1. Dr Steve Henderson Clinical Advisor, Tier 2 services Greater Manchester Health Authority

2. Tier2 services one of the key policies in SHA Franchise Plan adds services to support both primary and secondary care Builds additional capacity to address the access targets of the NHS Plan

3. Enhancing Capacity Tier2 – developing a broader range of choice closer to the patient Booking services – managing the referral pathways through primary and secondary care Greater Manchester Choice Centre – coordinating the capacity in secondary services Greater Manchester Surgical Centre – providing additional surgical capacity Clinical networks – involving clinicians in reform of pathways

4. Areas of focus Intermittent Care – Outpatient referrals Chronic disease management Emergency Care

5. Intermittent Care – Outpatient referrals Marked variability of thresholds for referral Dependence on levels of local provision Range of differentiation of clinical problem Quality of information in referral uneven Limited support and advice to referrer Poor choice of treatments and settings

6. Limited Threshold Management Standard Primary Care Management Standard Acute Care Management Management by Self Care and Prevention T1 T2 Disease Severity Progression over time

7. Threshold Management Primary Care Tier 1 Acute Care Primary Care Tier 2 Management by Self Care and Prevention T1 T2 T3 Disease Severity Progression over time Therapeutic Drive

8. The theory is that what we see as a homogenous waiting list problem is in fact made up of a set of distinct cohorts of patients. So the patients waiting for a first outpatient appointment at any one time can be thought of as being in one of the following categories. An anatomy of outpatient waiting Require Treatment Need second opinion Will not attend clinic Resolved with diagnostics Service inappropriate for need Alternative clearly indicated

9. Chronic disease management Poor integration between health sectors Markedly different services in neighbouring areas Unstructured transfers of care to Primary sector Specialist capacity not efficiently utilised Duplication between disease areas Inappropriate settings for services

10. Emergency Care Multiple access points – GP, Ambulance service, NHS Direct, Out of Hours services, Walk-in centres, A&E etc Poor information flows Patchy Intermediate care services Weak linkage to Social care

11. Main Applications of Tier 2 service Enhanced clinical capacity Improved clinical pathways

12. Enhanced clinical capacity Additional practitioners offering diagnosis and treatment :- GPSI, Specialist Nurse, Physiotherapist, etc. Increased diagnostic capacity including community based services e.g. endoscopy Specialist time released to provide further capacity Support for alternatives to admission or earlier discharge and follow-up

13. Improved clinical pathways Use tier 2 clinicians to develop and support use of clinical guidelines Act as an advice point for primary care on services available and management options Work with secondary care clinicians on preliminary investigation and clinical information requirements Support primary care in investigating and managing presenting and chronic conditions Co-ordinate responses to urgent clinical problems

14. Key factors in delivering change Value and build on existing clinical relationships Improve quality of clinical care as well as increasing capacity Place the patients needs at the core of the service provided Remove unnecessary hurdles and delays from current pathways

15. Tier 2 – 2003-2006 Proposed further £10m over 3 years Three waves: £4m Jan 2004 (£1m in year effect) £2m April 2004 £4m Jan 2005 (£1m in year effect)

16. Scope of existing GPwSI services Musculo-skeletal General/Minor Surgery Dermatology ENT Diabetes Total of 30+ GPwSIs Emergency care Cardiology Urology Rheumatology

17. Issues to address in GPwSI services Scope of the service to be commissioned Integration with other services Clinical governance / supervision Employment and contracting arrangements Accreditation of practitioner and service Measurement of outcomes and value

18. Future development opportunities Expanding Tier2 to other interface areas Combining approaches with new GMS and PMS contracts Working with other PwSI services Concordats with other health care provider organisations Further collaboration with secondary care