DELIVERING QUALITY IN PRIMARY CARE: THE JOURNEY SO FAR

1. DELIVERING QUALITY IN PRIMARY CARE: THE JOURNEY SO FAR Sir Lewis Ritchie Chair DQPC Steering Group

2. THE JOURNEY SO FAR Reflecting back...........

7. THE JOURNEY SO FAR Putting quality on the map........... .......a national perspective.......

9. The Journey So Far Delivering Quality in Primary Care (DQPC)..... So: What does the Quality Strategy mean for primary care? What can primary care bring to the table?

10. The Journey So Far A reminder of why we set out on this journey: - Huge challenges facing NHS – demography (60% increase in over 75s over next 20 years), money: ring fencing but still £300 million efficiencies

11. The Journey So Far A reminder of why we set out on this journey, cont… Primary care a critical part of the solution. 90% of contacts; 23 million GP consultations; 1.9 million eye examinations; 91 million prescriptions dispensed, highly trained and capable resource...... - But.....a sense of a dis‑engagement in recent years. So...need to re‑engage and re‑energise.

12. 2010 engagement process 6 regional events, 700 attendees from all PC players.... Some key themes to emerge: - Enthusiasm for the dialogue. Much scope for greater integration - Finances a huge challenge but in every place people up for being part of the solution Real issues around motivation but quality seen as potential to be a key motivator

13. Follow up Determined there should be actions as result – leading to a: Delivering Quality in Primary Care Action Plan DQPC Action Plan: not an exhaustive (and exhausting) list nor a rival to the QS. But key national actions which would make the biggest difference. Overseen by DQPC Steering Group. Bookend event – today: do stay! – to keep us honest and help refresh the plan.

14. Overarching themes Will mention a few of the actions, but first three very important overarching themes: 1 - Primary care's place at the table. Vital part of the solution. WHO has always said so. Increasingly recognised here

15. Overarching themes Primary care's place at the table… “We need to make sure people are admitted to hospital only when it is not possible or appropriate to treat them in the community ... doing all of these things will result in changes in the pattern of acute care and.. fewer acute beds and, as long as it is appropriate and as a result of the kind of service change we want to see, we should see that as a positive” (Cabinet Secretary to Parliament, June 2011)

16. Overarching themes Primary care's place at the table… Key part in the Health Boards’ annual review process. Today’s PC events as integral part of annual NHS Scotland event.

17. Overarching themes 2 – Need for grown up relationship with all independent contractors: For too long we’ve kept each other at arms length Multi-professional Involvement in DQPC Steering Group, in individual actions and as day‑by‑day partners

18. Overarching themes 3 – The Leadership Imperative: Visionary and vigilance Enablement and encouragement Courage and example

19. What’s the bottom line? • Actions set out in DQPC plan. Not list all now: a number, including local, will be showcased at 5.15pm • A few highlights: - eye care integration: potential to revolutionise primary/secondary care link • prevention: Keep Well and Childsmile rolled out; £70m Change Fund

20. What’s the bottom line? Highlights continued… • GP access: toolkit developed with profession • developing a HEAT target on timely, accurate info at the primary/secondary care interface • leadership: launch tomorrow of Strategic Clinical Leadership network; plus joint RCGP/ NES initiative on leadership in primary care

21. What’s the bottom line? • Looking forward to hearing your reactions on the journey so far and what lies ahead • Meanwhile: some more detail on 3 of the key areas of activity • Primary /secondary care interface • Patient safety and • “Productive General Practice”

22. WHATS GOING ON OUT THERE?PRIMARY CARE IN SCOTLANDDR SHEENA L MACDONALDSenior Medical Adviser Scottish Government

23. The Complete Works of William Shakespeare (Abridged)By Adam Long, Daniel Singer and Jess WinfieldDamien Devine and Red Lion TheatresNew Red Lion TheatreReview by Simon Sladen (2011)Take 90 minutes, 37 plays, 3 actors, 1 famous bard, blitz them in a theatrical blender and what do you get? An evening of pure Shakespearean fun courtesy of The Complete Works of William Shakespeare (Abridged).

