Cataract Community Follow Ups

OHT and Suspect Glaucoma Monitoring

WECS/EHEW Triaging

IT Connectivity across all Practices

Local, Primary Care Based Funding

Independent Prescribing

Joint Working

Post cataract follow-up appointments in

the community: Aneurin Bevan UHB

RESULT

Over 1,600 hospital appointments per year

were saved in the past year

Follow-up appointments in the

community for patients who have

glaucoma: Aneurin Bevan UHB

RESULT

1,698 appointments freed up in hospital eye

clinic in a 4 month period

What do the patients think?

Patient satisfaction results for the glaucoma

follow-up scheme:

Q1: Did you have confidence in the

optometrist who you saw for assessment?

100%

0% 0%

Yes completely

Yes to some extent

No

Q2: Was it easy to book an appointment

for your assessment to be undertaken?

96%

3%1%

Yes competely

Yes to some extent

No

Q3: Did the optometrist

understand your condition?

98%

2% 0%0%

Yes completely

Yes to some extent

No

Q4: Was the optometry practice

accessible?

85%

10%5%

Yes easier than hospital

Yes as easy as the hospital

No it was harder than the hospital

Triage of all referrals to

Ophthalmology: Betsi Cadwallader UHB

RESULT

2,000 appointments were saved during the

first year

Number of initial referrals 10,234

Referral continued to HES 8,335 81.4%

Referral diverted to WECS 1,348 13.2%

Referral returned to practitioner - insufficient

information

273 2.7%

Patient referred to an LVA practitioner 36 0.4%

What this means for patients in Wales

Skills and equipment are in place

Close to people’s homes

Better access for patients

NO waiting lists and NO workforce shortages

First port of call for eye problems

Avoid unnecessary referral to hospital eye

services

But What Does It Mean?

Smoking Cessation

Post Cataract Community Follow Ups

OHT and Suspect Glaucoma Monitoring

WECS Triaging

IT Connectivity across all Practices

Local, Primary Care Based Funding

Independent Prescribing

Joint Working

Specsavers Haverfordwest

The story so far…

Acquired the practice in 2006

Started gradual program of equipment upgrade

• Networked Fundus Camera £25K

• Hospital Standard Visual Fields Machine £14K

• Hospital Standard Tonometry £1K

• Pachymetry £1K

• Networked Optical Coherence Topography £40K

• Alongside program of improved eye examination equipment

Phoropters £36k

Digital Test Charts £12K

Improved Non contact tonometers £12K

Frequency Doubling Field Machines £8K

Disabled accessible consulting rooms £20K

All in all almost £200,000 of equipment investment in 12yrs…

A new hope

We outgrew our existing business because of the amount of

work that we could see being required to be delivered in

primary care…

Belief that delivery of primary care services HAS to be at the

heart of the professional offering…

Cue a £500,000 relocation to purpose built brand new

practice where we could put primary eyecare at the centre

of what we do……

Its not all about the toys….

Professional development is key

Job satisfaction

Recruitment

Higher qualifications / professional kudos

Ability to deliver services to the standards

demanded by the Royal College of

Ophthalmologists, General Optical Council and

College of Optometrists

Independent prescribing

Higher Glaucoma Qualifications

Medical Retina Qualifications

Warm and fluffy...

We make a difference

Brain Tumours

Strokes

Retinal Detachment

Reassurance

We are accessible

Let work together

Cluster Working

Work with the clusters to improve health and

healthcare outcomes

Mutual respect

Prescription requests

Training

Guidance

Does it add up….

Having invested around £700,000 on equipment and

practice relocation is a pretty big show of confidence

Can secondary care go it alone ?

We have the skills, the passion and the drive to deliver

excellence in care in the primary care setting and a

framework within which to do it….

The Future Is Bright

..................................

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General Dental Services

15 November 2018

Richard Jones

#PrimaryCare18

NHS General Dental ServicesOpportunities for Change

Richard Jones

BDS (Wales) PG Cert Med Ed

Brief History of NHS Dental contracts since 2006

• Pre 2006 dentists were paid on an ‘item of service’ basisi.e. paid for what they did – no limits and Registration

• 2006 units of dental activity [UDAs] introduced, banding and capping activity

dentists contracted to complete a specified number of UDAs per year

• UDA definitions flawed:e.g. same payment no matter how many patient visits needed to complete a course of treatment

Negative impact of 2006 contract

• Immediate visible consequences:• 900,000 less UK patients seen in first 18 months; with less complex

treatment provided• Exodus of disillusioned GDPs from NHS care

• Closed contracts stopped/limited capacity to ‘grow’ services

• Professional de-motivation/disengagement resulting from:• variation of >50% different UDA rates paid to practices• “Claw back” for under performance• Banding inequities provided barriers to treating high need patients

• Consequences:• complex or high need patients referred to secondary care or Community

Dental service• Primary Care dentists de-skilled – on a TREADMILL

Response

2008 the Parliamentary Health Select Committee investigation found

UDAs were unfit for purpose and sought alternative contract models

• Welsh Dental Pilots Programme instigated• 8 practices tested removal of UDA for adults or children

• 2011 two Pilots remained adult based and children only • Eastside and Belgrave Dental Centres, Swansea

