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The Integration of Primary and Secondary Care Michael Maguire, Linda Evans North Glamorgan NHS Trust

Current Problems - General Demise of Traditional 7/24 Family Practice Junior Doctors’ Hours and Numbers European Working Time Directive Need for 7/24 service locally Increased (Realistic) Expectations Equipment Specialised clinical skills (medical, nursing, PAM etc)

Current Problems - Particular Variable GP qualities and interests Many small/single person practices Ageing workforce Socio-economic Urbs in rure Deprivation and low health status Increased morbidity Decreased family ability to cope Poor access

The current model - elective Concerned Family Tertiary services GP DGH paediatric team Community services

The Current Model - emergency DGH paediatric team Tertiary services GP Health call DGH ER 999 Concerned Family Out of hours GP service/call centre

Requirement Care should be provided as locally as possible provided that: There should be easy and rapid access to high quality specialised care when needed This specialised care should be provided as near to home as possible consistent with maintaining quality (and rational economics.)

Zeitgeist The likely future divide is between those services which can be provided locally and those which require a specialised centre rather than between primary and secondary care. “Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanent” BMJ 19 January 2002 “In Kaiser, primary care physicians include doctors accredited in …..paediatrics, and obstetrics and gynaecology………supported by physician assistants and nurse practitioners…” “…some primary care physicians also follow their patients in the hospital setting” Various editorial comment (ibid): “Treating patients at the most cost effective level of care” “The key answer is that …..Kaiser integrates care much more reliably than the NHS…” “This vision - one integrated patient “journey” – is the right one for the NHS…” “Kaiser may perform better because primary and secondary care are better integrated…”

The Proposed Model-emergency Local paediatric team Tertiary services Concerned Family DGH ER 999

The proposed model - elective Concerned Family Primary care team Tertiary services Local paediatric team

Function of the DGH Reception, triage, resuscitation, stabilisation and transfer or return home of the sick or injured child. 24 hours 7 days Support to the Maternity Service Base for specialist out-reach clinics and services Diagnostic services to local care teams

The New Model Paediatrician CCST with general, community and neonatal experience (GP training?) Works as a member of the primary care team Ambulatory care Health maintenance Child protection Works as a member of the local paediatric team to provide 24/7 emergency cover Trains others

Questions

Summary Children’s care by children’s trained teams Local care as far as possible Appropriate access to (organ) specialist Maintenance of local emergency care skills Care by trained practitioners Trainees on 1:1 apprenticeship model

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