24. Estimated number of patient contacts by discipline Financial years 2003/04 to 2009/10 30 25 20 Health Visitor Contacts [million] District Nurse 15 Practice Nurse General Practitioner 10 5 0 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Financial Year WHO DO WE SEE?

25. WHAT DO WE SEE? Top 10 conditions - GP and practice nurse per 1,000 Circulatory and respiratory S&S GP PN General abnormal S&S NEC Hypertension Diseases of the skin & subcutaneous tissue Digestive/abdominal S&S Neurological/musculoskeletal S&S Psychological S&S Diabetes Soft tissue disorders Infectious diseases 0 40 80 120 160 200 240 280 GP & PN contact rate per 1,000 population

26. WHAT HAPPENS TO THEM? • “view the NHS as a service delivered predominantly in local communities rather than in hospitals; 90% of health care is delivered in primary care but we still focus the bulk of our attention on the other 10% - our current emphasis on hospitals does not provide the care that people are likely to need.” Professor David Kerr 2005

27. WHAT HAPPENS TO THEM? • Around 1 in 50 GP consultations results in an emergency inpatient admission. Thus 1000 GP consultations will result in 20 emergency inpatient admissions. If all GPs were able to refer only one fewer person in 1000 consultations ( i.e. referring 19 rather than 20 individuals), it would produce a 5% reduction in GP referred emergency admissions. Professor David Kerr 2005

28. LOTHIAN EXPERIENCE • 10% of practice population contact their practice every week • 87% managed in Primary Care for next 4 weeks • 13% - 48% OPD 6% A&E 10% admissions i.e. 2% result in unscheduled activity or 1.3% resulting in direct admission

29. 2,500 Contracted=£700m Non Contracted=£3.7bn 2,000 1,500 £m 1,000 500 0 QoF A&E Premises Enhanced Services Prescribing Admissions Unplanned Global Sum Funds Board Administered Direct access attendances New Outpatient SO WHY BOTHER?

30. SO WHAT ARE WE DOING? • The Quality Strategy & DQPC • Closer working – look at variation and engage in a dialogue – 20% reduction in plain x-rays from one board 40% reduction in dermatology referrals form another • QPQOF

31. QPQOF • 3 work-streams – referrals, admissions and prescribing • 3 activities – internal review of data, external peer review of data, agree on actions for prescribing and care pathways for referrals and emergency admissions

32. And so to the Future… • Continue to develop QPQOF and emphasis on whole system working • “Care delivered at the right time in the right place by the right person” • Align local and national enhanced services to support • Support AHP and Community Nursing to realign work priorities to support people to remain out of institutional care

33. Improving Patient Safety in Primary Care - The story so far Neil Houston, NHS Forth Valley

34. SUB HEADING

35. SUB HEADING

36. Safety Improvement in Primary Care (SIPC 1)

37. Aims: To enable 80 Primary Care teams to: 1.Identify and reduce harm to patients 2. Improve reliability of care for patients On High Risk Medications With Heart Failure 3.Develop safety Culture 4.Involve Patients in QI

38. Knowledge • Topics • Tools • What to spread? • How to spread?

39. 1. Reliable Care – Care Bundles 4 or 5 elements of care Evidence based Across Patients Journey Creates teamwork Done reliably All or nothing Small frequent samples

40. Heart Failure Bundle 1.Maximise medical therapy – On a licensed B Blocker B Blocker at max tolerated dose 2.Functional assessment - NYHA recorded in last year 3.Immunisation - pneumococcal vaccine ever 4.Self Management- information given to patient on recognition of deterioration Improve QOL Reduce admissions

41. Bundles - Successes “The care bundles were useful because it identified gaps” Revealing unreliable practice Indicating areas for improvement

42. 2 – Data

43. Seeing Improvement “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good”

44. Tayside

45. Lothian

46. Outcome Data

47. Trigger ToolsTo identify and reduce harm

48. SUB HEADING

49. SUB HEADING