• Removes UDAs focuses on quality, access and prevention

• Clinical freedom to best suit demographics

Belgrave Dental Centre

Instant Advantages

• Clinical Freedom without UDA

• Care pathways based on:• Risk• Need• Prudent health care • Co-production

• Flexibility for LHB seeking responsive services, e.g. • Asylum seekers, HMP support

• Urgent access offered a risk based care plan

Skill Mix

Freedom to really apply:

• Enhanced skill mix usage

• Prevention Better oral Health and evidence based toolkit

• Treating patients on risk and need: Red/Amber/Green

• Working at top of competencies

All ↑ increase capacity to see more patients

Janice -one of twoOral Health Educators

Positive Feedback

“First time in 30 years I really understand how to look after my mouth”

“having one child with dental pain and decay ,I now Feel confident I know how to look after my children’s dental Heath as well as my own!”

“ I am Happy for you to refer me for help”

2016: Dental Contract hit buffers or reached a crossroad?

• Pilots were to end – no prospect of new UK contract

• Belgrave faced reversion to UDA basis… but

WG review was positive:• Good patient feedback• increased access• Application of prudent healthcare principles• No impact on patient income

ABMU (only) supported continuing the 2 sites

as prototype and would continue to:

• work with practices to spread learning

• innovate in skill mix and combating health inequalities

So what about our sister practice ?

Our second practice (from 2013), left behind with:

• UDAs

• High needs population

• Frustration attempting to treat based on targets not need , risk , coproduction and prudent healthcare principles

• Retention issues - Young performers disillusioned with system

• Clawback from missing targets due to trying to treat a high needs population under current GDS contract and low UDA rate.

However...2017 - Contract Reform!

• WAG keen to drive learning from pilots & prototypes

• Need for evidence based data on risk and need

• Positive support from ABMU

• Phase 1: • 10% UDA reduction for collection of ACORN data

• ACORN also collected in 2 prototype sites

• Phase 2: higher percentage of UDA target reduced informed by phase 1

Collecting and reporting clinical need and modifiable risks

ACORN data gives us a predictable picture of our risk and need

Skill mix shows we can use more hygienist & OHE input

Frees up Dentist

Allows us to free more capacity to take on more patients, i.e. increases access

General Dental Practitioner Fellowship Scheme

• ABMU has developed, now piloting, a dental Fellowship which upskills Dentists, Pontardawe dental practice awarded first fellow

• With understanding from our ACORN our hygienist enables us to release our dentist to be upskilled

• Fellow focus is currently endodontics (MSc), possible opportunities in developing into a recognised Dentist with Enhanced Skills (DES)

• Currently with a 4 year waiting list within restorative dentistry’s secondary care service, pathway will help relieve pressure

• Actively involve patients

• Increase patient access to NHS dentistry

• Make more effective use of current resources

• Facilitate a preventive and prudent healthcare approach to care in more dental practices

• Provide opportunity for more specialised service provision in primary care which would relieve the burden on secondary care services

By supporting our practices ABMU has allowed us to not only meet such criteria but be a pace setter for its Formation

Aims to:

How has access to services improved by supporting prototypes and contract reform?

Future opportunities for innovation /access

• Multi-professional links

• Cluster working

• Community based projects

• Improved pathways supporting secondary care and community services

• http://www.youtube.com/watch?v=J55jlxR3nMY

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General Practice

15 November 2018

Dr Gaynor Thomas

#PrimaryCare18

Dr. Gaynor Thomas

• Prudent Health Care

• ‘only do what only you can do’

• Access

• GP workload

• Recruitment

• Retention

GP

Clinical personal assistants

Maximize use of clinical team

Pharmacists

Common ailments scheme

Dentists

Opticians

• GPNs backbone of general practice

• Highly skilled

• Highly valued

• Inspirational role models

• 33.4% of GPN are due to retire by 2020

• Average age of GPN in Cwm Taf is 45

• ATP scheme, which was developed in 2009 in Yorkshire.

• 10% of the undergraduates that pass through the primary care placements have been recruited into general practice

Hub and spoke model

Hub

Spoke

Spoke

Spoke

Spoke

Spoke

Spoke

Undergraduate nurse placements

• 6 week placement in year 2

• 12 week consolidation placement in year 3

• High quality placement

• Inter-professional learning

Nurse mentors

• Each practice to have two nurse mentors

• Each nurse to become signing off mentor

• Nurse Mentor Support Workshop

GPN Ready Scheme

• Newly qualified nurses/return to work

• 2 year career training and education path

• Practice apply to Hub

• Discussion around role and training

• Advertise for nurse

• Incentivised scheme

Timeline

Year 2

6 week placement

Year 3

12 week consolidation

block

Newly qualified nurse

GPN ready scheme

2 years

Fully trained Practice Nurse

Student Feedback

• High level of satisfaction

• University evaluation top 5% of placements

• Improved awareness of role

• Opportunity to learn new skills

Nurse Feedback

• Initial apprehension

• Enjoy placements

• Renewed enthusiasm for teaching

• Shared learning between mentors

• Retain current workforce

Future

• Hubs at heart of training and education

• Run by primary care for primary care

• Network of practices with training expertise

• Provide the infrastructure to train all future workforce

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National Primary Care Conference

15 November 2018

#PrimaryCare18