I’ve been reading the STPs, and I cant see much about reducing demand. The scale of the capacity issues facing the NHS, is showing up the flaws in the old fashioned model of Primary Care. There has to be a significant (fast) redesign of Primary Care, which has at its heart the following four areas:
- Reduce demand on primary care
- Re-align skills to meet real demand
- Make clinical and orgnisational decisions based on data and evidence
- Work in partnership – with communities (so that services really support people to be healthy) and other local providers (to get more efficient delivery -back office)
Nudging Practices along this journey is critical but needs a concerted effort, its a necessity not a luxury. Whilst there are programmes now to support primary care e.g. Quick Start, RCGP resilience, our own Primary Care Quality Academies (see London Primary Care Academy DRAFT Outline Proposal_03.04.2017), I don’t know any GPs that don’t need something. Thats a full scale challenge. So where should primary care teams focus their effort? The tendency has been on QI training, but we think the focus should be on a mix of data, flow, skill mix, access and coproduction.
What does good look like?
In our experience practices that are adapting are:
- Using data to review their activity and improve flow within their practices and across the system
- Looking for examples and ideas to manage demand from outside their own practice -through visits to other practices / international primary care systems
- Work collaboratively with local citizens in an asset based approach
These practices and primary care teams:
- Use their skill sets more effectively to meet need (diversifying their skills and offers, targeting these effectively)
- Use their contact time with patients more effectively
- Improve their back-office functions to be more efficient
- Partner effectively with care homes/ other practices to manage the health of frail elderly in care and reduce hospital admissions (see my previous blog)
- Co-produce new services with communities lead by communities
So what is the gain?
Well here are some examples of what is possible from our contact with leading primary care teams:
Appointments & Skills
20+% of GP appointments offer the opportunity to do something differently (clinician self-assessment). A more profound view of demand and failure demand (especially across a collective group of practices) enables practices to engage more effectively with the wider system to reduce sources of failure demand. It creates a much more objective basis, rather than perhaps unsubstantiated subjective views, on which to base discussions around.
Many GPs don’t know how much time their peers spend with patients, and why there is any variation. Here is an example from one practice, with each bar being one GP in a 5 -GP practice:
Here is an example of what’s possible from Tower Hamlets:
At Robin Lane Health and Wellbeing Centre in Leeds the biggest impact they had on reducing demand was increasing opening over the weekend and providing a walk-in appointment service. The faced these challenges:
Future challenges (examples) Population growth (6-8% Leeds 2004-13); 8% increase Dementia each year for next 30yrs; 31% to 51% increase in long term conditions
Which Meant that Each year for next 20 years they would need 2.5% GP appointments; 3% Hospital appointments; 5.25% Hospital bed days; 2% care needs (washing, dressing)
Their walk-in service generated this impact:
- 26% reduction in demand 2 months after initial launch
- Patient satisfaction significantly improved
- Reduction in DNA rates
- Reduction in A&E attendances
- 9% reduction in A&E attendances Dec(lowest in 3/5years)
- 13% reduction in A&E attendances Jan (lowest in 3/5 years)
- A&E: 1670 more patients seen in A&E city wide in November to January (highest in ten yrs)
- 1572 more patients seen by Robin Lane practice
- Further increase in patient satisfaction
- Improved accessibility
Their review showed this was due to:
- Guaranteed consultation and type of accessibility meant patients where less anxious about their problem – they knew they would get an appointment so they didn’t book a ‘just in case’ one.
- Attention given to patient education during attendance enables patients to try alternatives in order to self-manage in future. The walk-in operates with a skill mix of nurses, GPs and pharmacist so patients can see the best person for their problem.
- Improved efficiencies by facilitating a teamwork environment where clinicians draw on collective experience at point of patient attendance.
They have shown that they can increase their list size whilst reducing attendance. Of course open access appointments wasn’t the only change. You can find out more here
Collaboration with Citizens
I’ve written a few blogs here on Coproduction. There is no way of changing primary care if its not done in full partnership with communities. Communities has assets, talents, insights and connections that come together to solve some of the deeply routed issues that underpin vulnerability, be that isolation and loneliness, a peer group, a purpose, learning from others, or just someone to help out with some day to day living. There are some lovely impact stories from Leeds City Council’s work on this here
From the Altogether Better case study.
You can read more about the The Health Systems Innovation Lab at London South Bank University Learning Journey to discover what it takes to design and develop New Models of Primary Care
If you want to take part in a Learning Journey we are running a Safari Conference on Coproduction you can find out more and sign up here
In the morning you can choose one of these to visit:
- Visit 1: Rochedale Intermediate Care
- Visit 2: Shared Lives in Bolton
- Visit 3: Asset Based Community Development in Leeds
- Visit 4: Primary Care and partnership with population – Robin Lane Health and Wellbeing Centre, Leeds
- Visit 5: Altogether Better – bringing clinicians, patients and citizens together to deliver models of care, Leeds
- Visit 6: Sheffield Shared Haeomodialysis team
- Visit 7: Recovery College Kirklees
- Visit 8: Mental Health Concern, Newcastle
We then all meet in the afternoon to share learning and hear more about the power of coproduction from: