GP Update 31 st March 2011 Steve Kirk GatNet Vice Chair

Board Update Commissioning and new contract Practical steps to help practices review commissioning data and reduce referrals

GatNet Board Chair Dr Mark Dornan Vice ChairDr Steve Kirk Prescribing LeadDr Chris Jewitt Good Medical Practice Dr Neil Morris Urgent CareDr Gordon Orritt Nurse RepresentativeVoting in Progress Practice ManagersVal Hempsey, Susan Sohi, Sheinaz Stansfield PCT executive directorTBC PCT non-exec directorAlan Baty Public Health representativeAlyson Learmonth Co-opted members Prescribing LeadAnne-Marie Bailey PCT CommissionerJane Mulholland + (clinical leads in MSK, Dermatology, COPD, Sexual Health, etc.)

Changes to Contract Patient participation DES –Patient reference group –Agree priorities, local survey, action plan, publicise plan and actions Changes to QOF –Emergency Admissions47.5 points –1 st outpatient referrals21 points –Prescribing 28 points

Question 1 How do we reduce numbers of routine referrals to secondary care?

Reducing Routine Referrals What has been tried –Referral management schemes –CATS –Financial incentives –Peer review –Triage –Guidelines and proforma letters

What can Practices do? –Know your referral patterns, how do you compare? –What are your high referral areas? –What are the quality of your referral letters? –Do you use in house referral? –Have you had consultant feedback –Do you use peer review –Are you prescribing effectively? Reducing Routine Referrals

What can Practices do? –Use alternatives to referral to hospital –Intra-practice referral –Understand what patient wants from referral –Consider explicitly stating purpose of referral, ie management plan and discharge, diagnosis, treatment –Understand and manage variation within practice Reducing Routine Referrals

What can GatNet do? –Facilitate peer review/consultant review Targeted or general –Develop alternatives to referral –Provide comparative data –Develop proformas/guidelines –Training Reducing Routine Referrals

Question 2 How do we reduce numbers of emergency admissions?

What has been tried? Nuffield Trust report UCT Community matrons Risk modelling Assisted discharge Community support workers Reducing Emergency Admissions

What can Practices do? –Know the patterns/high risk areas –Triage of home visits –Good links with nursing homes –Effective patient information and LTC management –Use alternatives to referral –Look at pressure areas –End of Life Care Reducing Emergency Admissions

Fig 4: Rate of emergency hospital admissions per 100,000 population due to COPD (ICD10 J40-J44), directly age-standardised admission rate, persons all ages Rate of emergency hospital admissions per 100,000 population due to COPD (ICD10 J40-J44), directly age-standardised admission rate, persons all ages

Gateshead Practices: Emergency COPD Admissions per 100 Patients on Disease Register Period/Year: Rolling Year /2009; Cost Fell Cottage total cost £59,961 Beacon View £17, 020

Source: Admission rates taken from Association of Public Health Observatories, Hospital Episode Statistics Atlas at

Clinical Area Total Admissions Admission Process Non-infective gastro and colitis 6A & E 3 Minor injuries/Gatdoc 2 MAU no GP involvement 1 AF and flutter3GP 1 ? GP 1 Care of Elderly clinic 1 UTI6A & E 3 GatDoc 1 MAU/GP involvement 1 GP 1 Acute LRTI4GP 4 Chest Pain11A & E 4 GP/MAU 2 GP 3 No discharge info 2 Syncope6A & E 1 GP 3 No discharge info 2 COPD with acute LRTI 2A & E 1 No info 1 Special Screening11A & E 2 MAU 1 GP 5 No Info 3 Abdominal Pain6A & E 1 GatDoc/WIC 4 GP 1 Lobar Pneumonia5GatDoc 1 GP 4

What can GatNet do? –Improve effectiveness of support teams –Develop alternatives to admission –Integrate WIC/A+E –Work with Gatdoc and UCT –Identify and reduce the variation in how often best practice is being offered to patients –Universalise the best Reducing Emergency Admissions

Question 3 How do we reduce attendances at Walk in Centre and Accident and Emergency?

Reducing A+E/WIC attendances What can practices do? –Understand data –Ensure practice access is good Primary Care Federation work Same day/advance appointment ratio Telephone answering systems Appointment availability –Psychological support in some case –Use Dashboard

What can Gatnet do? –Support practices to improve access –Ensure access to information –Simplify options for patients who are seen out of hours –Develop alternative pathways Reducing A+E/WIC attendances

Question 4 How do we manage those who are frequent attenders to secondary care?

Managing Frequent Attenders to Secondary Care What has been tried? Risk assessment Integrated care teams Self Care Need all three in place to have an impact

What can practices do –Use Dashboard –Case management –Identify and treat psychological problems –Work with Nursing Homes Managing Frequent Attenders to Secondary Care

What can Gatnet do? –Provide information systems –Facilitate change in General Practice –Work with UCT etc to ensure support for patients available –Ensure community matrons working effectively –Resource changes that are needed in primary care –Improve links with Social Care Managing Frequent Attenders to Secondary Care

Take home messages Discuss in your practices Use the tools that are available Ensure access is as good as possible Use the services that exist to reduce referral to secondary care and admissions. Universalise the best