Multispecialty community provider symposium: Fylde Coast Local Health Economy Dr Tony Naughton, Clinical Chief Officer

Comorbidity

GP workforce Over a fifth of GPs are over 55 10,000 GPs plan to retire in the next five years High stress levels New trainees disappearing The GP workforce gender split in 2012 was 57% men and 43% women The average annual growth between 2020 and 2012 was much higher for women GPs (+4.8%) than men (-0.2%) In 2010, more than a fifth of GPs were aged 55 and over. Those leaving the profession rose by 7.8% and surveys indicated a further 10,000 GPs plan to retire in the next five years

Future Models of Care 3% population (4,530 patients) 50% budget Extensive Care Multiple complex conditions 10% population (15,100 patients) Single complex conditions Enhanced Primary Care Minor health issues Episodic Care Community Activation

Extensive care consultant GP Advanced practitioner Care coordinator Wellbeing support worker Pharmacist Referral criteria: A ‘risk score’ of 20 or more. Or, had two or more hospital/A&E/out-of-hours contacts in the last 3 months. Aged 60 or over. Two or more of the following: heart problems; respiratory problems; diabetes; dementia.

Extensive Care

Secondary care impact Results – are the average (mean) deflections for ECS overall i.e. for all risk score groups. Showing a reduction in acute activity across all points of delivery for the patients who have been managed by ECS. Continue to show most impact on acute activity for the 25-50 & 50-75 risk score groups, though 75-100 group has moved to show small level of deflections (was showing an increase in acute activity). Cost of 4 site ECS model for 2016/17 is £4.6m. Deflection saving equates to £500k, growth saving is £1.6m, therefore net cost of service in 2016/17 is £2.5m. Average length of stay is consistent at 20 weeks for each risk score group – no change from September figures. We are still seeing a greater proportion of patients from the higher risk score groups being referred compared to the risk score profile of the eligible population i.e. half of patients referred had a risk score greater than 52 but only 25% of the eligible population have a risk score greater than 52. FFT score is for ECS only and is better than the overall BTH FFT score (which is 96%). Regression to the mean – a phenomena where over time events will tend towards the average for those events – in this context – the theory that over time activity levels for patients who currently have high levels of activity will naturally (i.e. without additional intervention) reduce towards the overall average for all patients. We have done some initial work to identify the levels of acute activity growth for our eligible but not referred ECS patient cohort over a 4 year period from 2013/14 (including a projection for 2016/17) which for the cohort as a whole is showing continued growth i.e. no signs of regression to the mean. We will undertake further work on this analysis with a view to presenting data at the next quarterly review meeting.

Primary care impact This is a small scale snapshot audit. We are investigating whether the collection of this data can be automated from GP Practice systems going forward for both ECS & EPC. Using the 2015 Unit Costs of Health and Social Care data, financial implications are: Consultation appointments Cost of a 10 minute appointment with a GP approx. £44 Approx. total reduction in cost of GP appointments = £4840 Cost for a 10 minute appointment with a practice nurse costs approx. £14 Approx. total reduction in cost of practice nurse appointments = £280 Telephone appointments Cost of a GP telephone consultation lasting between 7 and 8 minutes is approx. £27 Approx. reduction in cost of GP telephone consultations = £1674 Home visits: Cost of a GP home visit is approx. £65 Approx. total reduction in cost of home visits = £5005 This is obviously just four practices and 40 patients. If we scaled up to look at all patients to have gone through ECS so far impact obviously far greater…

Enhanced primary care Coordination of care – different professionals working across organisational boundaries. Focus on prevention and self-care. Locally based teams support GPs to provide care for patients aged 18 and over. Wellbeing support workers GP Nurses Mental health Therapists Coordinators Social care

Enhanced primary care This is a small scale snapshot audit. We are investigating whether the collection of this data can be automated from GP Practice systems going forward for both ECS & EPC. Using the 2015 Unit Costs of Health and Social Care data, financial implications are: Consultation appointments Cost of a 10 minute appointment with a GP approx. £44 Approx. total reduction in cost of GP appointments = £4840 Cost for a 10 minute appointment with a practice nurse costs approx. £14 Approx. total reduction in cost of practice nurse appointments = £280 Telephone appointments Cost of a GP telephone consultation lasting between 7 and 8 minutes is approx. £27 Approx. reduction in cost of GP telephone consultations = £1674 Home visits: Cost of a GP home visit is approx. £65 Approx. total reduction in cost of home visits = £5005 This is obviously just four practices and 40 patients. If we scaled up to look at all patients to have gone through ECS so far impact obviously far greater…

Episodic care One-off minor ailments Pharmacy+ Practice triage Directory of services Extended access Health improvement Many people require healthcare services very rarely and when they do it can often be for a one-off minor ailment. We call this Episodic Care and have been working hard to make sure that when people do occasionally need healthcare advice or treatment that they can access this in a timely fashion and through the most appropriate source. PHARMACY+: Allows anybody living within Fylde and Wyre to access advice and treatment for a range of minor ailments at their local pharmacy instead of needing to book a GP appointment. Since its launch in May 2016, 26 local community pharmacies have signed up to the scheme. People get advice for things such as threadworms, thrush and head lice, with 99% rating it as ‘excellent’ or ‘very good’. 93% of those surveyed said they would have used GP services if they had not used Pharmacy+, and 99.5% said they now had the confidence to self-care if their condition reoccurred. DIRECTORY OF SERVICES: We are working with a range of partners to develop a comprehensive Fylde coast directory of health and care services which people will be able to access through the Internet on computers, smart phone and tablet devises. It will signpost people to services which they might not otherwise have known about. The directory will be launched in 2017/18. EXTENDED ACCESS: We are also offering extra GP services in the evenings and at weekends. Appointments with GPs, nurses or healthcare assistants are booked by a patient’s normal surgery. Patients then attend one of the designated health centres, which has full access to patients’ medical records. These extended hours services are currently available from Fleetwood and Freckleton with roll out across Fylde and Wyre complete by the end of March 2017. FLEETWOOD TOGETHER: Brings together the NHS with local charities and businesses to tackle ill health.

(£2,754 average per admission) WIN Care Home Pilot THE TEAM : GP, nurse practitioners, health care assistants, pharmacist, hospice nurse ACTIVITY RESULTS 360 Medication reviews 580 Care plans in place  43% Average length of stay 33% A&E attendances 381 Medicines stopped 384 DNACPR in place 79 NEL admissions (£2,754 average per admission) WORK: Provide proactive care, reduce need for urgent care, reduce hospital admissions

Delivery mechanism A group of practices that come together to form a ‘natural’ geography to improve the health and wellbeing of their neighbourhood population “ Most importantly we have moved from seven practices who hardly communicated to a relationship of genuine collaboration and trust Dr Wendy Ford, Wyre Integrated Neighbourhood

GP Quality Contract Variation of service provision across practices Standardised to reduce inequitable provision and allow consistent approach to allow new ways of working £

Co-production

Clinical prioritisation

Organisational form GP GP Partial Fully Practice Neighbourhood Virtual Federation Partial Fully Small scale No integration “corner shop” Cost of autonomy Cost of GMS Fixed partnerships

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