ASSUMPTIONS THAT DESIGN THE NHS What you see determines what you do - - PowerPoint PPT Presentation

ASSUMPTIONS THAT ‘DESIGN’ THE NHS

Prof Becky Malby

What you see determines what you do

Many practices hold numerous hypotheses that shape their current work

• Demand is rising
• We are just meeting it but can’t carry on – we

don’t turn people away

• We don’t have enough capacity and we need

more staff/ money

• Frequent attenders all have more than one

chronic disease

• Secondary care shifts the burden onto us
• Social care is failing

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The big picture of demand vs. capacity is optimistic

• While typically 15%
• 20%
• f appointment requests can’t be meet at reception in a practice
• This is far less than the 40%
• f GP appointments that are seen as inappropriate – unnecessary,

avoidable or potentially moveable within the practice

* Over 10,000 contacts / appointments ** Not including missed calls

Unmet demand* Inappropriate appointments

is far less than

Reception contacts GP appointments

Academies combined*

✓ Appointment booked No appt possible ✓ Appropriate appt

85% Yes

15% No

60% appropriate

40% Inapprop.

What is The Work of General Practice?

Variation between GPS from 40% of my appts are appropriate to 90% are appropriate

Super Attenders go to GP Surgeries because they have what sort of problems?

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Frequent attender review (top 100)

Over half are seen as having “health anxiety” – but this is of course the doctors’ view rather than the patients

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Identifier Age Gender GP appts Nurse appts Attender category GP #1 % GP #2 % QOF registers QOFs 1 64 yrs Female 46 5 Super attender 30% 20% 1 CHD, 2 49 yrs Female 39 2 Super attender 62% 15% 1

• besity,

3 51 yrs Female 35 6 Super attender 86% 14% 3 cancer,mental_health,obesity, 4 97 yrs Female 35 1 Super attender 54% 46% 1 atfib, 5 52 yrs Male 34 4 Super attender 38% 26% 1 depression, 6 23 yrs Male 33 4 Super attender 67% 12% 1 learning_disability, 7 47 yrs Female 33 Super attender 70% 15% 8 64 yrs Female 33 4 Super attender 33% 27% 2 CVD,hypertension, 9 72 yrs Female 32 7 Super attender 56% 16% 1 stroke_tia, 10 37 yrs Female 30 9 Super attender 27% 23% 1 asthma, 11 62 yrs Male 29 5 Super attender 28% 28% 3 asthma,CVD,hypertension, 12 63 yrs Female 28 2 Super attender 46% 29% 1 diabetes, 13 48wks Male 26 3 Super attender 38% 23% 14 61 yrs Male 26 1 Super attender 23% 23% 3 asthma,cancer,depression, 15 46 yrs Female 26 Super attender 73% 27% 2 depression,mental_health, 16 56 yrs Female 26 2 Super attender 54% 19% 17 96 yrs Female 26 2 Super attender 65% 27% 2 CKD,dementia, 18 48 yrs Male 24 2 biweekly 46% 17% 1 depression,

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Frequent attender review (top 100)

Life situation: Over half are known to be in a struggling or chaotic life style

Appointment Skew

The harder access is, the more that people who attend frequently dominate

The larger the practice, the larger the skew tends to be.

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Challenge1: Managing resources to frequent attenders and offering more appropriate services to them Challenge2: Looking after your revenue from infrequents (in the face of digital competition)

50% of your income comes from zero/single attenders And is used by the top 15% of attenders

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Standing back and looking at the whole practice population – example from one practice.

• Long term condition register (QOF) - occurrence by age/across appts

LTC occurrence by patient Proportion of GP appts taken by long- term conditions

Age 0 -100 years 

Ages 7 - 24

Who gets access?

People who attend frequently are a product of the General Practice’s behaviour not the population’s health

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EXAMPLE Q: Does loyalty/ continuity increase with attendance? A: Not in this practice

T able shows proportion of each segment who have 10%/20% etc of their appointments with a “main” GP

39% 40% 43% 47%

% “loyal” / “continuity” patients (50% or over appts with a main GP) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

TAKING AN EVIDENCE BASED APPROACH

A&E is Overburdened (Breaches ) Because

A Demand is rising – more people are coming to A&E B Primary Care is Failing C There are no beds in the hospital so there is backlog D A&E is doing more tests and interventions so the workload is changing E We don’t have enough clinicians in A&E

The evidence?

A&E breaches are related to

• increasing acuity/ complexity,
• increased length of stay,
• staffing and facilities out of pace with the changes in need in

A&E,

• increase in case management within A&E,

not as the dominant narrative suggests, as a result of increased numbers and poor primary care

Wyatt, S. (2019) Waiting Times and Attendance Durations at English Accident and Emergency

• Departments. The Strategy Unit

PC Contribution to Reducing A&E Attendance for Complex Needs

Its NOT more appointments It is…

• Active collaborative management of people with complex needs (PCN role)
• Active management in the practice of those tipping into unstable (e.g.

Complex Care Nurse)

• Care Homes need one practice per care home and practices who really

understand care home work (in one case in Leeds this reduced A%E admits

• f complex needs by 60%)
• Continuity within General Practice (Baker et al 2017)

6 months 6 months 6 months 6 months later admitted to Mental Health Hospital 6 months

2 years of 2.5 recorded

And the GP said…

“If all the teams this individual encountered in the past 2

years actually worked together (not just lip service to integration) e.g. sat in the same place, discussed cases together, she would have found herself in the right place having the right care for her much sooner

”

Managing Complex Needs

Mildly & Moderately Complex level 1

• Practice &

Community High Complexity level 2

• PCN

High Complexity (including specialist care) level 3

• ICS

Where to start in leading change – what’s really going on?

Challenging and checking Hypothesis Data Review Evidence Packs Deming SPK Citizen Dialogue Case History Studies Your experience Nick Downham Cressbrook Ltd

CLEAR PURPOSE

WHAT IS THE PROBLEM PCNS ARE THE SOLUTION TOO? (ESPOUSED INTENT)

We asked PCN Leaders…..

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PCN Range of Purposes/ Intent (Actual Intent)

a) Alleviate GP pressures (new staff), improve workload and therefore improve workforce job satisfaction b) T

• get the income (practices won’t survive without the NCDES) and

scalable investment c) Deliver extended hours d) Sort out failing / struggling practices

Transactional Approach: Economies of Scale

PCN Range of Purposes/ Intent (Actual Intent)

a) Learning and innovation b) Delivering complex care/ integrated care (for some as part of the ICS) together c) Support communities to help themselves – increasing community assets d) Get upstream into prevention by collaborating with schools/ nurseries/ families e) Act as an integrator – connecting and enabling partners

Network Approach: Working at Scale

THEORY OF CHANGE

Networks

“Networks have become the predominant organizational form of every domain of human activity” Castells (2011) “Networks are cooperative structures where an interconnected group

• f individuals, coalesce around a shared purpose and where members

contribute as peers on the basis of reciprocity and exchange (in turn based on trust, respect, and mutuality).” Malby & Anderson-Wallace (2016)

Useful For

• Generating creative and innovative solutions
• Rapid learning and development
• Amplifying the effectiveness of individual members

Networks Work When:

• There is clear shared purpose and identity
• They are creative and innovative
• They meet member needs
• They are supported by adapted leadership
• They have strong relationships and ties
• They generate helpful outputs

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